OST-249 - CPC Exam Prep - Combined - 1-8
Tracheostomy
31600 (Tracheostomy, not stated otherwise, should be assigned the least significant code, 31600.)
Retroperitoneal indicates that an organ is located
behind the peritoneum.
The noncancerous enlargement of the prostate gland refers to
benign prostatic hypertrophy.
What term describes an open fracture?
compound (A compound fracture describes an open fracture.)
Breast neoplasm
D48.60 (Not stated as malignant; therefore, coded as uncertain behavior.) WRONG
Repair broken denture base, mandibular, complete
D5511 (HCPCS code D5511 is the only code assigned for a complete repair of a mandibular denture base.)
Sickle cell anemia in crisis
D57.00 (Assign sickle cell disease, unspecified with crisis.)
The zygomatic bones are paired bones more commonly referred to as
cheek bones
CXR is the standard abbreviation for
chest x-ray
Stones or calculi formations in the gallbladder are termed as
cholelithiasis
The combining form for cartilage is
chondro
A chronic liver disease where liver tissue is replaced over time with nonfunctional scar tissue is called
cirrhosis
The combining form "cryo" refers to
cold
Chromo refers to
color
A fracture where the bone is splintered or broken into multiple fragments is called
comminuted fracture
In order for the most accurate coding to be produced by the practice, the management should ensure that
current year code books are maintained at all times. (Accurate coding may only be assigned if current year code books are maintained by the practice at all times. Management should make certain that only "definitive" sources are being utilized for coding purposes. Consulting with other coders, utilizing "cheatsheets," and coding newsletters are not considered definitive sources.)
Abnormal condition of blue color is known as
cyanosis
The word root "salpingo" refers to the
fallopian tubes
The long bone of the upper leg is called the
femur
When a sperm cell joins with an ovum, the process is referred to as
fertilization
The bone located on the lateral side of the tibia is the:
fibula
Phalange(s) refers to
fingers and toes
The total number of lobes of the lungs would be
five
Having knowledge that false statements were made with the intent to gain a greater amount than due is a definition of
fraud (Fraud is knowingly making false statements in order to gain reimbursement. Overbilling involves billing more services than were provided. Conversely, underbilling involves billing lesser or fewer services than were provided.)
The abbreviation FTSG stands for
full-thickness skin graft.
Myco is defined as
fungus
Modifier -TA denotes
great toe, Left foot. (The "TA" modifier denotes the great toe of the left foot. Fingers and thumbs of the hand are noted with "F" modifiers. The great toe of the right foot would be designated with the modifier "T5.")
Hgb is an abbreviation referring to
hemoglobin
Enlarged or varicose veins in the mucous membranes of the anus are referred to as
hemorrhoids
Abnormal pap smear
R87.619 (Located under "abnormality, Papanicolaou Smear, Cervix")
Which of the following refers to a protrusion of any organ through an abnormal opening?
hernia
The combining form that means "water" is
hydro
The primary function of the integumentary system is
protection, temperature regulation, vitamin D synthesis, and sensory perception
The term that describes the direction closest to the point of origin is
proximal
The larynx, trachea, bronchial tree, and lungs comprise the
lower respiratory tract. (The larynx, trachea, bronchial tree, and lungs are all part of the lower respiratory tract. The upper respiratory tract is comprised of the nose, mouth, and throat.)
The procedure where a spinal needle is utilized to remove CSF fluid from the subarachnoid space is a(n)
lumbar puncture
Masses should be coded as
mass (Masses are not necessarily neoplasms, and, therefore should not be assigned codes from the neoplasm table.)
The upper jawbone is the
maxilla
Inflammation of the membranous coverage of the brain/spinal cord is called
meningitis
The process of urination is also known as
micturition
Frequent urination occurring at night refers to
nocturia
Laceration of hand requiring extensive cleaning, 2.5 cm none of these codes 12001 12006 12011
none of these codes (Repair with extensive cleaning, an intermediate repair code should be assigned. None of the codes listed are intermediate closures.)
Excision of benign lesion trunk, 2.7 cm with simple closure 1400 none of these codes 11402 11401, 1200
none of these codes (Would be assigned excision, benign, trunk, 2.7 cm, code 11403 that is not listed. Therefore, "none of these codes" would be appropriate.)
NOS refers to
not specified further by physician. (Additional information not specified further by physician per ICD10 book) WRONG
The combining form that means ovaries is
oophoro
The combining form for testis/testicle is
orchio
The combining form for the mouth is
oro
Paresis refers to
partial paralysis
PTCA stands for
percutaneous transluminal coronary angioplasty
The two-layered sac covering the heart is known as
pericardium
In a teaching setting, what documentation must be present for resident services to be coded/billed for an initial hospital admission by the teaching physician?
personal notation entered by teaching/attending physician documenting their participation and presence during the encounter (In addition to the documentation of the resident, the teaching physician must document their participation in the history, exam, and/or MDM components of the service. Documentation by the resident is also required; however, without the documentation by the teaching physician, the service may not be billed.) WRONG
The suffix indicating surgical repair is
plasty
The combining form meaning gray matter is
polio
The word part meaning many is
poly
When fraudulent actions are taken by a provider, what penalties may be imposed by the government?
possible imprisonment (Imprisonment may be one penalty imposed for fraudulent activities.)
The definition of gravido refers to
pregnancy
Hearing loss due to aging is called
presbycusis
Hematopoiesis refers to the
production of blood cells ("Poiesis" means "production of," and "hemato" means "blood or blood cells.")
The term cystocele refers to
prolapse of the bladder.
This designation in CPT indicates that a procedure code may only be assigned if it is the only procedure performed that is not an inherent part of another procedure or service.
separate procedure (Procedures designated as "separate procedure" in the CPT book indicate procedures that may only be coded when performed alone for that anatomical area.)
When the varicella-zoster virus, also responsible for varicella or chickenpox, is reactivated at a later time, it is commonly referred to as
shingles
Laceration repairs completed with the use of Dermabond rather than sutures would be coded as
simple laceration repair. (Dermabond is considered surgical repair/closure; therefore, the appropriate repair/closure code would be assigned.)
Small, soft, pedunculated lesions that are harmless outgrowths of skin are referred to as
skin tags
The combining form "phaso" refers to
speech
Metastatic refers to
spread of cancer to another body part or organ
The size of a skin graft is measured in
square centimeters (Skin grafts are coded based on square centimeters (lesions are reported based on centimeters).)
Which of the following suffixes means control, stop, and standing?
stasis
Abnormal narrowing or tightening is called
stenosis
Ortho is defined as
straight
The combining form that means "mind" is
psycho (In medical terms, the mind is referred to with the combining form psycho.)
Blood tumor below the dura mater is referred to as
subdural hematoma.
When one is lying flat on one's back, face up, the position is referred to as
supine
When a diagnostic arthroscopy is performed followed by a surgical arthroscopic procedure, what service(s) are reportable?
surgical arthroscopy procedure only (According to CPT/NCCI guidelines, only the definitive procedure is reportable. Surgical arthroscopy always includes diagnostic arthroscopy.)
An orchidopexy refers to
surgical fixation of the testicle.
When the abbreviation "PRN" is listed on a prescription, this refers to
take as needed
The foot bones are referred to as
tarsals
The primary organ(s) of the male reproductive system is/are the
testes
An adenoidectomy involves the excision of
the adenoids.
The largest artery(ies) in the body is/are called
the aorta
Encephalo refers to
the brain
The clavicle refers to
the collarbone
Oogenesis is the process of
the formation of ovum.
Abuse is defined as
the overuse or excessive use of medical and health services. (The overuse or excessive use of medical and health services is one example of abuse. The remaining choices are all examples of fraud.)
The combining form myelo refers to
the spinal cord
Viral hepatitis, type C
B19.20 (Coded specific to viral, type C)
Common name for qui tam action is
whistleblower (Qui Tam legislation is frequently referred to as the whistleblower, named for the individual who "blows the whistle" on the provider or reports them to federal authorities.)
Multiple consultations were performed by multiple specialists during the same hospitalization. In order for each of these services to be considered for payment, what information must be documented and coded?
written request, referring physician, and written report for each consultant, as well as specific reason each unique specialist is seeing patient (The requirements for each consultation would need to be met, namely, a referral, a requesting physician, and a written report. It would also be necessary that each consultant stated the specific reason they are seeing the patient that is unique to their specialty.)
Graft from one species, often pig, to another is referred to as a(n):
xenograft
The cell that is formed when the nucleus of the ovum and the nucleus of the sperm unite is a
zygote
Bile is produced in which organ?
Liver
NCCI stands for
National Correct Coding Initiative.
Polycystic kidney disease
Q61.3 (Coded as congenital disorder)
Hearing screening
V5008 (Code V5008 only code for screening)
Thrombo refers to
a clot
Cephalgia refers to
a headache
The abbreviation OU refers to
both eyes
The word part meaning bad, difficult, painful is
dys
The study of cells and microscopic tissue is known as
histology
Repair of nail bed
11760 (Assigned as Nail, Repair, Nail Bed)
Diagnostic Left Shoulder Arthroscopy
29805-LT (Diagnostic shoulder arthroscopy only performed; therefore, assign 29805-LT.)
Acute onset of left-sided chest pain diagnosed as intercostal pain
R07.82 (Intercostal chest pain is confirmed and coded with R07.82.)
Chest pain, rule out MI
R07.9 ("Rule out" should not be coded per ICD10 guidelines, only the chest pain.)
Right upper quadrant abdominal pain
R10.11 (Code look-up as follows: pain, abdominal, upper, right upper quadrant)
Right and left upper quadrant abdominal pain
R10.11, R10.12 (Requires two codes for each site. There is no code for combined/multiple sites.)
Provision of standard bed pan
E0275 (Code E0275 is only code for standard bed pan.)
Nausea, vomiting, and fever, possible appendicitis
R11.2, R50.9 (Assign nausea and vomiting (one combination code) and fever only as "possible" appendicitis cannot be assigned per ICD10 guidelines.) WRONG
The surgical procedure to fixate a joint is called
arthrodesis
The combining form that means eyelid is
blepharo
CAD is the standard medical abbreviation for
coronary artery disease.
The blood in the fallopian tubes is referred to as
hematosalpinx
The suffix that means suturing and repairing is
orrhaphy
The prefix "peri" means
surrounding
Which modifier would you use if a re-excision procedure is performed during the postoperative period of the primary excision of a malignant lesion?
-58 (Modifier -58 would be appropriate when a staged and/or related procedure is performed in the global/postoperative period.)
Patient who had an A&P colporrhaphy performed four days prior was taken to the OR for bright red vaginal bleeding, which revealed a bleeding site. The same surgeon who performed the colporrhapy controlled the bleeding with placement of sutures. What modifier(s) would be appropriate for this service?
-78 (Modifier -78 would be appropriate for this service as the surgeon who performed the original surgery in the OR found it necessary to return the patient to the OR in a related procedure.)
Bronchoscopic transbronchial lung biopsy, left lower lobe and right upper lobe
31632, 31628 (Transbronchial biopsies are assigned based on the number of lobes; therefore, 31632 and 31628 would be assigned for two lobes.) WRONG
What modifier should be appended to a CPT code when an ABN form has been secured for services that are believed to not be covered under the Medicare program?
-GA (Modifier -GA denotes that an ABN form was obtained prior to rendered services as it was believed this service may not be covered. None of the remaining modifiers pertain to services performed that would require an ABN.)
When performing an angioplasty on the left circumflex coronary artery, what modifier(s) should be appended for these services?
-LC (Anatomical modifier "-LC" indicates left circumflex.)
What modifier would be appended to CPT code 28505 open treatment of great toe fracture to denote the right great toe?
-T5 (T5 would be appropriate because it designates the great toe on the right foot per CPT.)
Incision was made over right axillary abscess. Cultures were obtained and sent to pathology. The wound was packed and dressed.
10060 (Incision and drainage was performed. Since the report does not state any further information, the least significant would be assigned, namely 10060.)
Incision/drainage of cyst
10060 (Incision and drainage was performed. Since the report does not state any further information, the least significant would be assigned, namely 10060.)
A patient presents for removal of splinter in foot. Appears to be a small wood splint directly beneath the skin. Incision was made and after some minimal probing, the splinter was removed
10120 (Incision and removal of foreign body from the skin would be assigned code 10120.)
Removal foreign body, left long finger. Gentle blunt dissection was performed and entrance site of three BBs was found. They were delivered into the wound and removed.
10120 (Located in the integumentary section because the removal of the foreign body was in the skin. Incision/Drainage section, Incision and removal of foreign body, code 10120.)
An 84-year-old patient presents to a wound care center with bilateral lower extremity venous stasis ulcers. Five wounds were debrided through subcutaneous tissue in an excisional fashion.
11042 (The total area of the surgical debridement would be coded. Since the total area has not been documented, would assume the least significant, which would be 20 sq cm or less.)
Debridement of bilateral heel decubiti down through muscle
11043 (Excisional debridement through muscle is assigned to 11043 (size not specified).)
A 25-year-old male is having debridement performed on an infected ulcer with eschar on the right foot. Using sharp dissection, the ulcer and eschar infection was debrided all the way to down to the bone of the foot. The bone had to be minimally trimmed because of a sharp point at the end of the metatarsal.
11044 (Excisional debridement performed through bone is assigned 11044 (sq cm not specified).)
Excision of benign, hyperkeratotic lesions to the right clavicular area, right preauricular area and right parascapula area. The lesions were all cleaned and subsequently curetted off and cauterized with electrocautery.
11056 (Lesions were curreted off only; therefore, paring/cutting code would be assigned.)
Malignant lesion removed from right arm (excised diameter 4.6 cm). During the same visit, the dermatologist noticed a new growth on left arm. Biopsy of the new lesion taken and sent for pathology. What code(s), if any, would be assigned for the biopsy?
11106-59 (Would assign biopsy code 11106 with modifier -59 to indicate the biopsy was to a distinct, separate site from the malignant lesion removal. Note the question asks what code(s)would be appropriate for the biopsy only.)
A 42-year-old female presented for removal of two lesions located on nose and lower lip. Lesions were identified and marked. Utilizing a 3 mm punch, a biopsy was taken of the left supratip nasal area. The lower lip lesion of 4 mm in size was shaved to the level of the superficial dermis.
11310, 11106-59 (Shaving of lip lesion would be assigned 11310, biopsy of nasal lesion would be assigned 11100 with modifier 59 to indicate biopsy performed to a distinct, separate lesion.) WRONG
Excision lesion, 2.0 cm leg
11402 (Assigned as benign (as not stated as malignant), 2.0 leg; therefore, code 11402 is assigned.)
Morpheaform basal cell carcinoma of the nose. Incision was made along with marked areas, measuring 4 cm. Left preauricular incision was made and elliptical FTSG was taken and sutured into place.
11644, 15260 (Malignant lesion nose, 4 cm codes to 11644. Full thickness skin graft is coded to the recipient site, nose; therefore, 15260 would be appropriate.)
Skin lesion, right flank and back, possible melanoma in situ. Incisions made around lesions, allowing 0.5 cm border. Right flank lesion measured 1.5 cm, back 0.8 cm. Further dissection to margin borders was obtained and the specimens sent to pathology.
11403, 11402-51 (Possible melanoma cannot be assigned as malignant as "presumed" only. Flank lesion is 1.5 cm + 0.5 + 0.5 margins = 2.5 cm, code 11403. Back lesion measures 0.8 cm + 0.5 cm +.5 cm = 1.8 cm, code 11402-51. Modifier -51 is appended to multiple skin procedures performed during the same surgical session.)
Excision of benign lesion: 4.0 cm arm, 2.0 cm leg, and 2.0 cm back
11404, 11402-51, 11402-59 (Three lesions were excised; therefore, three codes are needed. Arm lesion largest, therefore, most significant, 11404; leg and back lesions are of same code, therefore, modifier -59 is assigned to the second 11402 code to indicate separate, distinct lesion. Append modifier -51 when multiple surgical procedures of the skin are performed during the same surgical session.) WRONG
Left nasal labial fold lesion was excised utilizing wide margins. Wound was closed. Patient also reported bilateral impacted cerumen prior to surgery with request to remove. After removal of lesion, an operating microscope was utilized to remove cerumen using a cerumen spoon.
11440, 69210-50 (Assign 11440 for nasal lesion excision. Per CPT, cerumen spoon is considered surgical instrument; therefore, 69210-50 would be appropriate.)
Excision of benign right forehead lesion. Right temple lesion was clearly evident, 1 x 1 cm, pigmented, mole-type lesion being excised due to sudden appearance. Area was cleaned, infiltrated with Xylocaine, and then excised completed and submitted to pathology.
11441 (Lesion is 1 cm, benign, face. Therefore, code 11441 would be appropriate.)
Wide excision of presumed basal cell carcinoma on the face, 2.5 cm. STSG was obtained from the left neck and applied to the site of wide excision.
11443, 15120 (Lesion only "presumed" malignant is, therefore, coded as benign. A 2.5 cm benign face codes to 11443. STSF codes to 15120.)
Excision, benign lesion, 4 cm cheek
11444 (Would be assigned code from the Excision Benign Lesions, cheek, 4 cm, code 11444) WRONG
A 4.5 cm (excised diameter) benign cystic lesion from forehead. The ulcerated lesion was anesthetized with 20 mg of 1% Lidocaine and then elliptically excised. The wound was closed with a layered suture technique and a sterile dressing applied. The wound closure was 5.3 cm.
11446 (Coded as Excision Lesion Benign, Forehead, 4.5 cm, code 11446.)
Procedure: Wide excision of left axillary hidradenitis suppurativa. The elliptical marking was done to the whole area and taken down through the fatty tissue with electrocautery where the excision was taken deep to accommodate prior sinuses and abscess pockets that reached deep into the tissue.
11450 (Excision of lesion codes is not appropriate in this instance, as there is a specific code for removal of hidradenitis (11450). Simple removal is assigned as the extent of the repair was not documented and, therefore, assumed to be simple.) WRONG
Excision of a 1 cm lower back lesion. Lesion on the arm, 1 cm in size, was also excised and closed. Surgical path indicated that lower back and arm lesions were malignant.
11601, 11601-59 (Two malignant lesions of the same anatomical grouping were excised. Unlike repair/closures, these codes are NOT summed together but listed separately. Since they assign to the same code, 11601, modifier -59 is assigned to indicate these are two distinct lesions excised.) WRONG
Excision of leg carcinoma and FTSG. Lesion in the distal leg at the anterior side was 2 cm. Excised the lesion with generous margin. Supposed to do a STSG, but dermatone was not available; therefore, FTSG was obtained from upper thigh, 3 x 1 cm, and applied to leg area.
11602, 15220 (Excision of malignant lesion, 2 cm leg is assigned code 11602. Also FTSG was performed; therefore, 15220 would be appropriate (intended to be STSG).)
Re-excision of melanoma left arm with 1 cm margins. Dissection through the previous skin incision was made, down to fascia, and all underlying tissue was removed.
11602-58 (Re-excision would require use of modifier -58 in this scenario. Size was not specified; however, the margins totaled 2 cm. Therefore, 11602 would be appropriate. Melanoma is assumed to be malignant and re-excision is treated the same as original excision.) WRONG
Excision malignant lesion, 2.0 cm leg with 0.5 cm margins
11603 (Assigned malignant lesion, leg, 2.0 cm + margins (0.5 + 0.5) for a total of 3.0 cm. Therefore, code 11603 would be appropriate.) WRONG
Excision of 2.5 cm malignant lesion of arm with 0.5 cm margins. Also removal of 1.5 cm malignant lesion from scalp was performed.
11622, 11604-51 (Two lesions were excised; therefore, two codes would be assigned. The lesions were specified as malignant. Code 11622 for the arm lesion (2.5 cm + 1.0 total margins = 3.5 cm), code 11622. Second lesion, scalp, 1.5 cm code, 11604-51. Modifier -51 is appropriate for multiple procedures on the skin during the same surgical session.)
Excision of malignant lesion, face, 2.0 cm
11642 (Coded as Excision Malignant Lesion, Face, 2.0 cm)
Destruction malignant lesion, 2.0 cm face; excision malignant lesion, 1.5 cm face; and excision benign lesion, 2.5 cm arm
11642, 11403-51, 17282-51 (Excision lesions are assigned first, malignant is primary, code 11642 for 1.5 malignant face, followed by benign lesion 2.5 cm arm, code 11403-51, and then destruction lesion 17282-51.) WRONG
Excision of a 2.75 cm basal cell carcinoma of the left nare
11643 (Code located in Integumentary Section, Excision Malignant Lesion, nose, 2.75 cm. There was no split thickness skin graft performed, therefore, the other answers would not be appropriate in this instance.)
Excision of malignant lesion, face, 2.0 cm with 0.5 cm margins
11643 (Coded as Excision Malignant Lesion, Face, 2.0 cm + 0.5 + 0.5 = 3.0 cm)
Excision of malignant lesion arm, 2.0; malignant lesion, face, 2.5 cm
11643, 11602-51 (Two codes are assigned: one for each lesion, 11643 for Excision Malignant Lesion, face, 2.5 cm; 11602-51 for Excision Malignant Lesion, arm 2.0 cm.)
Radical excision of 3 cm BCC on nose, repair with FTSG from right preauricular area
11643, 15260 (Two codes are appropriate: one for the excision of the malignant lesion (11643) and the other for the FTSG (15260).
Diagnosis: Basal cell carcinoma (BCC), left chin. Procedure: Wide local excision of 3.0 cm with 0.3 cm margin BCC of the left chin with a 4 cm closure. A 15-blade scalpel was then used to make an incision in the previously marked site. The lesion was then sharply dissected off underlying tissue bed using a 15-blade scalpel. It was tagged for pathologic orientation. The wound was then closed by advancing the tissue surrounding the lesion and closing in layers with 3-0 Vicryl for the deep layer, followed by 5-0 Prolene for the skin.
11644, C44.319 (Diagnosed as basal cell carcinoma; therefore, dx code C44.319 and CPT code 11644 for Excision Malignant Lesion, chin, 3.6 cm (3.0 +0.3 + 0.3).)
A 55-year-old male presents in the office with an ingrown toenail on both feet. The right foot was prepped and draped in sterile fashion. The right great toe was anesthetized with 50/50 solution of 2% Lidocaine and 0.05% Marcaine. The lateral border was incised and excised in total. At this time, the patient elected to only have one performed and will return in 2 weeks for the left foot.
11750-T5 (Assign code 11750-T5 for right great toe.)
Patient presents to the ED with a 1 cm laceration of the scalp for repair. Area was prepped and draped and the wound cleansed. Skin closure was accomplished with the two sutures.
12001 (Assigned 1 cm repair/scalp as complexity not stated would assume simple.)
Repair, 2.3 cm arm, simple
12001 (Assigned simple, arm, less than 2.5 cm) WRONG
Laceration repair of a 2.5 cm wound of hand
12001 (Coded as simple, hand, 2.5 cm; therefore, code 12001 would be appropriate.)
Repair of laceration to the left ring finger
12001 (Smallest size and complexity should be utilized when not specified, therefore, coded to simple, < 2.5 cm, which codes to 12001.)
Patient is 4 years old who cut his arm on broken glass. He has a 2 cm laceration on his arm and an additional 1 cm on the right hand. The larger wound as well as the smaller laceration is closed with 4-0 Ethilon.
12002 (Multiple lacerations in the same anatomical grouping should be added together and one code reported: 2 cm + 1 cm = 3 cm hand/arm, simple. Therefore, code 12002 should be assigned.) WRONG
Laceration repair, 2.0 cm, face
12011 (Assigned as Repair/Closure, Face, 2.0 cm)
A 78-year-old resident of nursing home presents for repair of 1.5 cm forehead laceration and skin tears on both hands. The forehead laceration was repaired but continue to ooze, so a pressure dressing was applied.
12011 (Only the forehead laceration was repaired. Stated as 1.5 cm, however, complexity was not specified and, therefore, would be assumed simple. Therefore, code 12011 would be assigned.)
Laceration repair, 1.5 cm face
12011 (Repair/closure, 1.5 cm face. Assumed simple complexity as not stated otherwise)
A patient presents for closure of a 6.5 laceration to the forehead. The wound was repaired in two layers, and dressing was applied.
12014 (Assigned simple repair/closure as documentation does not state repair extended into deep subcutaneous.)
A patient presents for closure of 6.5 cm laceration to forehead. The wound was repaired in two layers and dressing was applied and the patient discharged.
12014 (Does not qualify for intermediate closure unless extended into the deep subcutaneous. Therefore, code 12014, simple, 6.5 cm face, would be assigned.)
Laceration repair: 2.0 cm arm, simple; 2.0 cm arm, simple; 3.0 cm leg, simple; and 2.0 cm leg, intermediate
12031, 12002-51 (Three of the lacerations are simple and in the same anatomical grouping; therefore, they are all added together to make 7 cm to arms/legs, code 12002-51, and 2.0 cm leg intermediate, code 12031. Intermediate repair would be considered most significant; therefore, 12031 would be assigned as the primary code.)
Repair of three lacerations as follows: Upper arm, deep subcutaneous layer closed with 4-0 Nylon, skin with 4-0 Vicryl. Second wound on the lower left arm required only skin closure. Third laceration on the lower leg required 4-0 Nylon for deep subcutaneous layer and 4-0 Nylon for skin repair measuring 2.8 cm.
12032, 12001-51 (Only size of third laceration was specified as 2.8 cm. All lacerations/closures of same complexity and same anatomical groupings are added together. Therefore, the upper arm laceration and lower leg would be added: 0 cm (size not specified) + 2.8 cm = 2.8 cm intermediate, arms/legs = 12032. Second wound of arm was simple only. Size was not indicated; therefore, 12001-51 would be assigned. Modifier -51 is appropriate for multiple procedures performed on the skin in the same surgical session.)
Laceration repairs are performed as follows: simple arm, 2.0 cm; intermediate arm, 3.0 cm; and simple nose, 2.0
12032, 12011-51, 12001-51 (Each repair/closure requires a separate code as different anatomical grouping and/or different complexity. Therefore, intermediate arm would be assigned first, as most significant, code 12032, followed by simple nose 2.0, code 12011-51, followed by simple arm 2.0 cm, code 12001-51.)
Laceration repair right ring finger. Wound was cleansed and extensive debridement was performed to remove necrotic tissue. Suturing was performed utilizing 4-0 Ethilon sutures.
12041 (Extensive cleaning was performed prior to repair. Therefore, per CPT, intermediate repair code would be utilized, smallest size (since size not stated).) WRONG
Repair of right index finger laceration. Severely lacerated distal interphalangeal joint of finger from skill saw. Block performed, and extensive debridement performed prior to closing with 4-0 black Ethilon.
12041 (When extensive cleaning prior to closure is documented, it qualifies for intermediate closure. Therefore, intermediate, finger, smallest size (size not stated), code 12041 would be appropriate.)
Laceration repairs as follows: face, 2.0 simple; face, 3.0 cm intermediate; hand 2.0 cm simple; and arm, 2.0 simple
12052, 12011-51, 12002-51 (Three codes are assigned, as two of the repairs/closures are of same complexity/anatomical grouping (arm and hand). Intermediate codes are assigned first, code 12052 face, 3 cm, then face, simple 12011-51, then hand/arm 4.0 cm simple 12002-51.)
Lesion of the scalp was excised, and an adjacent tissue transfer totaling 4 sq cm was utilized to close the site.
14020 (Only adjacent tissue transfer is codable, therefore, assign 14020 for scalp. Per CPT guidelines, the excision of lesion when performed in conjunction with an adjacent tissue transfer is not separately codeable.)
Adjacent tissue transfer, arm, 20 sq cm with removal of malignant lesion, arm 16 cm
14021 (Excision malignant lesion is included in adjacent tissue transfer, and, not separately coded. Assign code 14021 as transfer is 20 sq cm.)
Excision of a 2 cm basal cell carcinoma of the neck with 5 sq cm adjacent flap closure
14040 (Only adjacent tissue transfer is codable, therefore, assign 14040 for neck. Per CPT guidelines, excision of lesions when performed in conjunction with an adjacent tissue transfer is not separately codeable.)
Excision of a basal cell carcinoma of the right nose and reconstruction with an advancement flap. The 1.2 cm lesion with an excised diameter of 1.5 cm was excised with a 15-blade scalpel down to the level of the subcutaneous tissue, totaling a primary defect of 1.8 cm. Electrocautery was used for hemostasis. An adjacent tissue transfer of 3 sq cm was taken from the nasolabial fold and was advanced into the primary defect.
14060 (Only the advancement flap (adjacent tissue transfer) is assigned. Code 14060 would be appropriate as lesion is included.) WRONG
Excision of nasal lesion and coverage with pedicle flap. Lesion measured 1.3 cm in diameter. The lesion was excised and a pedicle flap elevated along the nasal labial area and rotated into anatomical position.
14060 (Only the rotation flap (adjacent tissue transfer) is assigned when performed in conjunction with excision of lesion. Therefore, 14060 only is assigned.)
A 1.3 cm nasal lesion excised from nasal labial area. Pedicle flap was elevated along the nasal labial area and rotated into position.
14060 (When adjacent tissue transfers are performed, lesions excised are not separately codable. Therefore, only 14060 would be appropriate in this instance.)
A 4 cm lower lip lesion was excised and diagnosed as malignant. A skin flap was utilized from the nasolabial flap and rotated inferiorly to close the defect.
14060 (When rotation flap (adjacent tissue transfer) is performed with excision of lesion, excision is not codable per CPT. Therefore, only 14060 would be reported in this scenario.) WRONG
STSG from thigh to arm, 2 x 3 cm
15100 (Split-thickness skin graft to arm (assign recipient site); size is calculated as 2 x 3 cm = 6 sq cm.)
A total of 250 sq cm of split thickness skin grafting of the leg would be reported as
15100, 15101 x 2. (Code 15100 is for 100 sq cm and 15101 is for each additional 100 sq cm or portion thereof; therefore, 2 units of 15101 should be reported in addition to code 15100.)
Nonhealing wound on the tip of the nose. Documented an autologous split-thickness skin graft (STSG) to the tip of nose. A simple debridement of granulated tissues is completed prior to the placement. Using a dermatome, an STSG was harvested from the left thigh. The graft is placed onto the nose defect and secured with sutures. The donor site is examined, which confirms good hemostasis.
15120 (Coded to the split-thickness skin graft of the nose (recipient site). No additional codes are appropriate as debridement was not stated as excisional as required for preparation codes.)
FTSG, cheek, 3 x 5 cm
15240 (Full-thickness skin graft, cheek, size calculated as 15 cm (3 x 5 = 15 sq cm))
Redundant skin of the superior eyelids was demarcated and the skin and orbicularis was incised, elevated, and excised. Protruding fat pads were isolated and excised.
15822-50 (Superior eyelids would be the upper eyelids and blepharoplasty was performed. Despite the fact that stated fat pad excised, it does not indicate weighing down lid; therefore, 15822 would be appropriate. To report bilaterally, append modifier -50 to CPT code 15822.) WRONG
A 33-year-old male presents to have multiple lesions destroyed. Three benign lesions on her face are destroyed and five actinic keratoses on her left arm are destroyed.
17000, 17003 x 4, 17110 (The actinic keratosis would be assigned 17000 for the first lesion and 17003 for each additional lesion (total of four additional). 17110 would be assigned for the destruction of the benign lesions.)
In a 30-year-old patient, two actinic keratoses were removed by cryotherapy, each 0.5 cm in size. The physician also applied liquid nitrogen to a wart located on the left thumb.
17000, 17003, 17110-51 (Actinic keratoses are assigned codes in the 17000 series. Two were removed; therefore, 17000 would be assigned for the first lesion, and 17003 for the second lesion. The wart would be assigned 17110-51 as an additional procedure. 17003 does not need modifier -51 as it is designated as an "add-on procedure," which does not require modifier -51.)
Benign neoplasm of the mucous membrane of the mouth. Using a handheld laser set at 15 watts, super pulse power was applied around the circumference of the lesion, and dysplasia circumscribed with the laser. The central tumor and dysplasia were ablated and vaporized with the laser.
17280 (The tumor was ablated and vaporized; therefore, code 17280, destruction of malignant lesion, is appropriate.)
Excision gynecomastia, right breast. Area was marked and incision made. Margins of the breast around the areola were dissected circumferentially until all breast tissue marked was removed.
19300-RT (Specified as mastectomy being performed for gynecomastia; therefore, code 19300-RT would be appropriate.) WRONG
Patient has basal cell carcinoma on his upper back. Excisions of the tumor will be performed using Mohs micrographic surgery technique. There were three tissue blocks that were prepared for cryostat, sectioned, and removed in the first stage. Then a second stage had six tissue blocks, which were also cut and stained for microscopic examination. The entire base and margins of the excised pieces of tissue were examined by the surgeon.
17313, 17314, 17315 (Mohs surgery coded as 17313 for the first blocks, 17314 for each additional stage (1 additional), and 17315 for each additional block (one additional block).)
Needle biopsy, breast
19100 (Code located in the Integumentary Section, Breast, under Excision, Breast, biopsy, needle. Other code selections are for excision of the entire lesion or excision of breast (mastectomy).)
A 78-year-old female had recent mammographic and ultrasound abnormalities in the 6 o'clock position of the left breast. She underwent core biopsies, which showed the presence of a papilloma. The plan now is for needle localization with excisional biopsy to rule out occult malignancy. After undergoing preoperative needle localization with hookwire needle injection with methylene blue, the patient was brought to the operating room and was placed on the operating room table in the supine position where she underwent laryngeal mask airway (LMA) anesthesia. The left breast was prepped and draped in a sterile fashion. A radial incision was then made in the 6 o'clock position of the left breast corresponding to the tip of the needle localizing wire. Using blunt and sharp dissection, a generous excisional biopsy was performed around the needle localizing wire including all of the methylene blue-stained tissues. The specimen was then submitted for radiologic confirmation followed by permanent section pathology.
19101-LT, N63.20 (Diagnosis would be breast mass only as no pathology has been received at the time of the coding assignment; therefore, N63.20 would be appropriate. Surgeon performed incisional biopsy only; therefore, 19101-LT only would be appropriate. Other procedures performed prior to surgical procedure.) WRONG
Excisional breast biopsy, right breast
19101-RT (Assigned from Integumentary, Breast, Excisional, biopsy, breast, code 19101 with modifier -RT to indicate right breast.) WRONG
Duct exploration and excision. Curvilinear incision was made, and the areolar flap was elevated until the ductal tissue was encountered. An enlarged blue-black looking duct was encountered, and it was circumferentially dissected. Then further excised ductal tissue off the back of the nipple. All was submitted for pathology.
19120 (Code 19120 includes "excision of duct lesions.")
Patient presented for excisional breast biopsy. Incision was made around the whole lesion and removed in toto. Lesion appeared to be approximately 2 cm in diameter.
19120 (Stated as excisional biopsy. However, report indicates that the entire lesion was removed. Therefore, for excision of breast lesion, code 19120 would be appropriate.)
Excision of breast lesion, 1.5 cm, left breast
19120-LT (Assigned as Excision breast lesion, LT)
Left breast mass. A curvilinear incision was made and the topical abnormality was grasped with Allis clamps and circumferential dissection was performed to remove the abnormal mass.
19120-LT (No mention of preoperative radiological marker; therefore, only the mass was removed, which is reported with 19120-LT. Codes 19101 and 19100 are for biopsy only, when only a portion of the mass/lesion are removed.)
When excision of breast lesion is performed with the placement of a marker, the surgery would be coded as
19125 (Assigned from Excision, breast, lesion, with preoperative radiological marker, code 19125.)
A patient presents for a 2.5 cm excision of malignant breast lesion identified by preoperative placement of radiological marker.
19125 (Code 19125 is assiged for excision of breast lesion identified with preoperative radiological marker.)
Excision of breast mass, 2.5 cm identified on mammogram by preoperative radiological marker
19125 (Excision of breast lesion/mass, identified by preoperative marker, is assigned 19125.)
Excisional biopsy of an area of clustered abnormal microcalcifications of the left breast. Patient was brought to OR after having undergone needle localization earlier in the x-ray suite by the radiologists. A curvilinear incision was made in the upper quadrant, needle was identified, and a wide wedge excision was carried out encompassing the lesion in question. Assign the appropriate codes for the surgeon.
19125-LT (Assign code 19125 for excision of breast lesion identified with preoperative radiological market. Modifier -LT would indicate left breast.)
A patient was taken to the x-ray suite where the radiologist under ultrasonic guidance localized the right breast lump with a needle. The patient was then taken to the surgical suite. The localized needle was followed to its termination and a generous margin was achieved encompassing the needle and node in question.
19125-RT (The placement of the localization device was performed by the radiologist and therefore not reportable by this physician. However, code 19125-RT would be assigned since a localization device was placed prior to excision.)
The left breast was markedly enlarged consistent with gynecomastia and benign. The incision was made and breast tissue that had been previously marked out was dissected free.
19300-LT (Mastectomy for gynecomastia is assigned to 19300-LT.)
Left mastectomy for left gynecomastia, skin tag removal. Areola was elevated off the breast and breast tissue was excised. Following completion of the breast procedure, right groin was exposed and draped, and skin tag was excised by shave excision.
19300-LT, 11200-59 (Mastectomy for gynecomastia is assigned to 19300. Also skin tag was excised by shaving, which codes to 11200. To indicate that the skin tag was excised from a distinct site, modifier -59 would be assigned.)
Preoperative diagnosis: Left breast carcinoma. Postoperative diagnosis: Left breast carcinoma. Name of procedure: Left lumpectomy and sentinel node biopsy. Description of procedure: The patient is a 55-year-old female admitted with a diagnosis of left breast carcinoma. Incision was made with a 15 blade through skin and subcutaneous. Homeostasis achieved with bovie electrocautery. Flaps were formed in the usual manner. A wire was brought out through the incision. Then all the tissue around the wire down to the tip was circumferentially removed. A hot node in the axilla and at least two lymph nodes, which were blue-dyed within the sentinel nodes, were identified. Lymphoscintigraphy was performed, 2 cc of methylene blue dye was injected in the periareolar area preoperatively, and the breast was massaged for 5 minutes. A sentinel node biopsy was performed on one axillary nodes.
19301-LT, 38525-51-LT, 38792-51 (Lumpectomy considered partial mastectomy. Assigned to code 19301-LT. In addition, sentinel lymph node was excised, which codes to 38525-51-LT, as well as code for the injection for the lymphoscintigraphy, 38792-51. Lumpectomy code with axillary lymphadenectomy not assigned unless all or majority of lymph nodes excised.) WRONG
Lumpectomy, right breast
19301-RT (Lumpectomy considered partial mastectomy is assigned code 19301-RT.)
Diagnosis: Ductal carcinoma in situ, left breast. Procedure: Right partial mastectomy. Incision was deepened through skin and subcutaneous tissue. We dissected a large ball of breast tissue out from the medial right breast and used silk suture to close the lumpectomy site.
19301-RT (Partial breast was removed; therefore, mastectomy code is appropriate. Code 19301 is assigned for partial. RT is assigned for right breast.)
Two cc of Methylene blue dye was injected beneath the areola and incision was made along the axillary hairline for sentinel node biopsy. An enlarged deep node was identified and excised for biopsy. Next, an incision was made over the left lateral breast lump and a sharp dissection margin of normal tissue as well as the palpable lump was taken and excised completely. Sentinel node biopsy returned as positive, and complete deep axillary node dissection was performed.
19302-LT, 38900 (Partial mastectomy was performed with axillary lymphadectomy. Since the axillary dissection was completed, code 19302 (partial mastectomy with axillary lymphadectomy) would be assigned. In addition, code 38900 would be assigned for the injection of non-radioactive dye.)
Excisional biopsy of right breast with frozen section, followed by lumpectomy and axillary node dissection. Mass in the upper right breast was excised for biopsy. The pathology reported infiltrating ductal carcinoma. Elliptical incision was carried down to the pectoralis muscle; upper right breast quadrant was removed. Proceeded with axillary node dissection. Complete axillary node dissection was completed and submitted for pathology.
19302-RT (Initially biopsy performed, however, extended into lumpectomy with axillary node dissection, which codes to 19302-RT.)
Lumpectomy, right breast with axillary node dissection. An elliptical incision was made above the areola. Incision was made removing the tumor down to the pectoralis fascia. Axillary dissection was carried out and Jackson-Pratt placed into the axilla and secured. Breast incision was closed.
19302-RT (Partial mastectomy was performed (19301) with axillary lymphadenectomy. Since the dissection was completed, code 19302 (partial mastectomy with axillary lymphadectomy) would be assigned.)
Right subcutaneous mastectomy. Incision was made and areola was elevated off the breast tissue. Breast tissue was excised and removed.
19304-RT (Subcutaneous mastectomy is assigned code 19304-RT.) WRONG
Mastectomy, radical, right including pectoral muscles and axillary lymph nodes
19305-RT (Since mastectomy was performed to include a radical mastectomy and the pectoral muscles and axillary lymph nodes were excised, code 19305-RT would be the most appropriate choice. The other answer choices involve less than radical (such as 19301 and 19303) and more extensive (19306) than was documented.) WRONG
Right modified radical mastectomy was performed as follows: Superior and inferior flaps developed and breast taken off chest wall and axillary nodes removed as well.
19307-RT (Modified radical mastectomy was performed with axillary lymphadenectomy. Therefore, code 19307-RT would be appropriate.)
Replacement of deflated breast implant. Patient noted implant increasingly smaller and soft. A pinpoint hole on the posterior aspect of the implant was located. The new implant was inspected, prepared, and inserted using a no-touch technique and inflated with normal saline to 450 cc.
19325 (New breast augmentation with prosthetic (implant) performed. Removal of old prosthetic is included in new procedure.) WRONG
Right mastectomy was performed 10 days ago. The patient returned to the OR for a planned delayed insertion of a breast prosthesis for reconstruction.
19342-58-RT (Modifier -58 would be appropriate since this was a stage/related procedure. Code 19342 is the appropriate code for delayed insertion of the prosthesis.)
The patient is a 42-year-old female who was discovered to have breast cancer on the right side. She was treated with mastectomy followed by chemotherapy and radiation therapy. She now elects to proceed with reconstruction by TRAM flap, which is performed uneventfully.
19367-RT (Reconstruction/repair by TRAM flap is assigned 19367-RT. If performed during the postoperative period, it would need modifier to reflect those circumstances.)
Eight trigger point injections
20552 (Trigger point injections are assigned based on the number of muscles. Since it was not specified, assumed it was one.)
Palpation of the left longissimus muscle and multifidus muscle revealed eight trigger points. These were marked, skin prepped and each trigger point injected with Marcaine 0.25%.
20552 (Two muscles are identified; therefore, trigger point injections one to two muscle groups, code 20552, would be appropriate.)
Arthrocentesis, right knee
20610 (Arthrocentesis is "surgical puncture to aspirate or inject." The knee is considered a major joint per CPT, would assign 20610. RT/LT modifier would not be appropriate as the code is not specific to one anatomical site.) WRONG
Patient presents for knee injection. Patient has been treated conservatively in the past with joint injections successfully. Patient was prepped, Marcaine was used to inject the knee joint.
20610 (Joint injection, also known as arthrocentesis, was performed on a major joint. Therefore, assign code 20610.)
Spinal needle was inserted under ultrasonic guidance to aspirate fluid for diagnostic evaluation of the acetabulum and hip joint. A joint injection of Kenalog and Decadron was also performed.
20611 (Joint injection, also known as arthrocentesis, was performed on a major joint. Therefore, code 20611 is assigned as the procedure was performed under ultrasonic guidance.)
Removal of displaced pin from fracture site
20670 (Displaced pin was not documented as "deep," therefore, assumed superficial, which codes to 20670.)
Removal of surgical pin from distal radius
20680 (Code 20680 would be assigned because the surgical pin was removed from the bone; therefore, considered "deep." Code located under Removal of implant, deep.) WRONG
Small incision was made and incision carried down to the deep fascia. C-arm imaging was used to direct the extraction device on the derotational screw. The set screw was extracted without difficulty.
20680 (Removal of implant, deep; code 20680 would be assigned.)
Syndesmotic screw status post pons fracture with left proximal fibular fracture with removal of hardware
20680 (The screws were still in the fracture site; therefore, 20680 would be assigned for removal implant, deep.) WRONG
A 17-year-old male fractured his right hand approximately 3 weeks ago. It was felt that fracture had healed sufficiently to remove the surgical pins. The hand was examined closely and four separate incisions were made. Pins were removed with a bit of digging about the incision sites. Nylon 4-0 was utilized to close all four wounds.
20680-58 (Surgical pins were removed from the fracture; therefore, the fracture would be considered "deep." Also, performed in global surgical period; therefore, modifier -58 would be assigned. Assign code 20680-58.) WRONG
Incision was made through the deep subcutaneous tissue, removing the entire lesion located on the left chest wall. Following removal, the skin was closed in multiple layers.
21555 (Excision was made into the deep subcutaneous tissue; therefore, musculoskeletal code should be utilized. Code 21555 describes subcutaneous excision of lesion chest/thorax, smallest size since size not specified.)
After adequate anesthesia was obtained, the patient was turned prone in a kneeling position on the spinal table. A lower midline cervical incision was made and the soft tissues divided down to the spinous processes. The soft tissues were stripped way from the lamina down to the facets and discectomies and laminectomies were then carried out at C3-4, C4-5, and C5-6. Interbody fusions were set up for the lower three levels using structural autogenous bone from the iliac crest. The posterior instrumentation of dual titanium rods with hooks were then cut to the appropriate length and bent to confirm to the normal curve. It was then slid immediately onto the bone screws, and at each level, compression was carried out as each of the two bolts were tightened so that the interbody fusions would be snug and as tight as possible.
22551, 22552 X 2, 22842, 20938 (Assign code 22551 for first level (C3-4), and assign 22552 x 2 for two additional levels (C4-5 and C5-6). In addition, assign 22842 for posterior segmental dual rods and 20938 for structural autograft. As both 22842 and 20938 are add-on procedures, modifier -51 is not necessary in this instance.) WRONG
Patient had a Harrington rod placed posteriorly over L2-L3 at the end of the arthrodesis procedure. What code(s) and modifier(s) would be used to report the spinal instrumentation?
22840 (Assign 22840 for posterior nonsegmental instrumentation (Harrington rod).)
Excision Lesion Shoulder, 1.5 cm
23075 (Codable as Excision, Tumor, Soft Tissue, Subcutaneous, < 3 cm. Assign code 23075.) WRONG
Open rotator cuff repair
23410 (Rotator cuff repair performed open; therefore, code located in Musculosketal Section, Shoulder, Repair.)
Diagnostic arthroscopy, left shoulder with arthroscopic subacromial decompression performed to visualize rotator cuff. Unable to complete repair arthroscopically; therefore, open repair of torn rotator cuff was completed.
23410-LT (Subacromial decompression would be considered included in the definitive procedure because it was being performed to visualize the rotator cuff. After attempt, converted to open repair of rotator cuff, code 23410-LT.) WRONG
Shoulder capsulorrhaphy
23450 (Coded as Repair, Revision, Shoulder, Capsulorrhaphy. Since type of capsulorrhaphy not specified, assumed least significant (lowest code), which would be 23450.)
Anterior capsulorrhaphy, left shoulder. Incision was made and carried through subcutaneous tissue. An anterior capsulorrhaphy was then performed in a north-south type fashion with 0 Ethilon sutures. The subscapularis was reapproximated.
23450-LT (Coded from Shoulder, Repair, Capsulorrhaphy, anterior. Assign code 23450-LT because this is the least significant.)
Anterior instability of right shoulder with open Bankart repair. Loose fragments were irrigated and removed, and capsule advanced into position tying sutures down over the capsule. Humeral head manipulated back into place and closed with pants over vest fashion.
23455-RT (Open Bankart repair was performed; therefore, assign code 23455-RT.)
Patient suffers from a frozen shoulder. The patient was taken to the OR and the right shoulder was manipulated using first abduction. With this abduction, there were multiple fibrous brands, scarred tissue that was felt to be released. Rotation and abduction was performed and the patient appeared to have full motion of her shoulder.
23700-52-RT (Code found under Shoulder, Manipulation. Assign code 23700-52. Modifier -52 should be appended as no application of fixator device was performed as required for 23700, therefore the full CPT descriptor has not been met.)
A 10-year-old sustained a both-bone right forearm fracture recently treated previously with reduction and casting, however, has gone to malposition. Cast was removed and obvious deformity was identified. Closed reduction was able to be obtained and then a 1 cm incision was made over the area of Lister's tubercle, just proximal to the growth plate, where a 2.0 mm titanium rod into the intermedullary canal was passed and placed.
25415-RT (Radius/ulna were fractured, now in malunion. Therefore, coded from Repair/Revision section of Forearm. Code 25415-RT assigned for malunion/nonunion of radius and ulna.)
Fracture, radial shaft, left with cast application
25500-LT (Coded as 25500-LT because fracture not stated as closed/open repair; therefore, assumed to be closed. Closed fracture repair, radial shaft is assigned 25500-LT. Cast application is included in fracture repair and would not be separately reportable.)
Fracture, radial shaft, left
25500-LT (Fracture not stated as open, therefore, assumed closed. Code 25500-LT would be assigned for closed fracture radial shaft.
Open repair, ulnar shaft fracture
25545 (Repair of fracture was performed by open technique to ulnar shaft which codes to 25545.)
A closed distal radial fracture was repaired and then casted.
25600, 29075 (Initial cast is included in surgical procedure; therefore, only closed fracture code assigned, 25600, closed repair distal radial fracture. The fracture repair was not specified as open versus closed, therefore, the least significant, closed, would be coded unless provider query is possible.) WRONG
Patient presents to the ED where a diagnosis of closed fracture of the right distal radius was made by the orthopedic surgeon who performed a closed reduction of the fracture. The patient was referred to an orthopedist in his hometown for postoperative care. Assign the appropriate CPT code(s)/modifier(s) for the procedures performed in the ED.
25600-54-RT (Only the surgical portion of the surgery was performed by the orthopedic surgeon; therefore, modifier -54 should be appended as well as an anatomical modifier of "RT.")
Closed reduction of distal left radius and ulna. Traction was applied to the distal radius and ulna and countertraction placed into his upper arm. Satisfactory reduction was achieved after manipulating the fracture with the thumbs pushing the distal fragment into position.
25605-LT (Fracture of radius/ulna was repaired by closed reduction with traction and manipulation. Code 25605-LT would be appropriate.)
Comminuted fracture, left distal radius, percutaneous skeletal fixation. Pins were placed in the usual fashion via full-thickness skin incisions and spreading of the subcutaneous tissue down to bone. Drilling was performed and pins were placed. External fixator was applied and a closed reduction of the fracture was performed and the bolts of the external fixator were tightened down.
25606-LT, 20690 (Fracture repair performed by percutaneous skeletal fixation, code 25606. Also external fixation device was applied; therefore, assign additional code 20690.)
Patient had closed reduction of right distal radial fracture performed 3 days ago in the OR. Radiological studies demonstrate fracture is not in proper anatomical alignment. Surgeons return the patient to the OR to perform ORIF distal radial extra-articular fracture.
25607-78-RT (Patient was returned to the OR for a related procedure; therefore, modifier -78 should be assigned. Fracture is repaired by open reduction. Number of fragments is not specified and is assumed to be only one; therefore, code 25607-78-RT would be assigned.)
Left distal radial fracture is repaired by placing an intermedullary nail to fixate the fracture, followed by cast application.
25607-LT (Open treatment of distal radial fracture would be assigned because CPT states that the placement of an intramedullary nail constitutes open repair. Number of fragments was not identified; therefore, assume only one. Assign 25607-LT.)
ORIF, distal radial fracture, right
25607-RT (Open reduction fracture of the distal radius is assigned 25607-RT as the number of fragments is not specified, so assumed as one.)
Patient presents with painful wrist from automobile accident. Radiological studies revealed right distal radial fracture in two locations. Incision is made, distal radius is identified, manipulated into place, and two pins across both fragments to maintain alignment. A short arm cast is applied.
25608-RT (Open fracture repair was performed of the distal radius. Two fragments were identified and both were stabilized with pins. Therefore, code 25608-RT would be assigned.)
Right wrist arthrodesis with application of short-arm cast. Longitudinal incision was made on the dorsum of the hand and wrist. The extensor pollicis longus tendon was released from its sheath and was retracted. The dorsal hump of the distal radius was then removed with rongeurs. Soft tissue was removed from the dorsal bones, including the lunate capitate and base of the third metacarpal. A burr was used to decorticate the posterior aspects of these bones as well as the joint surfaces between the radius and lunate, lunate and capitate, and capitate and third metacarpal. Nine-hole 3.5 mm dynamic compression plate was bent into position.
25800-RT (Surgical fixation, or arthrodesis, was performed on the wrist, which codes to 25800-RT.) WRONG
Incision and drainage of abscess left index finger
26010-F1 (Assign 26010-F1 found in Incision, Hand/Fingers, I/D Abscess.)
Incision and drainage of tendon sheath of the right index finger
26020 (Assign 26020 found in Incision, Hand/Fingers, Incision Tendon Sheath, Finger.) WRONG
Patient presents with pain in lower leg after falling from ladder. Radiological study indicates a possible left hairline fracture and the patient will be placed in a short leg walking cast in the likelihood of a fracture.
29425-LT (No fracture repair, only application of walking cast; therefore, code 29425-LT would be appropriate.)
Release Dupuytren's contracture both hands. Incision was made over the left palm and the fourth and fifth fingers were carefully released, removing the thickened fascia scar layer of Dupuytren. Both of the fingers were released. Attention was then turned to the right side where the same procedure was performed successfully.
26045-50 (Release of Dupuytren's contracture is performed by decompression fasciotomy. The procedure is performed open, partial. Therefore, code 26045-50 is assigned to indicate same procedure performed bilaterally.)
Repair of right thumb trigger finger. A small incision was created over the A1 pulley of the right thumb. Under direct visualization, the A1 pulley was released freeing up the tendon for full motion without further triggering.
26055-F5 (Assign code 26055-F5 for Incision, Tendon, Finger (for trigger finger).)
Right trigger thumb release (tendon sheath release). Digital nerve was retracted radially to expose the A1 pulley and under direct vision, the A1 pulley was cut. After cutting the pulley, the triggering no longer occurred. Incision was closed.
26055-F5 (Coded from Incision, Hands/Fingers, tendon sheath. Assign code 26055-F5.)
Excisional removal of SQ right ring finger tumor. The tumor was located over the dorsolateral aspect of the middle phalanx distally. Incision was made and the tumor was excised through the subcutaneous soft tissue.
26115 (SQ = subcutaneous. Code 26115 is located under Excision, Hand/Fingers, Soft Tissue.)
Incision carried down to the right metacarpophalangeal joint. Incision was made directly over the capsule exposing the metacarpophalangeal joint. The extensor digitorum brevis tendon was exposed and a tendon graft taken from the extensor digitorum brevis tendon. A drill hole was made at the previous attachment of the ulnar collateral ligament and exiting dorsally on the proximal phalanx. Through this hole, the extensor digitorum brevis tendon was re-routed exiting the ulnar side of the joint. Two similar holes were then drilled on the metacarpal head of the thumb and the tendon graft was pulled through these two hole reestablishing ulnar collateral ligaments. With the reconstruction of the ulnar collateral ligament completed, the tendon was folded back on itself and sutured.
26541-RT (Reconstruction of the collateral ligament was completed with the use of a graft; therefore, 26541-RT would be assigned.) WRONG
Closed treatment of metacarpal fractures of the second, third, and fourth digits of the right hand
26600-RT X 3 (Three metacarpal bones were treated; therefore, code 26600-RT is assigned X 3 for three units because the code indicates "each.") WRONG
Closed reduction of a metacarpal fracture of the right thumb and index finger. Incision was made and metacarpal fractures were identified and manipulated into anatomical alignment. Percutaneous guidewires were inserted and a screw placed to secure.
26608-RT x 2 (Two bones were manipulated; therefore, code 26608-RT x 2 would be appropriate. Code indicates "each" bone; therefore, code would be listed as "2 units" on claim. Reduction was performed by percutaneous skeletal fixation.)
Fracture repair, proximal phalangeal shaft, third finger, right hand
26720-F7 (Fracture not stated as open; therefore, assumed closed. Code 26720-F7 would be assigned for closed fracture repair of the proximal phalangeal shaft.) WRONG
Open reduction left small finger proximal phalanx fracture. Underlying fracture site was identified and the fibrous tissue hematoma within the fracture site and small piece of bone was removed. Fracture site was reduced by rotating the fracture and pulling on the finger.
26735-F4 (Located under Hands/Fingers, Fracture/Dislocation, Phalanx, Open, Proximal Phalanx. Code assigned is 26735-F4.) WRONG
A 72-year-old male had a total hip arthroplasty approximately 4 years ago. When he was getting out of his chair today, he noticed severe pain in his hip and was unable to move. Examination revealed he had dislocated his prosthetic hip. The hip was manipulated back into aligned position.
27265 (Assigned code 27265 found by locating Fracture/Dislocation hip and pelvic joint, closed treatment post hip arthroplasty.)
Removal of deep FB, muscle, thigh
27372 (Code 27372 is located under Introduction/Removal, femur/thigh, removal foreign body, deep, muscle. Therefore, code 27372 would be appropriate.)
Repair tear, quadriceps tendon, right knee. There were two separate vertically oriented tears in the quadriceps tendon, both were sharply debrided to healthy tissue. The quadriceps tendon was reapproximated full thickness.
27385-RT (Located in Repair/Revision section of Femur/Thigh, repair of quadriceps tear. Assign code 27385-RT.)
Arthroscopy, left knee with open lateral retinacular release. Arthroscope cannula was introduced, and the anatomy was examined and appears normal. There was a tight lateral retinaculum noted through range of motion of the knee. A longitudinal skin incision was made, incision carried down to the subcutaneous tissue. Nick was made in the lateral patellar retinaculum and lateral patellar release was accomplished. Arthroscopic portal as well as the lateral release incision was closed.
27425-LT (Attempted arthroscopic lateral release; however, completed open. Therefore, only the definitive procedure (open) is coded. Assign 27425-LT only.)
Treatment/reduction of left tibial shaft fracture with application of short leg walking cast
27750-LT (Initial cast application is included in fracture care; therefore, only the fracture care would be assigned. Fracture care not further specified; therefore, assumed to be closed without manipulation, code 27750-LT.) WRONG
Patient fell in driveway, fracturing right fibula/tibia shaft. Closed treatment of these fractures after manipulation and traction was performed.
27752-RT (Assign code from M/S section, Fibula/Tibia, Fracture Repair, Fibular shaft (with tibia), with manipulation and traction, which assigns to CPT code 27752-RT.)
Patient fell and fractured right tibia/fibula. ORIF treatment of these shaft fractures with placement of a plate was performed.
27758-RT (ORIF was performed on right tibia/fibular fracture; therefore, 27758-RT would be appropriate.)
Repair of fractured tibia with syndesmosis injury. With c-arm control and "tight rope" Arthrex system, a stab incision was made under c-arm control and the drill utilized to drill across the syndesmosis. The syndesmosis was held in place using a large clamp and being in good position using the c-arm for evaluation. The tight rope was then placed through the fibula and tibia and secured tight and tied.
27829 (Repair fractured tibia with syndesmodic disruption is assigned 27829.)
Excision of left foot second interspace neuroma. Standard longitudinal incision was made in the second interspace and blunt dissection performed. The neurovascular bundle was identified and nerve selected, dissected out into each toe and clipped off sharply. It was also dissected down into the foot into the furthest point available and transected there.
28080 (Located in Excision, Foot/Toes, Neuroma. Code 28080.)
A patient presents for a 2.5 cm excision of a left foot mass identified as a ganglion cyst on pathology with simple closure.
28090-LT (Mass extends into musculoskeletal tissue; therefore, codes from musculoskeletal section are assigned. Code 28090 is for excision of foot lesion. Simple closure is included in all procedures in the musculoskeletal section.)
Resection of a ganglion cyst of the right foot
28090-RT (Code 28090-RT, which is located under Excision, Foot, Toes, Excision Lesion Tendon Sheath (e.g., ganglion).)
Ganglion cyst, right foot. Incision was made over the mass and sharp and blunt dissection revealed a ganglion-like cyst, which was removed in toto.
28090-RT (Reported as Excision, Foot/Toes, Lesion, Tendon or Tendon Sheath (cyst/ganglion). Therefore, code assignment would be 28090-RT.)
Attention was directed to the second on the toe left foot, a longitudinal incision was made, and the incision was extended to the level of the PIP joint. Utilizing an oscillating saw, the condyles of the proximal phalanx and the base of the middle phalanx were excised.
28285-T1 (When the condyles of the proximal phalanx and base of the middle phalanx are excised, a hammertoe repair is being performed. Therefore, code 28285-T1 would be assigned for second toe, left foot.)
Hammertoe digit syndrome, fourth and fifth digits, right foot. Foot was exsanguinated and attention directed to fourth digit where a 1.5 dorsal linear incision was made. The medial and lateral collateral ligaments were released and the extensor tendon reflected proximally. Using a sagittal saw, the distal third of the proximal phalanx was resected. The same procedure was performed on the fifth digit.
28285-T8, 28285-T9 (Hammertoe code is 28285, located in Foot/Toes, Repair/Revision, Hammertoe Repair. Modifier should be appended to indicate fourth/fifth digit, -T8 and -T9.)
A curved incision was made over the bunion on the right foot and the capsule dissected off the subcutaneous tissue. The capsule was entered in a "T" fashion and a very large bunion deformity was excised.
28292-RT (Assign 28292 with modifier -TA. Because bunionectomies are performed on the great toe only, -TA and -T5 are the appropriate modifiers.)
Bunionectomy, right
28292-RT (No documentation as to the specific type of bunionectomy; therefore, assume the least significant, which codes to 28292-RT. -RT is assigned as opposed to -T modifiers as a bunionectomy is only performed to the right or left great toe.)
Medial incision on the right lower extremity. Medial complex was excised and distal metatarsal osteotomy performed. The osteotomy was fixed with a single 2-0 screw and the medical proximal piece shaved.
28296-RT (Bunion was excised and distal metatarsal osteotomy performed, described in 28296-RT.) WRONG
Bunionectomy with distal first metatarsal osteotomy including K wire fixation, right foot. Curvilinear incision made over the first metatarsal joint. Prominent hyperostosis was then removed and all bony edges rasped smooth. The corresponding hyperostosis along the medial aspect of the base of the proximal phalanx was removed and rasped smooth. A drill hole from medial to lateral was made through the first metatarsal bed, forming the apex of the osteotomy. A cut was made in the bone and a similar cut made inferiorly, resulting in a separated fragment of bone. Second osteotomy was performed laterally and impacted back upon the first metatarsal shaft, aligning the articular surfaces. The osteotomy was secured utilizing a single K-wire.
28299-RT (Bunionectomy was performed with two/dual osteotomies to correct the misalignment. Therefore, 28299-RT would be appropriate.)
Repair left calcaneus fracture with cast application
28400-LT (Code 28400-LT would be located under Fracture, Foot/Toes, Calcaneus. Initial cast application is included in surgical procedure and not separately reportable.) WRONG
Osteomyelitis of right second distal phalanx requiring amputation. A fishmouth incision was placed at the distal top over the ulceration and deepened down to the distal phalanx where the bone was noted to be very soft. The soft tissue was freed from the distal phalanx plantarly, medially, and laterally. The phalanx of the toe was removed along with the metatarsophalangeal joint from the surgical site in toto.
28820 (Amputation performed, coded from Foot/Toes, amputation. The phalanx was amputated; therefore, amputation through the metatarsophalangeal joint, code 28820, would be appropriate.) WRONG
Partial first ray amputation, left lower extremity. Two converging incisions were made about the first ray. The left hallux toe was removed. Next partial first ray amputation was performed about the mid-shaft of the first metatarsal.
28820-TA (Amputation performed, coded from Foot/Toes, amputation. The phalanx was amputated; therefore, amputation metarsophalangeal joint, code 28820, would be appropriate.)
Right radial shaft fracture was diagnosed by the ED physician and it was determined the fracture would need ORIF by an orthopedic surgeon. Therefore, the fracture was immobilized in a short arm splint, and the patient was referred for orthopedic surgical intervention.
29125-RT (Code 29125-RT would be assigned for the application of splint. There was no definitive treatment of the fracture.)
Patient arrives 2 weeks postoperative following repair of tibial fracture for new short leg walking cast due to initial cast being damaged due to extensive walking. Would the cast be bundled or separately codable, and, if so, what code(s) would be appropriate?
29425-58 (Additional cast applications following the initial performed at the time of surgery are reportable with modifier -58.)
Patient arrives for visit 3 weeks after fracture repair. He is returning for a new short left walking cast due to the initial cast being damaged in the shower.
29425-58 (Initial cast included in surgical procedure. Subsequent casts are codable with modifier -58. Therefore, 29425-58 would be assigned for short leg walking cast.)
A 19-year-old female presents with left tibia shaft fracture. Splinting completed, referred to ortho for surgical intervention.
29515-LT (Tibia shaft fracture is assigned code 29515-LT as only splint/immobilization was applied.)
Arthroscope was inserted into the right shoulder. The rotator cuff showed fraying; however, not significant enough to require repair. Will follow patient if progresses and surgical intervention needed.
29805-RT (Diagnostic shoulder arthroscopy only performed; therefore, 29805-RT only assigned.)
Right shoulder arthroscopy with claviculectomy
29824-RT (Arthroscopic claviculectomy is assigned code 29824-RT only. Diagnostic arthroscopy would be considered included in definitive procedure.)
After incising the skin, arthroscope was inserted into the left glunohumeral joint confirming the partial thickness tear of the left supraspinatus tendon. A 5 mm cannula was inserted into the subacromial. Shaver was utilized to coplane the acromion. An acromioplasty was performed as well as a distal clavicle resection. The arthroscope was put back in the posterior portal and the rotator cuff repair was performed with a 1 anchor-2 suture configuration.
29827-LT, 29826-51-LT, 29824-51-LT (All procedures were performed arthroscopically, including rotator cuff repair (29827), subacromial decompression (29826-51-LT), and claviculectomy (29824-51-LT).) WRONG
Procedure performed: Diagnostic right shoulder arthroscopy and subacromial decompression. Diagnostic arthroscopy was carried out and revealed extensive partial thickness tearing of the rotator cuff. This was debrided. There was also a partial thickness tear of the subscapularis that was also debrided and repaired.
29827-RT (Only 29827-RT would be assigned for arthroscopic rotator cuff repair performed. Diagnostic arthroscopy would be included, and there is no documentation that subacromial decompression was performed; therefore, only 29827-RT is codable.) WRONG
Arthroscopic rotator cuff repair, right
29827-RT (Rotator cuff repair performed arthroscopically would be assigned 29827-RT only.)
Left arthroscopic carpal tunnel release. Portals were introduced, instrumentation was placed, and the carpal tunnel nerve was released.
29848-LT (Coded from arthroscopy, wrist, carpal tunnel. Assign code 29848-LT.) WRONG
Transverse incision was made at the right proximal wrist crease. A trocar was passed from the proximal to distal end, and incision was made in the palm to bring the trocar through. Scope was then brought in to visualize the transverse carpal ligament, and the carpal ligament was divided.
29848-RT (The carpal ligament was performed arthroscopically; therefore, CPT code 29848 would be appropriate with modifier RT to indicate right wrist.) WRONG
The arthroscope was introduced into the anterior lateral portal, The arthroscopic shaver was introduced and a lateral synovectomy was performed on the left knee.
29875-LT (Arthroscopic synovectomy of one compartment only would be assigned as a limited synovectomy, 29875-LT.) WRONG
Left knee arthroscopy and major synovectomy. Arthroscope was inserted and thickened synovial tissue was excised from the medial, lateral, and femoropopliteal compartments.
29876-LT (As synovial tissue was excised to two or more compartments, it would be considered a major synovectomy, which codes to 29876-LT.) WRONG
Patient presents with patellofemoral arthritis of the left knee. Introduction of the Stryker shaver up to the patella and arthroscopic chondroplasty was performed
29877-LT (Arthroscopic chondroplasty only performed; therefore, assign 29877-LT only.)
Right knee arthroscopy, chondroplasty of patella, arthroscopic lateral release. Examination showed localized chondromalacia of the lateral aspect of the patella that was smoothed with a shaver. Patient was noted to have small medial synovial plica that was trimmed with the shaver as well. Using an arthroscopic cautery, an arthroscopic lateral release was performed from the superior pole of the patella to the joint line.
29877-RT, 29873-51-RT (Arthroscopic chondroplasty was performed, which codes to 29877-RT as well as arthroscopic lateral release, code 29873-51-RT.) WRONG
A partial medial meniscectomy is performed as well as a lateral meniscectomy
29880 (Arthroscopic medial and lateral meniscectomy performed; therefore, 29880 would be appropriate.)
Left knee arthroscopy is performed utilizing four portals. Severe fibrosis and Grade II chondromalacia are identified in the femoral condyle. A partial medial and lateral meniscectomy is performed after which chondroplasty of the femoropatellar joint is performed.
29880-LT (Medial and lateral meniscectomy would be assigned 29880-RT as both compartments were excised. Diagnostic arthroscopy would be considered included in the definitive surgical procedure, and chondroplasty is inclusive in the meniscectomy code assigned.)
Diagnostic right knee arthroscopy with medial/lateral meniscectomy
29880-RT (Medial and lateral meniscectomy would be assigned 29880-RT as both compartments were excised. Diagnostic arthroscopy would be considered included in the definitive surgical procedure.) WRONG
Scope revealed extensive Grade III chondromalacia of the right patella, which was debrided with a full-radial shaver and chondroplasty completed. The right medial and lateral compartments were entered with the scope revealing a medial and lateral meniscus tear that was resected with a full-radial shaver. There was also a full-thickness chondral injury to the medial femoral condyle, and a large chondral flap was also resected. A microfracture was also performed on the medial femoral condyle.
29880-RT, 29879-51-RT (Both arthroscopic medial and lateral meniscectomy were performed, which is assigned code 29880-RT. In addition, microfracture was performed, which is assigned code 29879-51-RT.) WRONG
Left diagnostic knee arthroscopy with partial lateral meniscectomy and chondroplasty
29881-LT (Diagnostic knee arthroscopy is considered bundled in the definitive surgical procedures of the meniscectomy and, therefore, not separately reportable. Only lateral meniscectomy was performed; therefore, 29881-LT would be assigned.)
The arthroscope was inserted, and the anterior compartment and patellofemoral joint were intact. The left medial compartment was examined and there was a degenerative tear of the posterior horn of the medial meniscus. The torn portion of the meniscus was removed until a smooth, stable rim was established. The lateral compartment was completely intact.
29881-LT (Medial meniscectomy was performed. Code 29881-LT only.) WRONG
Patient presents for left knee arthroscopy after several months of knee pain. The arthroscope is introduced. Patellofemoral joint and lateral compartments appear intact; however, medial joint has some synovium that is excised as well as medial meniscus that is shaved.
29881-LT (Only medial meniscectomy performed; therefore, code 29881-LT would be appropriate.) WRONG
Diagnostic knee arthroscopy, right knee with lateral arthroscopic meniscectomy, right knee
29881-RT (Diagnostic arthroscopy included in meniscectomy, lateral only; therefore, code 29881-RT would be appropriate.) WRONG
Patient jumped a fence and twisted his left knee when he fell. The orthopedic surgeon performed a diagnostic arthroscopy and that patient was found to have a torn medial meniscus that was repaired.
29882-LT (Arthroscopic meniscus repair, not excision, was performed; therefore, 29882-LT would be assigned.)
Diagnostic knee arthroscopy, left knee with medial meniscus repair
29882-LT (Diagnostic arthroscopy included in arthroscopic surgical procedure; therefore, only 29882-LT would be assigned.) WRONG
Left diagnostic knee arthroscopy with meniscus repair to left lateral compartment
29882-LT (Diagnostic arthroscopy included in meniscus repair; therefore, only 29882-LT would be reportable.)
Arthroscopic meniscus repair, right medial posterior horn
29882-RT (Repair, not excision, of meniscus was performed; therefore, 29882-RT would be appropriate.)
Right arthroscopic medial meniscectomy with ACL repair. Arthroscope inserted and the right medial meniscus revealed a small, posterior horn tear. A medial meniscectomy was performed as well as a chondroplasty with shaving of the articular cartilage. Further exploration revealed a torn anterior cruciate ligament, which was repaired arthroscopically as well.
29888-RT, 29881-51-RT (Arthroscopic anterior cruciate ligament repair was performed, which codes to 29888-RT. In addition, a medial only meniscectomy was performed, which codes to 29881-51 (for multiple procedures)-RT. The diagnostic arthroscope is included as it is designated as a "separate procedure." According to CPT, the chondroplasty is included in the meniscectomy code.)
Rhinoplasty to correct damage caused by a broken nose. One year later patient had a secondary rhinoplasty with major revisions. At the end of the second surgery, the incisions were closed with a single layer technique. How would you report the second surgery?
30450 (Secondary rhinoplasty code would be assigned 30450 when major revisions are performed.)
Traumatic external nasal and internal nasal septal defect. There were several fractures of the septum. Portions of the cartilaginous septum were missing, and there were several tears in the mucoperichondrium. Remnants were removed as well as spurs off the maxillary crest. Tip support was reconstructed with cartilaginous graft obtained from removed cartilaginous septum remnants.
30520 (Repair of the nasal septum (septoplasty) was performed, coded to 30520.)
Open reduction of nasal fracture, septoplasty, and bilateral inferior turbinate reduction. First, the septoplasty was performed. The mucoperichondrial flap was elevated off the cartilage and bone of the septum. The deviated portions of the septum were removed or replaced. Lateral and medial osteotomies were performed due to the significant deviation of the nose. Reduction of the inferior turbinates was performed by outfracturing and reducing them with bipolar electrocautery. The bony nasal work was done via intercartilaginous incisions between the upper lateral and lower lateral cartilage of the nose. Splints were placed in the nose, and a splint was placed on the dorsum of the nose.
30520, 30130-51 (In addition to the septoplasty (repair of the nose) code 30520, code 30130-51 is assigned for reduction of the inferior turbinates.)
ED visit for epistaxis. Both nares were treated with cauterization, and the bleeding appeared to be well controlled.
30901-50 (When epistaxis is controlled solely by cauterization, code 30901 is assigned. In this instance, the procedure was performed bilaterally; therefore, code assigned would be 30901-50.)
The patient had trouble breathing for 3 days. Her urgent care physician referred her to an ENT physician. The ENT performed a diagnostic maxillary sinusoscopy.
31233 (Endoscopic nasal sinusoscopy without any surgical intervention is assigned 31233, diagnostic sinusoscopy.)
Endoscopic ethmoidectomy, bilateral, right maxillary antrostomy, concha bullosa resection
31254-50, 31256-51-RT, 31240-51 (When multiple endoscopic procedures are performed, bilateral procedures are reported first. In this case, 31254-50, followed by the right maxillary antrostomy, 31256-51-RT, and the concha bullosa resection, 31240-51, would be assigned.)
Bilateral endoscopic anterior and posterior ethmoidectomies. Polyps were identified and we followed them into the anterior and posterior ethmoid air cells, and a large amount of mucus and tissue was removed. The left maxillary sinus opening was enlarged endoscopically.
31255-50, 31256-51-LT (Total (anterior and posterior) ethmoidectomies were performed bilaterally and, therefore, are assigned as the primary code as bilateral would be more significant than unilateral (31255-50). Only left maxillary antrostomy was performed; therefore, 31256-51-LT would be assigned.)
Hypertrophic mucosa of the left lateral nasal wall and anterior wall of the ethmoid sinuses were removed with microdebrider. Maxillary sinus was addressed and thickened mucosal tissue was removed, widening the maxillary tract.
31267-LT, 31254-51-LT (Maxillary antrostomy with tissue removal was performed endoscopically (code 31267), as well as anterior ethmoidectomy (code 31254). Code 31267-LT should be listed first, with 31254-51-LT listed second.) WRONG
Endoscopic right anterior ethmoidectomy, bilateral maxillary antrostomy, bilateral frontal sinus exploration
31276-50, 31256-50-51, 31254-51-RT (Bilateral frontal sinus exploration was performed (31276-50), as well as bilateral maxillary antrostomy (31256-50-51) and right ethmoidectomy (31254-51-RT). All subsequent procedures should have modifier -51 appended.) WRONG
Endoscopic sphenoidotomy with tissue removal
31288 (Endoscopic nasal sphenoidotomy was performed, which is assigned 31288.)
A sinus endoscopy with tissue removal from the sphenoid sinus was performed.
31288 (When sinus endoscopic sphenoidotomy is performed that includes removal of tissue, code 31288 is assigned.)
Emergency endotracheal intubation
31500 (Code assigned is 31500.)
Patient positioned properly and given 2 mg of Versed and 40 mg Amidate. After one attempt, she was intubated with a French 7.5 ET tube without difficulty.
31500 (Endotracheal intubation is assigned 31500.)
Procedure performed: Laryngoscopy with excision of laryngeal lesion. Laryngoscope was advanced into the larynx. There was a yellow cystic lesion along the left false vocal cord. The scope was advanced just superior to the lesion. Lesion was grasped, and by using straight and upbiting scissors, the entire capsule was excised.
31540 (Laryngoscopic excision of lesion is assigned 31540.)
Microdirect laryngoscopy with CO2 laser excision of polyps. Anterior commissure laryngoscope was passed where the polyp on the left vocal cord was immediately visible. There also appeared to be a small polyp on the left false vocal cord. Biopsies were taken. CO2 laser was used to carefully excise the polyps without injuring the vocal cords themselves.
31540 (Laryngoscopy was performed, biopsies were taken, and the polyps were excised. When biopsies are performed and the polyps/lesions removed, only the most definitive procedure is assigned. In this instance, 31540 only would be assigned.) WRONG
The patient had been hoarse for a month. His surgeon scheduled a direct laryngoscopy with injection of his vocal cords. During the surgery, it became necessary to use an operating microscope.
31571 (When direct laryngoscopy is performed with injection of vocal cords with the use of an operating microscope, the code assigned would be 31571. Code would be located in the Larynx, Endoscopy section.)
A 10-month-old child suffering from chronic inflammation of the trachea, which is causing difficulty in breathing, was presented to the emergency room. Physician inserted a planned incisional tracheal tube. This procedure was completed under general endotracheal anesthesia.
31601 (The procedure was planned (not stated as emergency) on a child < 2 years old; therefore, code 31601 is assigned.)
Emergency tracheostomy, transtracheal
31603 (An emergency tracheostomy was performed transtracheal, which is assigned 31603.)
The patient is 2 years old who attempted to swallow a quarter. The patient was in acute respiratory distress when arrived in the ED. A temporary tracheostomy was accomplished, allowing oxygen exchange. X-ray revealed the coin to be deeply wedged in the trachea. Several attempts were made to remove the coin in the ED with the use of forceps, without success. The patient was given a mild sedative and taken to the OR where a scope was used to successfully remove the coin.
31603, 31530-59 (An emergency tracheostomy was performed transtracheal, which is assigned 31603. Following this procedure, a direct laryngoscopy was performed with removal of a foreign body, coded to 31530-59. Modifier -59 is assigned to indicate that the laryngoscopy was distinct and separate from the emergency tracheostomy that was required to stabilize the patient until the foreign body could be removed.)
Bronchoscope was inserted, and the tracheobronchial tree showed extensive bronchitis and mucous plugging. Trachea; right mainstem; and upper, middle, and lower lobe segments were visualized and appeared normal. Left mainstem also found to be free of any endoluminal gross foreign bodies.
31622 (Only diagnostic bronchoscopy was performed; therefore, code 31622 would be appropriate.)
Diagnostic bronchoscopy with endoscopic BAL
31624 (Bronchoscopic bronchoalveolar lavage was performed, code 31624.)
Upon introduction of the bronchoscope, a large amount of mucus was removed from the tracheal lumen. Findings were consistent with emphysema. As soon as the large amount of mucus was suctioned, a large endobronchial lesion was visualized. Numerous bronchoalveolar lavage specimens were obtained for cytological purposes. Brushings were also obtained from these areas.
31624, 31623-51 (Bronchoscopy was performed with bronchoalveolar lavage (31624) as well as brushings (31623-51).) WRONG
The bronchoscope was passed in the tracheobronchial tree. Right upper lobe, middle lobe, and lower lobe were all patent. Bronchoscope was taken through the right upper lobe, and biopsies were obtained of the density in the right upper lobe.
31625 (Bronchoscopic biopsies were obtained; therefore, 31625 would be appropriate.) WRONG
The bronchoscope was passed via the left nares without difficulty. The scope was passed into the tracheobronchial tree. Scope was then taken into the right lower lobe, and multiple tracheobronchial brushings and biopsies were obtained.
31625-RT, 31623-51-RT (Bronchoscopy was performed, where biopsies (31625-RT) and tracheobronchial brushings (31623-51-RT) were obtained.)
Bronchoscope was passed into the tracheobronchial tree. All lobes were patent. The scope was taken into the right upper lobe where two transbronchial biopsies were obtained of a density in the right upper lobe.
31628 (Bronchoscopy was performed with transbronchial biopsies, all in the same lobe; therefore, 31628 would be appropriate.)
Bronchoscope was passed into the transbronchial tree. The right upper, right middle, and right lower lobes were all patent with no endobronchial lesions seen. Bronchoscope was then taken in the left tracheobronchial tree. A total of four transbronchial biopsies were obtained from the left lower lobe.
31628 (Transbronchial biopsies are assigned codes based on each lobe; therefore, 31628 should be assigned for the left lower lobe only.) WRONG
Endoscopic transbronchial biopsies six times, RUL
31628 (Transbronchial biopsies were obtained endoscopically, all to the same lobe, that is, right upper lobe (RUL); therefore, code 31628 only would be appropriate, as these are coded by lobe.)
Scope was introduced through right nare and past into trachea, which appeared normal. There was a thick mucous plug in the right main stem of the tracheobronchial tree and the right lower lobe that was thinned with saline and aspirated and sent for culture and sensitivity.
31645 (Aspiration of the tracheobronchial tree was performed, which codes to 31645.)
Bronchoscope passed through right nare and advanced to the trachea and carina. Right main stem and lower, middle, and upper lobes appeared normal. Left main stem bronchus was almost completely occluded. Lavage with therapeutic aspiration was performed with the two large mucous plugs removed. Biopsy was obtained of the left main bronchus as well as two endobronchial biopsies were performed.
31645, 31625-51 (Bronchoscopic biopsy, 31625, was performed as well as aspiration of the tracheobronchial aspiration, code 31645. Codes should be listed in order of significance, listing 31645 first and then 31625 with modifier -51 for multiple procedures listed last.) WRONG
Diagnostic bronchoscopy performed with specimens taken from the mass identified. Pathology report was positive for malignancy. Procedure proceeded and lobectomy was performed.
32480, 31625-59 (Lobectomy was performed, which codes to 32480. Prior to the lobectomy, a bronchoscopy was performed with biopsy, code 31625. Modifier -59 would be appended to indicate that it was performed for a specific purpose and to determine the need for additional surgical intervention, which is allowed as per NCCI guidelines.) WRONG
A patient is brought from an MVA to the ER with multiple fractured ribs, labored breathing, and complaints of chest pain and palpitations. In the ER, the thoracic surgeon performs a tube thoracostomy with some relief of the patient's most severe symptoms.
32551 (When tube thoracostomy is performed, locate code 32551 in the Introduction/Removal of Procedures on Lungs/Pleura.)
Thoracentesis
32554 (Thoracentesis performed, not stated whether with guidance or indwelling, therefore, assumed without guidance or indwelling catheter, which codes to 32554.)
Thoracentesis. A Pharmaseal thoracentesis kit was used with aspirating catheter. Patient was prepped in the posterior position and catheter advanced into the intercostal space, two interspaces below the scapula. About 1 liter of cloudy amber fluid was removed.
32554 (When thoracentesis is performed without imaging, and no catheter is placed indwelling, code 32554 is assigned.)
Left side of the chest was probed, and area appropriate for thoracentesis was marked. Probe needle used to locate the effusion before inserting needle. Needle inserted and straw-colored fluid was withdrawn. At that point, patient complained of chest pain; therefore, the thoracentesis catheter was withdrawn and patient discharged to PACU.
32554-LT (CPT code 32554 was completed prior to the patient's chest pain.) WRONG
Thoracentesis. Right posterior chest was prepped, and Pharmaseal catheter was instilled into the right posterior clavicular line. About 1.2 liters of serosanguineous fluid was removed.
32554-RT (Thoracentesis was performed with no imaging, and no indwelling catheter was placed; therefore, 32554-RT is assigned.)
The right posterior chest was prepped with Betadine and Pharmaseal catheter instilled in the right posterior clavicular line. About 1.2 liters of serosanguineous fluid was removed without difficulty. Once thoracentesis was completed, the patient reported no shortness of breath.
32554-RT (Thoracentesis was performed, and catheter was not indicated as left in place or imaging performed; therefore, 32554-RT would be appropriate.)
Physician performed a subsequent thoracentesis of the pleural cavity for aspiration with needle fluoroscopic guidance.
32555 (When thoracentesis is performed with imaging guidance, code 32555 is assigned when no indwelling catheter is left in place.)
A thoracentesis kit including water seal was advanced into the intercostal space and half liter of cloudy fluid removed. Due to the recurring nature of this condition in this patient, it was decided to leave the catheter sutured into place. Patient will be monitored for additional aspiration as necessary.
32556 (Thoracentesis was performed, and catheter was left indwelling; therefore, 32556 would be assigned.)
An area in the right posterior chest was punctured using an 18-gauge needle, and an 8.5 French drainage catheter was inserted. Pus was withdrawn with approximately 100 cc of yellowish pus without odor. The catheter was secured and left in position.
32556-RT (Thoracentesis was performed with a catheter left indwelling, which codes to 32556-RT.)
A 60-year-old male with symptomatic bradycardia and syncope is taken to the operating suite where an insertion of a DDD pacemaker will be performed. A left subclavian venipuncture was carried out. A guide wire was passed through the needle, and the needle was withdrawn. A second subclavian venipuncture was performed, a second guide wire was passed, and the second needle was withdrawn. An oblique incision was made in the deltopectoral area incorporating the wire exit sites. A subcutaneous pocket was created with the cautery on the pectoralis fascia. An introducer dilator was passed over the first wire, and the wire and dilator were withdrawn. A ventricular lead was passed through the introducer, and the introducer was broken away in the routine fashion. A second introducer dilator was passed over the second guide wire, and the wire and dilator were withdrawn. An atrial lead was passed through the introducer, and the introducer was broken away in the routine fashion. Each of the leads were sutured down to the chest wall with two 2-0 silk sutures each, were connected to the generator, and were curled, and the generator was placed in the pocket.
33208 (Pacemaker was inserted with two leads; therefore, code 33208 would be assigned.)
Dual-chamber pacemaker placement with dual leads
33208 (Pacemaker with dual leads was inserted; therefore, 33208 would be assigned.)
A patient has a temporary pacemaker system placed due to significant trauma.
33210 (Only a temporary pacemaker was placed; therefore, code 33210 would be appropriate.)
Revision of pacemaker skin pocket
33222 (Revision of skin pocket is assigned 33222 only.)
Procedure Performed: Pacemaker replacement due to generator end of life. Incision made over prior incision, capsule opened, and pacemaker delivered out of pocket. Lead checked and found to be adequate. New pacemaker readied and old pacemaker disconnected and replaced with new SESR01 pulse generator, serial number YS1234.
33227 (Old pacemaker (pulse generator) removed and replaced, and assigned 33227 as single lead only.)
Incision made over the previous pacemaker scar and pulse generator extruded and leads disconnected. Atrial lead is number 6586, serial number 9937589, and ventricular lead is number 6878, serial number 97759587. The new pacemaker is model 3535, serial number 3938465. The leads were reconnected and the pocket irrigated, and all was inserted back into the pocket and the pocket closed.
33228 (Pacemaker pulse generator was inserted; however, leads were left intact. Therefore, code 33228 would be appropriate.)
Removal of old pacemaker pulse generator, insertion of new pacemaker pulse generator for a two-lead system
33228 (Pacemaker pulse generator was inserted; however, leads were left intact. Therefore, code 33228 would be appropriate.)
End of life pacemaker replacement. Small incision was made over the previous scar, and the old pulse generator was extruded and the leads were disimplanted. Leads were tested and found to be in satisfactory condition. The new pulse generator was implanted into the existing pocket, and the atrial and ventricular leads were reimplanted and hooked to the new pulse generator. The pocket was closed.
33228 (Pulse generator for pacemaker only was inserted; therefore, 33228 would be assigned. The dual leads were not replaced.)
Patient presents for replacement of pulse generator, which has reached end of life. Pacemaker pocket is incised and the pulse generator and leads are removed from the pocket. The battery is replaced and the two leads tested, reinserted, and reconnected.
33228 (Pulse generator only replaced for a dual-lead pacemaker; therefore, 33228 would be appropriate.)
Patient has a dual-chamber pacemaker. The leads in this system were recalled. The leads were extracted via transvenous technique, the generator was left in place, and new leads were inserted via transvenous technique.
33235, 33217-51 (In this instance, only the dual leads are being replaced and then reconnected to the existing pacemaker. Therefore, code 33235 is assigned as well as 33217-51, one for the removal of the old leads and one for the insertion of the new leads.)
Procedure: Dual-chamber permanent defibrillator implantation. Indications: A 67-year-old who has significant underlying ischemic cardiomyopathy with EF of 25%, prior infarcts. Description of procedure: A 5 cm incision was made at the left deltopectoral groove. With blunt dissection and cautery, this was carried down through the prepectoralis fascia. The cephalic vein was identified and ligated distally. Through the venotomy, a subclavian venogram was performed to provide a roadmap. The atrial and ventricular leads were then advanced into the vessel to the level of the right atrium under fluoroscopic guidance. The ventricular lead was maneuvered to the right ventricular outflow tract and then through the RV apex where it was actively fixed. Good sensing and pacing thresholds were demonstrated. The lead was anchored to the prepectoralis fascia with interrupted 2-0 Tycron sutures. A 10-volt pacing did not result in diaphragmatic capture. The atrial lead was maneuvered to the anterolateral right atrial wall where it was actively fixed. Good sensing and pacing thresholds were demonstrated. A subcutaneous pocket was created with good hemostasis achieved. The generator was connected to the lead and then placed in the pocket with no tension on the lead.
33249 (Insertion of permanent defibrillator with single or dual leads is assigned 33249.)
A 62-year-old female with three-vessel disease and supraventricular tachycardia, which has been refractory to other management. She previously had pacemaker placement and stenting of the coronary artery stenosis, which has failed to solve the problem. She will undergo CABG with autologous saphenous vein and a modified maze procedure to treat the tachycardia. A median sternotomy incision is made, and cardiopulmonary bypass is initiated. The endoscope is used to harvest an adequate length of saphenous vein from her left leg. This is uneventful and bleeding is easily controlled. The vein graft is prepared and cut to the appropriate lengths for anastomosis. Three bypasses are performed, one to the LAD, one to the circumflex, and another distally on the circumflex. A modified maze procedure was then performed and the patient was weaned from bypass. Once the heart was again beating on its own, an attempt was made to induce an arrhythmia, but this could not be done. At this point, the sternum was closed with wires and the skin reapproximated with staples.
33254, 33512-51 (A modified maze procedure was performed during the session (code 33254), as well as a coronary artery bypass graft, three venous grafts (33512-51).) WRONG
Patient with history of mitral stenosis is now symptomatic, requiring mitral valve replacement. Physician performs mitral valve replacement necessitating cardiac bypass.
33430 (Mitral valve replacement was performed with cardiac bypass, which codes to 33430.)
Thromboendarterectomy, subclavian thoracic incision
35301 (When thromboendarterectomy is performed through a subclavian incision, assign code 35301.) WRONG
The patient is a 69-year-old white male who underwent carotid endarterectomy for symptomatic left carotid stenosis a year ago. A carotid CT angiogram showed a recurrent 90% left internal carotid artery stenosis extending into the common carotid artery. He is taken to the operating room to redo left carotid endarterectomy. The left neck was prepped and the previous incision was carefully reopened. Using sharp dissection, the common carotid artery and its branches were dissected free. The patient was systematically heparinized, and after a few minutes, clamps applied to the common carotid artery and its branches. A longitudinal arteriotomy was carried out with findings of extensive layering of intimal hyperplasia with no evidence of recurrent atherosclerosis. A silastic balloon-tip shunt was inserted first proximally and then distally, with restoration of flow. Plaque blocking the vessel and vessel lining were separated from the artery and removed, following which a patch graft was applied and sutured to the vessel.
35301, 35390 (Excision of plaque was performed; therefore, the thromboendarterectomy would be assigned code 35301. Per CPT guidelines, when the procedure is a "reoperation" and is performed more than one month after the original surgery, code 35390 should also be assigned in addition to the thromboendarterectomy.)
Venipuncture, age 7
36415 (When venipuncture is performed for a patient aged 7, code 36415 is assigned.)
Patient was admitted for observation, was transfused two units of packed red blood cells, hemoglobin was 13, and was clinically feeling better and discharged.
36430 (Only one transfusion code is assigned, 36430, found in Arteries/Veins, Venous Procedures. The number of units of blood product is assigned HCPCS "P" codes, which would be assigned by the facility that provides the units of blood.)
Crohn's disease in a 47-year-old male requiring central venous access for hyperalimentation. Left side of chest was prepped and draped and subclavian vein was percutaneously entered, and guide wire was advanced into the superior vena cava. Double-lumen central venous catheter was placed. Catheter was sutured to skin using 2-0 silk sutures.
36556 (Central venous catheter was placed, however, nontunneled with no port/pump; therefore, 36556 would be appropriate.)
The placement of an infuse-a-port on the right anterior chest wall. A 51-year-old patient with history of colon cancer with poor peripheral access presents for placement of an infuse-a-port. Using Seldinger technique, a guide wire was placed into the right internal jugular vein to the superior vena cava. Pocket was then made in the right anterior chest wall. The guide wire and dilator were removed and the catheter itself threaded into the superior vena cava. The tunneling device was used and the catheter tunneled into the anterior chest wall, hooked to the infuse-a-port, and the port placed into the pocket.
36561 (A central venous catheter was placed, which involved tunneling and the placement of a port. Therefore, code 36561 is assigned.)
Insertion of tunneled central venous catheter, subclavian vein, with subcutaneous port, age 61
36561 (Central venous catheter was inserted with a port for a patient aged 61; therefore, code 36561 would be appropriate.)
A 65-year-old patient undergoing chemotherapy with poor peripheral IV access presents for insertion of port. Guide wire placed into the right internal jugular vein to the superior vena cava. Pocket was made and catheter was threaded into the superior vena cava. Tunnel device was utilized to tunnel the catheter, hooked to the port, and pocket closed.
36561 (Central venous catheter was placed, utilizing tunneling device and port; therefore, code 36561 would be appropriate.)
The patient is a 77-year-old gentleman with metastatic colon cancer recently operated on for a brain metastasis, now for placement of an infuse-a-port for continued chemotherapy. The left subclavian vein was located with a needle and a guide wire placed. This was confirmed to be in the proper position fluoroscopically. A transverse incision was made just inferior to this and a subcutaneous pocket created just inferior to this. After tunneling, the introducer was placed over the guide wire and the port line was placed with the introducer and the introducer was peeled away. The tip was placed in the appropriate position under fluoroscopic guidance and the catheter trimmed to the appropriate length and secured to the power port device. The locking mechanism was fully engaged. The port was placed in the subcutaneous pocket and everything sat very nicely fluoroscopically.
36561 (Central venous tunneled catheter was inserted with a port for a patient aged 77; therefore, code 36561 would be appropriate.)
A 60-year-old patient was admitted for the removal of an old port-a-cath. The capsule was opened, and the port was delivered out of the chest. Sutures were cut, and the tunnel that housed the catheter was closed. Access was via the left internal jugular vein and into the right atrium. Pocket was developed and catheter tunneled from that site to the exit site of the previously placed guide wire. Catheter inserted into the sheath and placed at the right atrial superior vena cava junction. Port was also placed.
36561, 36590-59 (Old catheter was removed from one site and assigned 36590-59 to indicate distinct, separate from newly placed catheter. New catheter was tunneled; therefore, code 36561, central venous catheter with port, is assigned.) WRONG
Removal of tunneled central venous catheter
36589 (When a tunneled central venous catheter is removed, code 36589 is appropriate.)
An area of the infuse-a-port was prepped and incision made over the port. Capsule opened and port delivered out of the chest. Suture was cut, and tunnel was closed.
36590 (Removal of tunneled central venous catheter is assigned 36590.)
Balloon angioplasty, percutaneous, iliac vessel
37220 (When angioplasty is performed of the iliac vessel percutaneously, code 37220 is assigned.)
Peroneal artery revascularization with stent and atherectomy, open
37231 (Revascularization of the peroneal artery was performed, which includes stent and atherectomy. Open revascularization is assigned 37231.)
Patient scheduled for a temporal artery biopsy to rule out temporal arteritis. A Doppler probe was used to isolate the temporal artery, and using a marking pen, the path of the artery was drawn. Lidocaine 1% was used to infiltrate the skin, and using a 15 blade scalpel, the skin was opened in the preauricular area and dissected down to the subcutaneous tissue where the temporal artery was identified in its bed. It was a medium-sized artery, and it was dissected out for a length of approximately 4 cm with some branches. The ends were ligated with 4-0 Vicryl, and the artery was removed from its bed and sent to pathology as specimen.
37609 (Code 37609 is assigned when ligation or biopsy is performed of the temporal artery.)
Left axilla prepped and incision was made. Axillary contents and several enlarged lymph nodes were removed for pathology.
38500 (When lymph nodes are biopsied/excised, code 38500 should be assigned unless specified as deep.) WRONG
What code would you report for a cervical approach of a mediastinotomy with exploration, drainage, removal of foreign body, or biopsy?
39000 (Code would be located in the Mediastinum, Incision section. Code 39000 would be assigned when exploration, drainage, removal of foreign body, or biopsy are performed.)
When multiple polypectomies by snare are performed at two different sites during the course of a colonoscopy, what code(s) should be reported?
45385 only (Per CPT, code 45385 indicates polyp(s) in the description; therefore, 45385 should only be assigned one unit of service.)
When colonoscopy with biopsy (CPT code 45380) is performed as well as colonoscopy with polypectomy removed by snare to a different site/polyp (CPT code 45385) during the same surgical session at another site, what code(s) are reported?
45385, 45380-59 (Both codes are reported. A modifier -59 is appended to the subsequent procedure 45380 to indicate the biopsy was taken from a location other than the site of the polypectomy.)
When snare polypectomy is performed on one polyp during the course of a colonoscopy as well as polypectomy by hot biopsy forceps to another polyp during the same session, what service(s) are reportable?
45385, 45384-59 (Both codes 45385 for the snare and 45384 for the hot biopsy forceps should be assigned as these are two distinct methods to two distinct sites. Modifier -59 should be appended to the subsequent procedure, 45384, to indicate same approach, same surgical session.)
What modifier should you report when the same physician provided a re-reduction of a fracture?
58 (Modifier -58 would indicate staged or related procedure. It cannot be assumed that the first procedure was performed in the OR, and therefore, return to OR modifier would not be appropriate.) WRONG
Medial right elbow approached through a posteromedial incision. Ulnar nerve was identified, freed, and dissected. Next a palmar incision was made in line with the 4th ray, the palmar aponeurosis was divided. The carpal ligament was divided well into the distal forearm to ensure complete incision of the transverse carpal tunnel. External neurolysis was performed.
64721-RT (Open carpal tunnel repair/neuroplasty was performed; therefore, 64721-RT would be appropriate.)
What should be reported for a complex extracapsular cataract extraction with intraocular lens implantation?
66982 (For the complex cataract extraction, code 66982 should be assigned. Code 66984 is for a "routine" cataract extraction. These codes are reversed in the CPT book in regards to the higher code typically is of greater significance. You may wish to mark your CPT book accordingly.)
When impacted cerumen is removed by irrigation only, what code(s) would be appropriate?
69209 (Impacted cerumen with the use of irrigation only is assigned 69209. Code 69210 would be assigned for the removal of impacted cerumen when removed by surgical instrumentation.)
When bilateral tympanostomies requiring general anesthesia are performed during the same surgical session, what code(s) are reported?
69436-50 (Bilateral procedures are typically listed once with the modifier -50. Per CPT guidelines, the code should not be assigned twice with the RT/LT modifiers when one code with an appropriate modifier would appropriately describe the service.)
When the patient has completed two treatments of radiation treatment management, what code(s) should be assigned?
77431 (Code 77431 should be assigned which includes one to two treatments.)
Hemoglobin
85018 (Hemoglobin is assigned 85018 from the Hematology section of Pathology.)
When assigning the surgical pathology code 88305 and a total of five specimens are sent to pathology in the cassette, how would these be coded?
88305 only (When multiple specimens are not individually identified and are sent in one container, they are coded as one unit; therefore, 88305 would be appropriate.)
When performing the interpretation only for an electrocardiogram, what code(s) should be assigned?
93010 (The specific code for EKG interpretation and report only is 93010.)
When hydration is performed for a total of 4 hours, what code(s) should be assigned?
96360, 96361 x 3 (Hydration for 4 hours would be assigned 96360 for the first hour and 96361 x 3 for the 3 additional hours.)
Patient presents with nausea, vomiting, and was determined to be suffering from dehydration. IV Normal Saline was administered from 9:00 AM to 9:45 AM for dehydration. Phenergan was administered IVP at 11:25 AM, following another IVP of Phenergan at 12:15 PM. Patient's symptoms appeared improved and the patient was released. What services would be appropriate to code/bill?
96360, 96375, 96376 (Codes 96360 should be assigned for the infusion of normal saline. Since this service was performed first, and appeared to be the main treatment for the patient's condition, then, in physician coding, it would be assigned first, followed by the IVP of Phenergan with 96375 (as only one initial code may be utilized per encounter) and 96376 for the subsequent IVP of the same substance.)
When an intravenous infusion of medication is documented from 8:00 AM to 12:15 PM, what code(s) should be assigned?
96365, 96366 x 3 units (Infusion for 4 hours 15 minutes would be assigned 96365 for the initial hour and 96366 x 3 for the 3 additional hours. The remaining 15 minutes is not assigned additional hours as greater than 30 minutes is required for an additional unit of service.)
When an intravenous medication infusion is performed for 1 hour as well as an intravenous injection (IVP) during the same encounter, how are these services reported?
96365, 96375 (Both codes are assigned. Based on the coding guidelines contained in CPT, the infusion code would be assigned first (96365), followed by a subsequent IVP code (96375). Only one "initial" code may be assigned per encounter per CPT.)
When non-excisional debridement is performed to a selected area of a wound that is less than 20 sq cm, what code(s) are assigned?
97597 (When selective debridement is performed without excision, code 97597 would be assigned.)
When wound debridement is performed by curette to fibrin and slough, what code series would be utilized?
97597-97602 (Codes from the Medicine Section, Active Wound Care Management would be assigned. The surgery debridement codes are for surgical excision with surgical instrumentation only and therefore not appropriate in this instance.)
When nonexcisional debridement is performed to an entire wound area, what code(s) are assigned?
97602 (When non-selective debridement is performed without excision, code 97602 would be assigned.)
Patient presents to clinic, status postarthroscopy of left knee 7 days ago for follow-up. Problem-focused history and exam and straightforward MDM were performed. What code(s)/modifier(s) would be appropriate for this encounter?
99024 (All surgical procedures include a global period that covers the normal, uncomplicated postoperative care; therefore, CPT code 99024, postoperative visit would be assigned for which there is no value/charge.)
Patient arrives to have long arm cast removed following a fracture repair done approximately 6 weeks previously by the same surgeon.
99024 (Service included in postoperative global service; therefore, no charge is appropriate. However, code 99024 (postoperative office visit) would be assigned to designate a visit occurred.)
Patient presents with gastroenteritis due to Salmonella infection.
A02.0 (Specific code for gastroenteritis due to Salmonella)
Replacement batteries (except J cell) for medically necessary alkaline blood glucose machine owned by patient
A4233 (A4233 only code for alkaline batteries (except J cell) for blood glucose monitor)
Central nervous system syphilis
A52.3 (Syphilis is affecting the central nervous system; therefore, "syphilis" alone would not be appropriate, only nervous system syphilis.)
Poliomyelitis
A80.9 (Since no additional documentation is provided, assign poliomyelitis unspecified only.)
Radiopharmaceutical diagnostic imaging agent, sestamibi, TC99M
A9500 (Radiopharmaceutical is stated as "sestamibi"; therefore, A9500 only.)
When a diagnostic colonoscopy and colonoscopy with biopsy are performed during the same surgical session, what code(s) are reported?
Colonoscopy with biopsy only (According to CPT/NCCI guidelines, only the definitive procedure is reportable. Therefore, report only the colonoscopy with biopsy.)
When bilateral procedures are performed during the same surgical session, how should those services be reported?
One line with modifier -50 appended (Bilateral procedures for purposes of the CPC exam should be assigned on one line with the modifier -50.)
Patient presents for nausea and vomiting as a result of ingestion of gasoline.
R11.2, T52.0X1A (Code nausea/vomiting combination code. As the intent of the poisoning is unknown or unspecified, ICD-10 guidelines instruct coding intent as an accidental intent.) WRONG
Pelvic mass, rule out cervical cancer
R19.00 (Rule out should not be coded per ICD10 guidelines, only the pelvic mass, found under Mass, abdominal/pelvic which codes to R19.00.)
Cervical or vaginal cancer screening including pelvic/breast exam
G0101 (G0101 is used for Medicare pelvic and breast screening.)
A 70-year-old Medicare patient presents with no risk factors for screening colonoscopy. The colonoscopy was completed to the cecum, with no abnormalities noted.
G0121 (Medicare assigns HCPCS code for screening colonoscopy without risk as G0121.
Congenital hereditary muscular dystrophy
G71.0 (Coded as "congenital." Hereditary included in muscular dystrophy diagnosis.)
Breaching assignment agreements resulting in the beneficiary being balance billed is an example of what?
Abuse (Breaching assignment agreements and balance billing the patient is an example of abuse.) WRONG
These digestive organs contribute to digestion, however, are not part of the alimentary canal as no food travels through them.
Accessory organs
When chronic and acute conditions are coded, which is coded first?
Acute condition (ICD10 guidelines indicate that "acute" conditions are assumed to be the primary reason for the encounter, and, therefore, should be assigned as primary.)
Medicare patient requests EKG/blood work for which there is no documentation to support medical necessity. What modifier should be appended to these services?
GA (Append modifier -GA after securing an ABN as the services most probably will not be paid by Medicare.)
Upper lip lesion about 1 x 2 cm was excised. The deep subcutaneous layer was closed, followed by sutures to close the skin. Pathology report indicated the lesion was benign. CPT code 11442 was coded/billed. Was this coded appropriately, and, if not, what should have been assigned?
Addition of closure code 12051 (Code 11442 for the excision of the lesion is appropriate. In addition, since the closure was "more than a simple closure," CPT guidelines indicate that the intermediate closure may also be assigned. An intermediate closure indicates a "layered" closure was performed including the deep subcutaneous.)
When administering an immunization, what service(s) should be captured?
Administration of Immunization and Immunization materials (Both the administration and the immunization/vaccine codes would be assigned. Modifier -51 is not appropriate in this circumstance.)
When Medicare services being provided are believed to not be covered under the Medicare program, what form should be secured and signed by the patient prior to services rendered?
Advance Beneficiary Notice (ABN) (An ABN should be obtained when Medicare services are being rendered that are believed will not be covered by the Medicare program. While the Advance Beneficiary Notice (ABN) is a waiver form, it is more specific than a generic waiver form. Patient releases are typically signed to release records while an assignment of benefits assigns monies due on claims to the provider. Therefore, the most correct answer would be "Advance Beneficiary Notice (ABN).")
Which of the following refers to the front of the body?
Anterior
Which of the following scenarios constitutes a violation of Medicare's incident-to-billing provisions?
An established patient with a new complaint presents to the physician's office. The patient is seen by the nurse practitioner. (In order to bill services, incident to any new problem must first be evaluated by a physician. In addition, if the service is to be billed under the physician's name, the physician must participate and perform any portion of the service.) WRONG
If a coder or biller finds that the documentation in a patient's chart does not support billing for a particular service, they should take which of the following step(s)?
Ask the physician to clarify and/or provide more information. (The coder or biller should either query the physician or request clarification and/or additional information. It would not be appropriate to complete the claim with fraudulent information or utilizing documentation other than for the current visit.)
Per CPT guidelines, would it be appropriate to code a procedure or service on the same date of service as an E/M service that is significantly separately identifiable. If so, what modifier should be appended?
Append modifier -25. (Modifier -25 would be appropriate when a "significantly, separately identifiable" E/M is performed in conjunction with a procedure.)
When the descriptor of a CPT code cannot be totally met during the surgical procedure and is reduced by a part not being completed, how is the service coded?
Append modifier -52 (Modifier -52 should be appended if the CPT descriptor is not met. Modifiers -73/74 are for outpatient facility only and should not be utilized for the physician.)
When the physician makes the medical decision to discontinue a procedure in the hospital operating room due to a decline of the patient's medical condition, how should the service be coded?
Append modifier -53. (Modifier -53 is appended when a procedure is discontinued due to the patient's condition. Modifiers -73/74 are for outpatient facility and ASC only.)
A 47-year-old patient with commercial insurance is seen in consultation the morning the MD performs an abdominal hysterectomy. The consultation was coded but denied as "included in global service." What corrections, if any, should be made to the consultation code?
Append modifier -57 to consultation code. (If allowed by the specific carrier, modifier -57, decision for surgery should be appended to the consultation for this major procedure.)
What is the OIG Work Plan?
Areas of concern to be investigated during the calendar year by the OIG (The OIG Work Plan includes areas that the OIG have identified as areas of concerns that will be investigated during the current calendar year. While it is the investigation plan for the year, it is more specifically issues identified as areas of concern that will be investigated during the calendar year. Remember, for purposes of the CPC exam, always select the most correct answer.) WRONG
Viral illness, known strep carrier
B34.9, Z22.338 (One would need to code both reason for visit, viral illness, and the known strep carrier as it contributes to the complexity of treating the presenting condition.)
What are the two most common types of skin cancer?
Basal cell and squamous cell carcinoma
A provider submits the following E/M services to the third-party carrier: Level 1 99211 10%, Level 9 99212 20%, Level 3 99213 40%, Level 4 99214 20%, Level 5 99215 10%. What is the common terminology when the carrier reviews levels of service to determine the appropriateness of the distribution levels?
Bell curve (The bell curve refers to the distribution of E/M codes for a given provider.) WRONG
Which of the following blood types is considered the universal donor?
Blood Type O
Which designates the first vertebrae of the neck?
C1 (The vertebrae of the back are referred to as "Cervical" (C), "Lumbar" (L), and "Thoracic" (T) and then referred to by numbers. In this case, the first vertebrae of the neck would be C for cervical and 1, or C1.)
Ca rectosigmoid junction and prostate
C19, C61 (Both coded as primary sites as they are not stated as metastasized.)
Breast ca, left, history of colon ca
C50.912, Z85.038 (Neoplasm, breast, primary, colon ca coded as Z code for "history of")
Breast cancer
C50.919 (Assume site is primary when not stated otherwise per ICD10 guidelines.)
Metastatic carcinoma of brain
C79.31, C80.1 (Primary diagnosis is coded as secondary brain. Since no primary site is listed, assign C80.1, unspecified site.) WRONG
Lymphoid leukemia
C91.90 (Leukemia is coded to "lymphoid" category.)
Acute myeloid leukemia
C92.90 (Leukemia is coded to "myeloid" category.) WRONG
Which of the following coding practices is NOT considered an example of unbundling?
Coding a service that is not considered to be reasonable and necessary (While coding for a service not considered medically necessary is inappropriate, it is not considered unbundling. Note the question asks which of the following is NOT unbundling. The remaining selections are all examples of unbundling and therefore, would not be appropriate in this scenario.)
When the term "malignant" is noted as it refers to a lesion, it would be considered what type of lesion?
Cancerous
A fracture of the distal end of the radius at the epiphysis is called a
Colles' fracture.
A complete abdominal ultrasound is ordered, and all structures are identified, the appendix is documented as "surgically absent." What service(s) should be assigned?
Complete abdominal ultrasound (Documentation reflects all structures were either identified or documented as surgically absent; therefore, it would be appropriate to assign the complete abdominal ultrasound code in this circumstance.)
Commonly referred to as "pink eye," this highly contagious disease is bacterial in nature.
Conjunctivitis
A new physician has joined the practice, and an application for a Medicare provider number has been submitted to Medicare for this provider. In the interim, how should the Medicare billing be handled for this new provider?
Hold charges until a Medicare provider number has been assigned. (A new physician may not bill Medicare for services until such time as a Medicare provider number has been assigned specific to that physician. According to Medicare guidelines, it would not be appropriate to bill services for a provider who has not been assigned a Medicare provider number under a different provider or the practice's group provider name. Based on CMS/Medicare guidelines, the practice may also not bill the patient for the services.) WRONG
PA and lateral chest x-ray performed for complaint of weight loss. Findings: normal heart size and pulmonary vascularity, minute amount of pleural fluid bilaterally. Remainder of exam unremarkable.
R63.4 ("Minute" findings are not assigned codes as not considered significant for encounter. Therefore, only code would be sign/symptom of weight loss.) WRONG
Delivery of heavy duty transfer bench, for tub or toilet transfer to the patient's home
E0248 (Specified as "heavy duty." Code E0248 is only heavy duty designated code.)
Delivery of over door cervical traction equipment to patient's home
E0860 (E0860 is only code designated as "over door.")
IDDM
E11.9, Z79.4 (Insulin-dependent diabetes mellitus is coded as diabetes, mellitus, Type II or unspecified is used when the type is not specified. An additional code should be assigned from category Z79.4 to identify the long-term (current) use of insulin.) WRONG
An otorhinolaryngologist is commonly referred to as what kind of specialist?
ENT Specialist
In addition to maintaining medical record documents for the facility/practice, what additional responsibility does medical records staff in the physician practice typically perform?
Release of records (Medical records staff typically maintains the records for the practice as well as release of records. They are typically not involved in non-records services such as payroll or billing for services.)
In the procedure known as a "lithotripsy" what technique is being performed to the calculi or kidney stones?
Crushing
Intraoral x-rays, complete
D0210 (D0210 is for regular intraoral x-rays. Other codes are for special views.)
Severe dysplasia, cervix
D06.9 (Coded as in situ ca per ICD10 coding guidelines.)
Bronchial adenoma
D38.1 (Adenoma is listed in the alphabetic index and then bronchial, which points to D38.1. The tabular confirms code as a neoplasm of uncertain behavior of the trachea, bronchus, and lung.)
Greenstick fracture of the left radial shaft after falling into an empty bathtub 30 minutes ago
S52.312A, W18.2XXA (Two codes must be assigned: one for the fracture and one for the external cause code. S52.312A is assigned to greenstick fracture of shaft of radius, left arm. Also, external cause code requires seventh digit; therefore, placeholders (x) must be placed in fifth and sixth positions.)
Which of the following is NOT part of a physician compliance plan?
Develop practice E/M guidelines (While it is recommended the practices develop guidelines for E/M services, it is not part of the requirements for a compliance program.)
Fracture left distal radius following fall from bus
S52.502A (Code needs to encompass "distal" (Lower end) radius as well as seventh digit for treatment period and anatomical location "left.")
Also known as Trisomy 21, this disorder results in mental retardation and physical abnormalities and is the single most common birth defect:
Down syndrome (Trisomy 21 is more commonly known as Down syndrome. It is caused by an extra copy of chromosome 21. Fragile X is the defect of the X chromosome. Cystic fibrosis is a genetic disease with the production of abnormal secretions, leading to mucus buildup that impairs lungs and other organs. Hemophilia is an inherited disorder in which the ability to clot blood is impaired.)
ER visit for left distal radial fracture, splint application only
E/M-25, 29125-LT (No fracture code would be assigned because no definitive treatment was provided. Assign E/M level with modifier -25 to indicate "significantly, separately deniable" E/M service was provided in addition to splint code 29125-LT.)
Fall from ladder, fracturing right fourth distal phalanx. Minimal fracture requiring no reduction, application of static finger splint only.
E/M-25, 29130-F8 (Fracture required no definitive treatment; therefore, fracture code not appropriate. Only assign splint code, application of finger splint, which codes to 29130 with modifier -F8 to indicate right fourth digit. E/M would also be appropriate to evaluate and determine what care would be appropriate.) WRONG
Folding walker, wheeled, adjustable
E0143 (E0143 is the only code for folding walker, adjustable; others listed are for heavy duty and/or rigid.)
Commode chair, mobile, with detachable arms
E0165 (E0165 only mobile commode chair with detachable arms)
When excision of two sentinel lymph nodes is performed, what services are coded?
Excision of lymph nodes (The axillary lymphadenectomy codes should only be utilized when the majority of the axillary nodes are removed. Since only two are removed, this would be coded with the excision of lymph node codes.)
The application of steri-strips should be assigned what category of codes?
Evaluation and Management (According to CPT, the application of steri-strips does not constitute repair/closure; therefore, only an E/M service would be allowed.)
Closed fracture, left distal radius and ulna
S52.502A, S52.602A (Codes for both closed radius and ulna fractures, left must be assigned; therefore, two codes are needed.)
Cast application, long leg, and repair of femur fracture
Fracture Care Code Only (Initial cast application is included in fracture care; therefore, only the fracture care would be assigned.)
The most common inherited cause of learning disability, which disorder is the result of one of the genes in the X chromosome being defective, making it susceptible to breakage?
Fragile X syndrome
Patient presents with severe depressive disorder, recurrent.
F33.2 (Coded as "severe" and "recurrent" depression)
Anxiety with depression
F41.8 (Combination code for both conditions may be assigned as stated as "with.")
Patient presents 18 weeks for follow-up on healing left distal radial fracture as a result of fall from tree.
S52.502D (Seventh character is assigned "D" as there is no active treatment. Subsequent seventh character "D" is to be used while the patient is in the healing/recovery phase.)
Presenting a claim on behalf of a person excluded from the Medicare program is an example of what?
Fraud (Presenting claims on the patient of a provider excluded from the Medicare program is considered fraud. Underbilling or overbilling would be billing fewer or more services, while abuse is usually submitting excessive services or medically unnecessary services.)
Laceration of the right middle finger without nail damage
S61.212A (Located under "laceration, finger")
Patient encounter due to finger laceration from broken glass
S61.219A, W25.XXXA (Code laceration, finger unspecified and external cause code for broken glass. External cause code will need three placeholders in order to assign seventh digit required of "A.")
Child presents with painful ear and diagnosis of possible otitis media.
H92.09 ("Possible" cannot be coded per coding guidelines, only otalgia which codes to H92.09.) WRONG
Myocardial infarction
I21.9 (It is not stated as STEMI or NSTEMI; therefore, one would assign myocardial infarction unspecified only.)
Patient presents with unstable angina related to her atherosclerotic heart disease
I25.110 (Atherosclerotic heart disease with unstable angina is assigned I25.110.)
Old, healed myocardial infaction
I25.2 (Utilize code for "old," not current MI.)
Cerebrovascular accident
I63.9 (Cerebrovascular accident is coded as current condition.)
Varicose veins causing inflammation and ulceration of right calf
I83.212 (Patient condition is described fully with code I83.212.)
Initial visit for a greenstick femur fracture, right
S72.8X1A (This is coded as "other" fracture of the right femur since "greenstick" is documented and is specific. Also it needs placeholder "X" for fifth digit and "A" for seventh digit per ICD10 guidelines.)
When excessive TSH is secreted, it may result in this disorder.
Hyperthyroidism
A hysterectomy is performed and an incidental appendectomy performed. What services should be reported?
Hysterectomy only (Incidental appendectomies are not reportable when performed through the same incision. However, if it is performed for a clinically indicated separate purpose, CPT codes are available for coding this service.)
Essential hypertension
I10 ("Essential" hypertension codes to the hypertension code.)
Uncontrolled hypertension
I10 (There is no specific ICD10 code for "uncontrolled"—it is included in the verbiage for hypertension I10.)
Malignant hypertension with CHF
I11.0 (Combination code utilized for HTN with CHF that must incorporate both conditions.) WRONG
Hypertensive heart disease
I11.9 (Combination code for both HTN and heart disease would be assigned. ICD10 guidelines indicate that two codes should not be assigned when one combination code is available.)
Hypertensive crisis
I16.9 (Code specifically for hypertensive crisis, I16.9.)
Chest pain appears to be worsening and is diagnosed as unstable angina.
I20.0 (This is diagnosed as unstable angina; therefore, only I20.0 would be assigned.)
An 85-year-old patient presents with leg pain. He was prescribed Keflex 500 mg bid for 10 days. However, it has been worse since yesterday and he is not ambulating well. He was given 75 mg IM of Kenalog (triamcinolone acetonite) for his pain and prescribed Dilaudid 2 mg every 20 hours for pain. Assign the appropriate HCPCS code for the medication administered.
J3301 X 8 units (J3301 represents 10 mg per unit of triamcinolone acetonite. Therefore, a total of eight units must be reported, J3301 x 8.)
Drug administered through metered-dose inhaler
J3535 (J3535 is only code for metered-dose inhaler.)
COPD with acute bronchitis
J44.0 (The ICD-10-CM alphabetic index directs the coder to J44.0.)
Prednisone, oral, 10 mg
J7510 X 2 units (Oral prednisone is assigned code J7510 for each 5 mg. Therefore, J7510 x 2 would be appropriate.)
Injection, cyclophosphamide, 40 mg
J9070 (Only code for cyclophosphamide is J9070.) WRONG
COPD with acute respiratory failure
J96.00, J44.9 (Acute coded first per ICD10 guidelines; therefore, acute respiratory failure assigned as primary, J96.00, and COPD as secondary, J44.9.)
Productivity for coding staff should be based on
Industry standards as well as the unique work for the practice. (Many factors should be taken into consideration when developing productivity standards for coding staff including standards from organizations such as AAPC, AHIMA, and MGMA as well as the specific work of the practice.) WRONG
Gastritis due to erythromycin
K29.70, T36.3X5A (Code gastritis as primary with adverse effect as secondary per ICD-10 coding guidelines. No external cause code is necessary for this scenario per ICD-10 guidelines, Chapter 19.)
Inguinal hernia
K40.90 (Coded as hernia without obstruction or gangrene. Coded as unspecified as nothing else documented.)
When repair of the deeper layer of the subcutaneous tissue is performed, what level of complexity of laceration repair should be assigned?
Intermediate (An intermediate repair is assigned when the repair extends into the deeper layer of the subcutaneous or further, and if it is not qualified for complex repair as indicated in CPT.)
What is one measure the practice can implement to minimize the possibility of the allegation of fraud and/or abuse?
Internal and/or external audits (Internal and external self-audits will assist the practice in minimizing the allegations of fraud and/or abuse. Not accepting Medicare assignment does not exclude the possibility of fraud/abuse allegations as even non-participating providers may commit fraud/abuse. Providers must submit claims on behalf of a Medicare recipient in order to obtain reimbursement for services; therefore, this would not decrease the possibility of fraud/abuse claims. The employment of an attorney also would not minimize allegations of fraud and/or abuse unless the attorney mandates or requires internal and external audits.)
Patient presents to physician's office with complaints of nausea, vomiting, and diarrhea. History of hypertension and diabetes still under treatment. Exam reveals no irregularities. Lab revealed elevated WBC, indicative of viral illness. Will treat patient for gastroenteritis, probably viral in nature.
K52.9, I10, E11.9 (Code gastroenteritis, however, cannot code "viral" as listed as "probably." Also code hypertension and diabetes as still being treated and managed.)
Patient presents to physician's office with complaints of nausea, vomiting, and diarrhea. History of hypertension and diabetes still under treatment. Exam reveals no irregularities. Lab revealed elevated WBC, indicative of viral illness. Will treat patient for gastroenteritis, probably viral in nature.
K52.9, I10, E11.9 (Code gastroenteritis, however, cannot code "viral" as listed as "probably." Also code hypertension and diabetes as still being treated and managed.) WRONG
Patient presents with concerns of rectal bleeding and diarrhea. Patient has a past history of colon cancer diagnosed 12 years ago, treated with surgery and has remained cancer free. Patient will undergo colonoscopy. Until that time, patient will refrain from anti-diarrhea medications and use Preparation H for what are believed to be hemorrhoids.
K62.5, R19.7, Z85.038 (Hemorrhoids cannot be coded as "believed to be." Code signs/symptoms for presenting problem: rectal bleeding and diarrhea. Also code history of colon cancer as increased complexity of medical decision making.)
Nontraumatic perforation of the bowel
K63.1 (It is specified as "nontraumatic"; therefore K63.1 would be correct.)
Acute cholecystitis with cholelithiasis
K80.00 (Cholecystitis is acute, combination code for "with cholelithiasis.")
Acute pancreatitis
K85.90 (No statement of alcoholism, idiopathic, chronic; therefore, assigned as acute pancreatitis only.)
Patient arrived in ER in full cardiac arrest. Drugs were administered as follows: Epinephrine 0.3 mg IVP at 10:00 AM. Atropine 0.01 mg at 10:15 AM without a response. He had no pulse; he was in asystole. Code was stopped at 10:20 AM. Assign HCPCS code(s) for the drugs administered.
J0171 x 3 units, J0461 (Two drugs were administered, namely J0171 (Atropine per 0.01 mg), therefore, J0171 x 3, and Epinephrine, J0461, one unit only.)
Acute streptococcal pharyngitis
J02.0 (Coded specific to streptococcal infection of throat)
Administration of penicillin G benzathine, 1.2 million units
J0561 X 12 units (Code J0561 is per 100,000 units; 1.2 million administered. Therefore, J0561 x 12 is appropriate.)
Penicillin G Benzathine, 1.2 million units
J0561 X 12 units (Code J0561 per 100,000 units, 1.2 million administered; therefore, J0561 x 12 is appropriate.)
Leucovorin calcium, 75 mg
J0640 X 2 units (Code is per 50 mg. Since 75 mg administered would assign J0640 x 2.)
Kefzol, 750 mg administered during office visit
J0690 X 2 units (Code J0690 is listed as 500 mg per unit; therefore, J0690 x 2 would be appropriate.)
Ciprofloxacin, 600 mg IV use
J0744 x 3 units (Code J0744 is per 200 mg; therefore, J0744 x 3 is appropriate.)
Patient presents at the primary care office with cough and fever that has been present for several days. Diagnosis of acute bronchitis was made.
J20.9 (Acute bronchitis was definitive diagnosis for encounter.)
Upper respiratory infection with acute bronchitis
J20.9, J06.9 (Acute coded first per ICD10 guidelines.)
Lorazepam, 2 mg
J2060 (HCPCS code J0260 refers to the injection of up to and including 2 mg of Lorazepam. Therefore, J0260 is appropriate in this instance without the need for additional units of service.)
Patient arrives at physiatrist's office to pick up his removable heel orthotic pad for a heel spur previously diagnosed.
L3485 (L3485 describes a removable heel orthotic specifically prescribed for a heel spur.)
Prosthetic partial foot with molded socket, ankle height
L5010 (L5010 only code for partial foot with molded socket)
Painful scarring of right hand due to old third-degree burns
L90.5, T23.301S (Code for current condition first, painful scarring, followed by code for third-degree burns, sequela as original condition resolved.)
A provider has set a standing office policy that states EKGs should be ordered and performed on all patients over the age of 35 regardless of their medical condition or complaint. What would be the common denial for this scenario?
Lack of medical necessity (Medical necessity must be met for all services performed. Standing orders will often result in denials for services that are not considered medically necessary.)
The function of which organ is to absorb water, produce certain vitamins, and form and expel feces?
Large intestine (The large intestine absorbs water, produces certain vitamins, and forms and expels feces, while the stomach digests food and the small intestine is responsible for absorbing nutrients and minerals from food.)
A myringoplasty would be the repair of what anatomical part?
Middle ear
Patient presents with right wrist pain from a fall from stairs. X-ray suggests a spiral radial fracture possible. Images will be sent to orthopedics for confirmation later.
M25.531, W10.9XXA (Cannot code "possible" or "suggest"; therefore, right wrist pain and external cause code only for scenario. Seventh digit for treatment period is NOT required for "pain" diagnosis.)
Chronic low back pain
M54.5, G89.29 (As reason for pain is not known, low back pain would be assigned. Chronic pain is assigned when there is no definitive diagnosis.) WRONG
Low back pain from lifting heavy objects
M54.5, X50.0XXA (Back pain needs to specify "low." Additional X code for strenuous activity, X50.0 requires seventh digit; therefore, addition of two "X" placeholders for fifth and sixth digits is necessary.)
X-ray, right hand, three views. Chief complaint: right hand pain. R/O fracture. No fracture, misalignment, or foreign body was evident.
M79.641 (No definitive diagnosis; therefore, sign/symptom of right hand pain only assigned.)
The name of the administrative contractor for each Medicare region is
MAC or Medicare administrative contractor. (The Medicare administrative contractor or MAC refers to the regional contractor for Medicare.)
The most common cause of vision loss in the United States, this progressive eye disease usually affects older people due to the retina not receiving adequate blood supply.
Macular degeneration
When multiple surgical procedures are performed during the same surgical session, what determines the appropriate order for reporting those services?
Most significant procedure is listed first. (The most significant procedure should be listed first, followed by the next most significant procedure.)
This system supports and shapes the body, is responsible for movement, protects internal organs, and is responsible for forming some blood cells and storing minerals.
Musculoskeletal system
During the physician's absence in the office, a patient is seen by the nurse, vital signs are taken, a urinalysis is performed, and the nurse calls in a prescription for medication for a UTI under the physician's name who is usually in the office. What services, if any, are appropriate for this encounter?
No service may be coded/billed. (As no licensed provider has supervised or performed the service, it would not be appropriate to bill for any service in this instance.) WRONG
Provider documents the diagnosis as both chronic kidney disease stage 4 and end-stage renal disease.
N18.6 (If both a stage of CKD and ESRD are documented, assign code N18.6 only.)
Ureter calculus
N20.1 (Code to calculus of ureter)
Hematuria as a result of UTI
N39.0 (Hematuria was directly linked as caused by the UTI; therefore, sign/symptoms would not need to be coded. Only assign code for UTI, N39.0.) WRONG
Patient with urinary incontinence presents for diagnostic testing. Cystometrogram and uroflowmetry performed and findings of urinary stress incontinence were confirmed.
N39.3 (Encounter for testing indicates diagnosis of urinary stress incontinence.)
Benign hypertrophy of prostate
N40.0 (Not coded as congenital, no additional symptoms such as lower urinary symptoms)
Breast mass, suspect breast carcinoma
N63.0 ("Suspect" cannot be coded per ICD10 guidelines; therefore, only mass, breast would be assigned code.)
Patient presents for excisional biopsy of breast mass. Incision is made around the lesion and removed in toto. Lesion presentation was 2 cm in diameter and sent to surgical pathology for evaluation.
N63.0 (Code as breast mass only; it was not diagnosed as neoplasm at the time of encounter.)
Lab interpretation billing is performed by the provider. What documentation, in addition to the interpretation, is necessary to properly bill this service?
NPI number and order (The ordering provider's NPI number and a written or documented order must be present as well. While a written report may be appropriate in some instances, coding/billing guidelines allow for documentation of the results in handwritten format on the lab record as long as it contains the minimum documentation requirements.) WRONG
A scope was introduced into the esophagus and advanced to the stomach and duodenum. Multiple erosions were biopsied through the scope. The remainder of the EGD was normal. With the patient repositioned in the left lateral position, a scope was introduced into the rectum and advanced through the colon to the rectum. With the exception of hemorrhoids, the scope was normal. The practice coded 43235 and 45378 for these services. Are the codes submitted correct, and, if not, what correction needs to be made?
No, code 43235 should be corrected to 43239 as biopsies were performed. (The code assigned for the EGD is incorrect as biopsies were performed. CPT code 43235 should be rebilled as 43239.)
Provider submits an average of 100 claims for E/M services per day. All E/M services performed in conjunction with a procedure are appended with modifier -25. Would this practice be appropriate?
No, not all procedures should have E/M services coded/billed. (Modifier -25 should only be appended to the E/M service when a "significantly, separately identifiable procedure" is performed in addition to the procedure.) WRONG
Multiple simple laceration repairs are performed on the right arm and leg. What modifier(s), if any, would be appropriate? None -59 -51 -51-RT
None (When multiple lacerations are repaired that are of the same complexity and anatomical grouping, they should be grouped together and summed together.) WRONG
Carpal tunnel surgery is performed on 01/01/XX. The patient returns 5 days following surgery for follow-up as instructed. The service is coded/billed as 99213. What was the reason the insurance company denied this service?
Normal postoperative care is included in bundled surgical package. (The normal uncomplicated follow-up care for the surgery is included in the procedure; therefore, the office visit would be considered bundled.)
Patient presents with gestational hypertension.
O13.9 (Hypertension during pregnancy is assigned an "O" code.)
Postpartum hypertension
O13.9 (Hypertension not stated as preexisting; therefore, assign as OB only, stated as postpartum.) WRONG
Threatened abortion
O20.0 (Condition codes to abortion, threatened. Not coded as spontaneous abortion, attempted abortion, or hemorrhaging as documentation does not support.)
Patient presents to hospital for normal delivery of single live newborn.
O80, Z37.0 (ICD10 guidelines require two codes: one for normal delivery, code O80, and one for single liveborn (outcome of delivery), which codes to Z37.0.)
Maternal venereal disease, not delivered
O98.319 (Coded as unspecified trimester)
Patient reports to the office and demands a service be provided that the physician considered to be not medically necessary. As a participating provider, your office has given the patient a full explanation and requested the patient sign an Advance Beneficiary Notice; however, the patient has refused to sign. How should the physician handle this situation?
Obtain the signature of a witness on the ABN, render the service to the patient, and bill the service to Medicare with the appropriate modifier. (The ABN may be signed by obtaining the signature of a witness on the ABN and billing the service to Medicare. It would not be appropriate to refuse care or refer to another provider/physician. Rendering services would also not be appropriate, as without the ABN, the services would not be reimbursable.) WRONG
Which federal agency publishes the Annual Work Plan?
Office of the Inspector General (The Annual Work Plan is published by the Office of the Inspector General.)
Laceration, 2 cm, left eyebrow, extending into the dermis and subcutaneous tissue. Wound was closed with the placement of Steri-strips to the area. 12011 12013 12001 Office visit only
Office visit only (Per CPT, when repair/closure performed utilizing Steri-strips, does not qualify for repair/closure codes. Therefore, only an E/M office visit would be appropriate.)
Multiple surgical procedures were performed during the same surgical session for separate diagnosis through the same approach. Only the first service was reimbursed. What action/correction(s) should be made to the claim for appropriate reimbursement?
Only first service submitted appropriately. All subsequent services should have modifier -51 appended if appropriate. (Subsequent services performed during the same surgical session need the appropriate modifier(s) appended to be considered for payment. When services are performed utilizing the same approach, modifier 51 should be appended to all subsequent services when appropriate.)
When a procedure is started laparoscopically, however, it is necessary to complete the procedure open, what procedure(s) should be assigned?
Open only (CPT and NCCI guidelines indicate that only the definitive, restorative procedure is reportable. Therefore, in this instance, only the open procedure would be reportable.)
Patient is seen in observation for 2 days and the services are coded/billed as follows: 01/01/XX Code 99218, Place of Service Inpatient Hospital, 01/02/XX Code 99217, Place of Service Inpatient Hospital. What is incorrect in the coding for these services?
POS should be outpatient 22 for observation care. (The place of service for this claim should be reflected as 22 outpatient service rather than 21 inpatient as submitted.)
What is one of the main reasons that providers are investigated for fraud and abuse?
Patient complaints (Patient complaints are one of the main reasons providers are investigated for fraud and abuse. The other main reasons providers are investigated are employee complaints and statistical analysis of claims submissions.)
What body part is being resected in the procedure known as a "TURP"?
Prostate (The procedure is known as a "transurethral resection of the prostate")
Blood pressure reading of 220/150
R03.0 (One cannot assign hypertension diagnosis without physician diagnosis of condition. Therefore, without further documentation, abnormal blood pressure reading without diagnosis of hypertension would be appropriate which codes to R03.0.)
Orthopnea, rule out ventricular dysfunction
R06.01 ("Rule out" cannot be assigned as the condition has not been diagnosed by the physician. Therefore, only the orthopnea would be assigned a code.)
What is a sonogram?
Radiological imaging formed by sound waves
What program was created through the Medicare Modernization Act of 2003 (MMA) to identify and recover improper Medicare payments paid to health care providers under fee-for-service (FFS) Medicare plans?
Recovery Audit Contractors (RAC) (The RAC program was created to identify and recover improper Medicare payments.)
The combining form pyelo is defined as
Renal pelvis.
When a coder suspects fraud/abuse, what is the first action that should be taken?
Report to supervisor (Coders should report suspected fraud/abuse to their immediate supervisor. Only after reporting suspected fraud/abuse to a supervisor and no action is taken, should the coder consider other actions such as resigning or contacting an attorney.)
In what surgical section of the CPT book would one find a copy for the repair of vestibular stenosis?
Respiratory System (Repair of vestibular stenosis refers to the nose and, therefore, would be included in the Respiratory System section.)
Patient calls the office and indicates their insurance carrier will not cover the previous visit for the date of service listed on the claim as it was prior to the effective date of her insurance and asks that the date be changed to include a date during which her insurance was valid. What would be the appropriate action by the staff?
Review the record to determine if the appropriate DOS was submitted. If so, inform patient the DOS must remain unchanged. (The staff should review the record to make certain the date of service reported is appropriate. If so, they should inform the patient the DOS was correct and must remain unchanged.)
What guidelines are utilized in ICD-10-CM when determining the extent of body surface area?
Rule of Nines (The Rule of Nines describes the total body surface area of burns in ICD-10-CM. CPT uses the Lund Browder method.)
Patient presents for closure of 6.5 cm temple laceration. Initially seen in ED and referred to plastic surgery for closure.
S01.81XA (Chief reason for encounter is laceration. Not coded as open wound.) WRONG
Fracture of four ribs
S22.49XA (Multiple ribs were fractured, as well as the need for a seventh digit for treatment period, therefore, requiring an "X" placement for sixth digit and "A" for seventh digit.)
Upper right arm contusion from fall from bed. An x-ray is ordered to rule out fracture.
S40.021A (Select the "most correct answer"; therefore, since none have "fall from bed," code would be assigned based on "contusion, upper right arm." "Rule out" cannot be assigned per ICD10 guidelines as the condition has not been diagnosed yet by physician.)
This Physician Self-Referral Law prohibits a physician from making referrals for certain designated health services payable by Medicare to an entity with which he or she (or an immediate family member) has a financial ownership interest or compensation arrangement, unless an exception applies:
Stark Law (Under the Stark Law, physicians are prohibited from making referrals to entities in which they have financial ownership.)
When sequencing diagnoses codes for multiple fractures, what is the correct order?
Severity of the fracture (The most severe diagnosis is listed first.)
When repair of the dermis and epidermis is performed, what level of complexity of laceration repair should be assigned?
Simple (A simple repair is assigned when only the dermis and epidermis are repaired. An intermediate repair involves closure into the deep subcutaneous layers.)
This type of skin cancer arises from keratinizing epidermal cells and is invasive with a potential for metastasis that occurs most commonly in fair-skinned individuals.
Squamous Cell Carcinoma
What part of the HIPAA guidelines pertain to coding?
Standard code sets and standard claim forms (HIPAA guidelines indicate that all code sets and claim forms will be uniform. While the other choices are part of the HIPAA guidelines, they do not relate to coding and therefore are not the most correct answer.)
Which of the following refers to the misalignment of the eyes, most commonly referred to as crossed eyes?
Strabismus
A general surgeon performs both laparoscopic and open cholecystectomies as a part of their regular surgical procedures. An internal audit of these cases reveals that a number of these procedures were erroneously coded and are open rather than laparoscopic as performed. The following documentation was provided for training purposes: Procedure: Cholecystectomy. A supraumbilical incision was made, trocar was placed, and pneumoperitoneum was insufflated. Ports were placed and adhesions were taken down. The gallbladder was identified and dissected free. The gallbladder was brought out through the Endobag. What words or phrases in this example are most beneficial for training staff to recognize a laparoscopic cholecystectomy?
Supraumbilical incision, trocar(s), pneumoperitoneum, Endobag (The header(s) of an operative report should never be utilized alone to code surgical procedures. Terms such as "supraumbilical incision," "trocar(s)," "pneumoperitoneum," and "Endobag" are all indicative of a laparoscopic procedure.)
Patient arrived at the outpatient facility earlier in the morning and a localization wire was placed by the radiologist under mammographic guidance in the x-ray suite. The surgeon infiltrated around the wire and an incision was made between the left areola and the wire. A generous excision was made at least 2 cm around the wire, removing the lesion in question in toto. The margins were marked and specimen sent to pathology. The following codes were coded/billed by the surgeon's office: 19125-LT, 19281-LT, and 76098. The surgeon's office received notification from Medicare indicating they are under investigation for inappropriate billing for the services. Determine what inappropriate billing practices have been coded/billed by the surgeon's practice.
Surgeon may not submit claims for radiological services not performed. (The surgeon did not perform the radiological services performed earlier in the day and therefore may not code/bill for the radiological services.) WRONG
First-, second-, and third-degree burns, upper arm
T22.339A (ICD10 guidelines indicate only code highest degree burn to same location. Since third degree would be the highest degree to the same location, only the third degree would be assigned.) WRONG
Suicidal ingestion of acetaminophen
T39.1X2A (No signs/symptoms listed; therefore, no adverse affect code. Therefore, assign only self-harm poisoning code.)
Accidental ingestion of diphenhydramine
T45.0X1A (No signs/symptoms were documented; therefore, no information for adverse affect codes. Therefore, only accidental poisoning code assigned.)
Evaluation following suspected rape, adult
T76.21XA (Code as "suspected" rape requires "seventh" digit for treatment period; therefore, "X" placeholder needed as sixth digit.) WRONG
When documenting for burns of the skin, how is the total surface area recorded?
TBSA (The total area of the body affected by the burns is recorded by "total body surface area," or the abbreviation TBSA.)
Patient presents to the physician's office with complaints of high blood pressure, chest tightness, and dizziness. An expanded problem-focused history and exam and low MDM are performed before the patient is instructed to present for admission to the local hospital. The physician sees the patient later in the afternoon for admission, where a comprehensive history and exam and moderate MDM are performed on admission. What services are appropriate to be coded/billed by this physician?
The hospital admission only would be appropriate. (Generally, each provider is allowed one E/M per day. Therefore, if the patient is seen more than once by the same provider, only one service would be assigned. CPT guidelines instruct the office/outpatient E/M service to be included in the admission when performed by the same provider.)
New coding staff should be trained on the appropriate authority to report potential fraud/abuse or other activities that are contrary to compliance standards. According to OIG guidelines, what individual within the practice is usually designated with this responsibility?
The compliance officer (The compliance officer is the individual assigned as the authority to report potential fraud/abuse within the practice.)
All employees, coding or other, should understand that the medical records are the property of whom?
The practice/provider (The medical records are the property of the health care provider; however, the patient is entitled to copies of the records at their request.)
Patient presented for knee pain associated with an injury that occurred at work approximately 6 weeks ago. Expanded problem-focused history and exam and low MDM were documented and coded/billed to Medicare. Determine why these services were denied by Medicare?
Visit coded to Medicare, visit should be billed to Workers' Compensation as injury at work. (The injury occurred at the workplace and, therefore, should have been billed to Workers' Compensation, not Medicare.)
How should procedures designated as "each" in the CPT manual be coded/billed?
They should be billed as per unit on the claim form. (Procedures designated as "each" should be billed per unit.)
When an organ or disease-oriented panel is ordered and performed, however, one of the components is not included in the order, what service(s) should be assigned?
Those services performed must be coded/billed individually. (Per CPT when the organ disease panel is not complete, each service performed should be coded individually.)
What is the minimum number of codes that should be assigned when two lesions are excised through two separate excision sites?
Two (Each lesion should be assigned an applicable CPT code. For two lesions, a minimum of two codes would be assigned.)
Bronchial alveolar lavage and four endobronchial biopsies were performed and submitted to the insurance carrier as follows: 31625-RT x 4 units, 31624-51-RT. Is this claim coded appropriately?
Units should be deleted from 31625, only one unit is reported. (Code 31625 for the endobronchial biopsy(s) should be assigned one unit only as specified in the CPT manual.)
A surgical bronchoscopy includes a diagnostic bronchoscopy.
True (All surgical procedures include any diagnostic test performed on the same anatomical location. This is indicated by the designation of "separate procedure" assigned to these diagnostic codes.)
Acute conditions are usually coded as primary.
True (ICD10 guidelines instruct that "acute" conditions are assumed to be the chief reason for the encounter, and, therefore, would be assigned primary.)
When a radiology service is performed utilizing oral contrast only, how should it be coded?
Without contrast (Per radiology guidelines in CPT, oral contrast is NOT considered "with contrast" and, therefore, should be assigned the without contrast code only.)
When a radiology service is performed without contrast, followed by the same radiology service with intravenous contrast, how should it be coded?
Without contrast, followed by with contrast (Assign the appropriate code for without contrast, followed by with contrast (for the contrast).)
When a radiology service is performed with oral contrast, followed by the same radiology service with intravenous contrast, how should it be coded?
Without contrast, followed by with contrast (Since radiology guidelines indicate oral contrast should be considered "without" contrast, assign the appropriate code for without contrast (for the oral), followed by with contrast (for the contrast).)
A right arthroscopic medical/lateral meniscectomy with synovectomy was performed. The insurance rejected the claim for services as follows: 29880-RT Paid, 29875-RT Denied, included in surgical allowance for major procedure. Was this claim handled appropriately?
Yes, code 29875 is a "separate" procedure and would be considered as "incidental." (Yes, code 29875 is listed in CPT as a "separate" procedure, and when performed with the meniscectomy, it is considered incidental and not separately billable.)
A worried mother brought her child in to be cleared of any injuries following involvement in a motor vehicle accident earlier in the day. The child has no complaints; however, the physician decides to observe the patient for a few hours just to be sure.
Z04.1 (Observe suspect following transport accident codes to Z04.1.)
Patient presents to oncologist for annual follow-up. Patient has history of Stage I breast cancer. Patient underwent mastectomy and completed 5 year course of Tamoxifen 2 years ago. No complaints, no symptoms.
Z08, Z85.3, Z90.10 (Annual follow-up for malignant neoplasm is assigned Z08. Breast cancer not currently present; therefore, assign Hx for breast cancer. Also assign absence of breast as S/P mastectomy.)
Patient presents with concerns regarding her exposure to rubella last week at work.
Z20.4 (Not coded as disease since patient only exposed to rubella. Assign code from "Encounter for.")
Contraceptive counseling
Z30.09 (Code look-up as follows: counseling, contraceptive)
Encounter for determining pregnancy state
Z32.00 (As encounter did not include the result of pregnancy, would code as "results unknown.")
Encounter for pregnancy
Z34.90 (Code as "supervision" pregnancy.)
Breast ca mets to uterus, patient presents for chemo.
Z51.11, C50.912, C79.82 (Chief reason for encounter is chemo (Z code). Primary assigned first (breast), secondary assigned (uterus).) WRONG
Patient presents with malignant neoplasm of the breast with metastasis to the uterus. Primary site has been treated and is no longer present. Patient presents for chemotherapy.
Z51.11, C79.82, Z85.3 (Order should be primary reason for encounter (Chemo Z51.11), secondary site (C79.82), and primary site Hx (Z85.3))
History of allergy to penicillin
Z88.0 (Not current condition; therefore, "Z" code is appropriate, specific to penicillin.)
This federal program was created to identify cases of suspected fraud, investigate them, and take action to ensure any inappropriate Medicare payments are recouped:
Zone Program Integrity Contractor (ZPIC). (The Zone Program Integrity Contractor (ZPIC) program was created to identify fraud and recoup inappropriate payments. The other programs listed were not created for this purpose.)
When brain cells die as a result of the lack of inadequate blood perfusion of the brain, it is referred to as
a cerebrovascular accident or CVA. (Death of brain cells is known as a cerebrovascular accident, abbreviated as CVA. The prefix cerebro refers to the brain and the suffix vascular refers to the vascular system. Therefore, an accident or injury resulting in the lack of blood flow in the vascular system of the brain would be a cerebrovascular accident.)
An anastomosis would be defined as
a surgical connection between two normally distinct structures
Tissue destruction or removal by means of high-frequency electrical current is called
ablation
A dysrhythmia refers to
abnormal variation in the heart rhythm.
Amenorrhea is defined as
absence of menstrual period(s)
Amenorrhea is defined as
absence of menstrual period(s).
Filing claims for services deemed not medically necessary is an example of
abuse (Underbilling and overbilling are examples of billing excessively or billing fewer codes than are appropriate.)
The surgical excision of yellow fatty plaque from a vessel wall is called
atherectomy
The upper chambers of the heart are called
atrium/atria
The "+" sign in the CPT manual denotes
additional procedures billed in conjunction with another specified service. (The "+" sign refers to an "add on" procedure that is billed in addition to another specified procedure code.)
EGD stands for a visual inspection of the scope of which organ(s)? Esophagus Duodenum/Jejunum Stomach all of these are correct
all of these are correct
Under what circumstance(s) can a provider be considered for exclusion from the Medicare program? * Conviction of a misdemeanor or felony relating to fraud/abuse * all of those listed * Failure to pay medical education loans * Suspension of provider license
all of those listed (Conviction for fraud and abuse, suspension of the provider's license, and/or failure to pay medical education loans could result in exclusion from the Medicare program. All of the items listed constitute reasons a provider could be excluded from the Medicare program; therefore, "all of those listed" would be the most correct answer.) WRONG
The dilation of an artery due to weakness in the wall is called a(n)
aneurysm
A coronal plane divides the body into
anterior and posterior portions
When fracture is not specified as open or closed, it should
be coded as closed. (Default per coding guidelines is "closed.")
The prefix "ante" is defined as
before
The substance(s) created in the liver that is used in the digestion of fats is/are
bile
Which of the following most certainly would describe upcoding?
billing for a procedure that is more extensive or intensive than what was actually performed (According to NCCI guidelines, a less extensive procedure performed in the same anatomical area is considered bundled in the more extensive procedure.) WRONG
The surgical repair of the eyelid is called
blepharoplasty
The wrist bones are referred to as
carpals
The term rectocele is defined as
bulging of the rectum into the vagina.
Mental illness characterized by binge eating followed by purging is termed as
bulimia
Carcino refers to
cancer
The smallest blood vessels in the body are called
capillaries (Capillaries are the smallest blood vessels. The others listed are also vessels but are not the smallest.)
The hyposecretion of insulin results in the common disease of
diabetes mellitus
Fractures not specified as "displaced" or "nondisplaced" should be coded as
displaced (ICD10 guidelines instruct that fractures should be coded as "displaced" unless otherwise specified in the documentation.)
Development of small pockets in the lining of the large intestines is referred to as
diverticulosis
The position that refers to the back of the body or organs is
dorsal
Painful menstrual discharge is the definition of
dysmenorrhea
Abnormal cardiac rhythms are
dysrhythmias and arrhythmias
NCCI edits refer to
edits that indicate whether procedures may be separately reported in conjunction with other procedures coded. (Edits that indicate whether procedures may be separately reported in conjunction with other procedures coded.)
The recording of the electrical signals of the heart is called a(n)
electrocardiogram
Operative Report: A ventricular lead and and atrial lead were positioned into place and secured. They were then connected to the pacing device. Set screws were tightened and adjusted, and the pacemaker and leads were placed in pocket formed under blunt dissection. The pacemaker was secured to the underlying pectoral muscle, and the pocket was then closed. Codes 33208 and 33213 were submitted for the above services. What is incorrect regarding the coding for these services?
electrodes and pacemaker pulse generator included in 33208, code 33213 not appropriate (The placement of the electrodes and pacemaker pulse generator are already included in 33208; therefore, the assignment of 33213 is not appropriate.)
Inflammation of the brain is referred to as
encephalitis
Hepatomegaly refers to
enlargement of the liver.
The condition in which the brain has repeated seizures as a result of abnormal electrical activity to the brain is called
epilepsy
The ends of the long bones are called
epiphysis
Cholecystectomy refers to the
excision of gallbladder
The inability to control urination is
incontinence
Myringitis is defined as
inflammation of the middle ear. ("Myringo" refers to middle ear, and "itis" refers to inflammation.)
Atelectasis
is a collapsed lung.
Arthritis refers to
joint inflammation
Tears are produced by the
lacrimal ducts
The pleura refers to the
layer of tissue lining the pleural cavity.
The femur, tibia, and fibula are all referred to as
leg bones
A neoplastic condition in which the bone marrow produces an abnormally large number of WBCs is referred to as
leukemia
The white blood cells are known as
leukocytes
Pediculosis is more commonly referred to as
lice
Bones are attached to each other by dense connective tissue fibers known as
ligaments
A complete abdominal ultrasound is ordered, however, all abdominal structures are not documented as identified, what service(s) should be assigned?
limited or follow-up ultrasound only (A complete ultrasound includes documentation that all the structures within the area are examined. If only portions of the abdomen are visualized, then a limited/follow-up ultrasound would be appropriate.)
When an abdominal ultrasound is ordered for purposes of evaluating the gallbladder only, what services should be coded?
limited or follow-up ultrasound only (A complete ultrasound includes documentation that all the structures within the area are examined. If the purpose is only to visualize a limited portion of the abdomen, then a limited/follow-up ultrasound would be appropriate.)
A fatty tumor is termed a
lipoma
When further explanation for describing services provided is necessary, what might be appropriate to append to the CPT code?
modifier (A modifier provides additional information or clarification on services performed. None of the other choices are appended to the CPT code.)
When E/M services for unrelated services are billed within a global period, what modifier should be appended?
modifier -24 (Modifier -24 denotes an E/M service performed during a global period that is unrelated. Modifier -57 denotes decision for surgery, while modifier -25 is assigned to indicate a "significantly separately identifiable service." The modifier -59 is assigned to indicate separate and distinct services. Therefore, modifier -24 is appropriate in this instance.)
When surgical or evaluation and management services are mandated by the third-party carrier, what modifier should be appended to those services?
modifier -32 (Modifier -32 is appended when a third-party carrier requires a service be performed.)
Patient presents for excision 1 cm lesion of arm and also wishes excision of 1 cm lesion on the right shoulder at the same time. What modifier would be appropriate, if any?
modifier -59 (Two distinct, separate excisions were performed; therefore, modifier -59 would be assigned since both services will be assigned the same code.) WRONG
An inherited muscular disorder characterized by muscle weakness and loss of muscle tissue that is primarily passed from mother to son is referred to as
muscular dystrophy.
The death of cardiac/heart tissue due to deprivation of oxygen is called
myocardial infarction
The term "nocturia" refers to
nighttime urination.
The type of bone cancer that originates from the cells that make bone tissue is referred to as
osteosarcoma
The condition of inflammation of the middle ear is called
otitis media
The combining form "to give birth" is
para
The combining form that means "deliveries" or the number of pregnancies that has culminated in viable offspring is
para
Erythrocytes refers to
red blood cells
The system that brings oxygen into the body for transportation to the cells and removes carbon dioxide from the body is the
respiratory system
Costo refers to
ribs
Modifier -RT should be assigned to denote
right anatomical site. (The modifier "RT" denotes the right anatomical site. The right thumb, right index finger, and right toe are designated with specific modifiers "F5," "F6," and "T5," respectively.)
Mini strokes are caused by temporary or transient interruptions of the blood supply to the brain and are medically termed
transient ischemic attacks or TIAs.
The prefix "salpingo" means
tube (The prefix "salpingo" refers to the tubes, usually the fallopian tubes. However, "salpingo" can represent any tubes in the body.)
Neuroma is a term referring to
tumor of nerve tissue.
When physical therapy that is reported in 15-minute increments is performed for 35 minutes, how many units of service should be reported?
two units only (Two units of the physical therapy code would be assigned. A third unit is not reportable, as half of the time requirement (8 minutes) would need to be met, and only an additional 5 minutes is remaining.)
The tubes that drain urine from the kidneys and carry to the bladder are known as
ureters
The combining form "colpo" is defined as
vagina
Angio refers to
vessel
The female external organs or genitalia are collectively known as the
vulva
Determination of primary/secondary neoplasms are determined by
where the neoplasm started/spread to. (Primary sites are determined by where the neoplasm started and secondary sites by where the neoplasm spread.)