Chapters 23 & 24 -Coding Practice - CPT Evaluation and Management Coding/CPT Anesthesia Section

David Wolff, a 53-year-old male, was previously diagnosed with benign hypertension due to morbid obesity. Dr. Adams administers general anesthesia so that Dr. McKnight can perform a direct venous thrombectomy on his lower left leg. NOTE: The CPT Changes: An Insider's View; CPT Assistant and Clinical Examples are not considered symbols or notations for this exercise. What is the principal anesthesia code? 01522-P3

Explanation Anesthesia Code: Where should you begin to look up the code in the coding manual - CPT Alphabetic Index What is the key term - Anesthesia What type of procedure - Direct venous thrombectomy What is the anatomical site - Lower leg What is the laterality - Left Begin to code the encounter Did you verify the code in the numerical listing - Yes Is there a symbol for this code - No If so what does the symbol mean - Does not apply Is there additional notation(s) - No If so does the notation(s) apply - No Do you need to add a physical status modifier - Yes If so what is the physical status modifier - P3 Do you need a qualifying circumstance code - No If so what is the qualifying circumstance code - Does not apply Did you check the guidelines - Yes Did you code to the highest level of specificity - Yes What is the correct anesthesia code - 01522-P3 Overall Feedback: 01522-P3: Index>anesthesia>leg>lower>venous thrombectomy>P3 Physical status modifier P3: Patient with severe systemic disease (hypertension and morbid obesity)

ANYTOWN ANESTHESIOLOGY ASSOCIATES 241 MAIN STREET • ANYTOWN, FL 32711 • 407-555-1234 PATIENT: PERSILE, LORRAINE ACCOUNT/EHR #: PERSLO001 DATE: 10/15/22 Preoperative DX: Locked right knee, rule out medial meniscus tear Postoperative DX: 1. Grade 2 tear, anterior, cruciate ligament 2. Medial meniscus tear, anterior, horn 3. Grade 2 chondrosis, medial femoral condyle Procedure: 1. Arthroscopy 2. Partial anterior cruciate ligament debridement 3. Partial medial meniscectomy Attending Physician: Renee O. Bracker, MD Anesthesia: General Anesthesiologist: Lawrence Miller, MD INDICATIONS: The patient is a 33-year-old female who was in her usual state of good health until about 10 days ago when she sustained a twisting injury to the right knee with inability to fully extend the knee, with pain and swelling. PROCEDURE: Estimated blood loss: None. Complications: None. Tourniquet time: See anesthesia notes. Specimens: None. Drains: None. Disposition: To the recovery room in stable condition. Pt was taken to surgery and placed on the OR table in the supine position. After adequate general anesthesia was administered, she received a gram of intravenous Kefzol preoperatively. A proximal thigh tourniquet was applied. Examination revealed no significant Lachman or drawer and a moderate effusion. No varus or valgus instability. Distal pulses intact. The right lower extremity was placed in the arthroscopic leg holder; shaved, prepped, and draped in the usual meticulously sterile fashion for lower extremity surgery. Esmarch exsanguinations of the limb were performed, and the tourniquet was inflated. Proximal medial, anteromedial, and anterolateral portals were fashioned. A systematic evaluation of the knee was performed. The undersurface of the patella demonstrated normal tracking with no chondrosis. The suprapatellar pouch, medial, and lateral gutters were well within normal limits, and in the notch a grade 2 tear of the anterior cruciate ligament was identified. There were some bloody fragments of the ACL that seemed to be impinging in the medial compartment. This was meticulously debrided. Approximately 50% of the ACL appeared to be intact. Attention was turned to the lateral compartment. The articular surface of the meniscus was normal. On the medial side, a grade 2 lesion in medial femoral condyle, lateral side, was noted. This was not debrided. Also, an anterior tear of the medial meniscus, which was frayed and torn, was another potential source of impingement. This was meticulously debrided to a smooth, stable mechanical limb, and the wound was irrigated and closed with 4-0 nylon simple interrupted sutures. Xeroform, 4 × 4s, Webril and Ace bandage from the tips of the toes to the groin completed the sterile dressing. There were no intraoperative or immediate postoperative complications. The prognosis is good, although it may be limited by potential for arthritis and instability in the future. Be sure to list the codes, one code per box, in the correct sequence, from top to bottom, and in the proper row. Capitalization, punctuation, and spacing can impact whether or not your answer is correct. Follow coding best practices. Please list modifiers with the code they relate to as necessary. Include a hyphen in between the code and the modifier. Example Procedure: 43846-74 or for Anesthesia: 00797-P2. NOTE: The CPT Changes: An Insider's View; CPT Assistant and Clinical Examples are not considered symbols or notations for this exercise. Determine the most accurate anesthesia code(s) and modifier(s), if appropriate. The number of spaces provided does not indicate the number of codes required to accurately report this encounter. Anesthesia code(s) and any applicable modifier(s) 01400-P1

Explanation Anesthesia Code: Where should you begin to look up the code in the coding manual - Alphabetic Index What is the key term - Anesthesia What type of procedure - Arthroscopic procedure What is the anatomical site - Knee Begin to code the encounter Did you verify the code in the numerical listing - Yes Is there a symbol for this code - No Is there additional notation(s) - No Do you need to add a physical status modifier - Yes If so what is the physical status modifier - P1 Do you need a qualifying circumstance code - No Did you check the guidelines - Yes Did you code to the highest level of specificity - Yes What is the correct anesthesia code - 01400-P1 Overall Feedback: 01400-P1: Index>anesthesia>arthroscopic procedure>knee Physical status modifier P1: Normal healthy patient

ANYTOWN ANESTHESIOLOGY ASSOCIATES 241 MAIN STREET • ANYTOWN, FL 32711 • 407-555-1234 PATIENT: DRESSLER, SIMONE ACCOUNT/EHR #: DRESSI001 DATE: 11/15/22 Preoperative DX: Chronic cholelithiasis Postoperative DX: Chronic cholelithiasis; subacute cholecystitis Procedure: Laparoscopic cholecystectomy; intraoperative cholangiogram Attending Physician: Renee O. Bracker, MD Anesthesia: General endotracheal Anesthesiologist: Melinda Abruzzo, MD PROCEDURE: The patient, a 57-year-old female, was taken to the OR. The patient was induced and an endotracheal tube was placed. The patient was then placed in the supine position. The abdomen was prepped and draped in the usual fashion. The patient had several previous lower midline incisions and right flank incision; therefore, the pneumoperitoneum was created via epigastric incision to the left of the midline with a Verres needle. After adequate pneumoperitoneum, the 11-mm trocar was placed through the extended incision in the left epigastrium just to the left of the midline, and the laparoscope and camera were in place. Inspection of the peritoneal cavity revealed it to be free of adhesions, and another 11-mm trocar was then placed under direct vision through a small infraumbilical incision. The scope and camera were then moved to this position, and the gallbladder was easily visualized. The gallbladder was elevated, and Hartmann's pouch was grasped. Using a combination of sharp and blunt dissection, the cystic artery was identified. The gallbladder was somewhat tense and subacutely inflamed. Therefore, a needle was passed through the abdominal wall into the gallbladder, and the gallbladder was aspirated free until it collapsed. One of the graspers was held over this region to prevent any further leakage of bile. Again, direction was turned to the area of the triangle of Calot. The cystic duct was dissected free with sharp and blunt dissection. A small opening was made in the duct, and the cholangiogram catheter was passed. The cholangiogram revealed no stones or filling defects in the bile duct system. The biliary tree was normal. There was good flow into the duodenum, and the catheter was definitely in the cystic duct. The catheter was removed, and the cystic duct was ligated between clips, as was the cystic artery. The gallbladder was then dissected free from the hepatic bed using electrocautery dissection, and it was removed from the abdomen through the umbilical port. Inspection of the hepatic bed noted that hemostasis was meticulous. The region of dissection was irrigated and aspirated dry. The trocars were removed, and the pneumoperitoneum was released. The incisions were closed with Steri-Strips, and the umbilical fascial incision was closed with 2-0 Maxon. The patient tolerated the procedure well; there were no complications. She was returned to the recovery room awake and alert. Be sure to list the codes, one code per box, in the correct sequence, from top to bottom, and in the proper row. Capitalization, punctuation, and spacing can impact whether or not your answer is correct. Follow coding best practices. Please list modifiers with the code they relate to as necessary. Include a hyphen in between the code and the modifier. Example Procedure: 43846-74 or for Anesthesia: 00797-P2. NOTE: The CPT Changes: An Insider's View; CPT Assistant and Clinical Examples are not considered symbols or notations for this exercise. Determine the most accurate anesthesia code(s) and modifier(s), if appropriate. The number of spaces provided does not indicate the number of codes required to accurately report this encounter. Anesthesia code(s) and any applicable modifier(s) 00790-P1

Explanation Anesthesia Code: Where should you begin to look up the code in the coding manual - Alphabetic Index What is the key term - Anesthesia What type of procedure - Cholecystectomy What is the anatomical site - Intraperitoneal/upper abdomen How is the procedure performed - Laparoscopic Begin to code the encounter Did you verify the code in the numerical listing - Yes Is there a symbol for this code - No Is there additional notation(s) - No Do you need to add a physical status modifier - Yes If so what is the physical status modifier - P1 Do you need a qualifying circumstance code - No Did you check the guidelines - Yes Did you code to the highest level of specificity - Yes What is the correct anesthesia code - 00790-P1 Overall Feedback: 00790-P1:Index>anesthesia>abdomen>intraperitoneal>upper abdomen>laparoscopy Physical status modifier P1: Normal healthy patient

ANYTOWN ANESTHESIOLOGY ASSOCIATES 241 MAIN STREET • ANYTOWN, FL 32711 • 407-555-1234 PATIENT: WAYMEN, MARK ACCOUNT/EHR #: WAYMMA001 DATE: 11/07/22 Preoperative DX: Inguinal hernia, right Postoperative DX: Inguinal hernia, right, direct and indirect Procedure: Repair of right inguinal hernia with mesh Attending Physician: Oscar R. Prader, MD Anesthesia: General Anesthesiologist: Lawrence Miller, MD PROCEDURE: The patient is a 41-year-old male who was taken to the OR and prepped in the usual sterile fashion. After Dr. Miller, the anesthesiologist, administered anesthesia and a satisfactory state was achieve, a transverse incision was made above the inguinal ligament and carried down to the fascia of the external oblique, which was then opened, and the cord was mobilized. The ilioinguinal nerve was identified and protected. A relatively large indirect hernia was found. However, there was an extension of the hernia, such that one could definitely tell there had been a long-standing hernia here that probably had enlarged fairly recently. The posterior wall, however, was quite dilated and without a great deal of tone and bulging as well, and probably fit the criteria for a hernia by itself. Nonetheless, the hernia sac was separated from the cord structures, and a high ligation was done with a purse string suture of 2-0 silk and a suture ligature of the same material prior to amputating the sac. The posterior wall was repaired with Marlex mesh, which was sewn in place in the usual manner, anchoring two sutures at the pubic tubercle tissue, taking one lateral up the rectus sheath and one lateral along the shelving border of Poupart's ligament past the internal ring. The mesh had been incised laterally to accommodate the internal ring. Several sutures were used to tack the mesh down superiorly and laterally to the transversalis fascia. Then the two limbs of the mesh were brought together lateral to the internal ring and secured to the shelving border of Poupart's ligament. The mesh was irrigated with Gentamicin solution. The subcutaneous tissue was closed with fine Vicryl, as was the internal oblique. Marcaine was infiltrated in the subcutaneous tissue and skin. The wound was closed with fine nylon. The patient tolerated the procedure well. Be sure to list the codes, one code per box, in the correct sequence, from top to bottom, and in the proper row. Capitalization, punctuation, and spacing can impact whether or not your answer is correct. Follow coding best practices. Please list modifiers with the code they relate to as necessary. Include a hyphen in between the code and the modifier. Example Procedure: 43846-74 or for Anesthesia: 00797-P2. NOTE: The CPT Changes: An Insider's View; CPT Assistant and Clinical Examples are not considered symbols or notations for this exercise. Determine the most accurate anesthesia code(s) and modifier(s), if appropriate. The number of spaces provided does not indicate the number of codes required to accurately report this encounter. Anesthesia code(s) and any applicable modifier(s) 00830-P1-AA

Explanation Anesthesia Code: Where should you begin to look up the code in the coding manual - Alphabetic Index What is the key term - Anesthesia What type of procedure - Hernia repair What is the anatomical site - Lower abdomen Begin to code the encounter Did you verify the code in the numerical listing - Yes Is there a symbol for this code - No Is there additional notation(s) - No Do you need to add a physical status modifier - Yes If so what is the physical status modifier - P1 Do you need a qualifying circumstance code - No Did you check the guidelines - Yes Did you code to the highest level of specificity - Yes What is the correct anesthesia code - 00830-P1-AA Overall Feedback: 00830-P1-AA: Index>anesthesia>hernia repair>abdomen>lower Physical status modifier P1: Normal healthy patient

ANYTOWN ANESTHESIOLOGY ASSOCIATES 241 MAIN STREET • ANYTOWN, FL 32711 • 407-555-1234 PATIENT: LYNDON, JAMES ACCOUNT/EHR #: LYNDJA001 DATE: 12/01/22 Preoperative DX: Sensory deficit of common digital nerve; tendon laceration Postoperative DX: Same Procedure: Repair of digital nerve, right hand; repair of tendon laceration Attending Physician: Renee O. Bracker, MD Anesthesia: General Anesthesiologist: Eric Keist, MD INDICATIONS: The patient is a 23-year-old male who was stabbed in the right hand during a street fight. Examination showed a sensory deficit of the thumb and index finger due to an injury to the common digital nerve and a tendon laceration involving the abductor pollicis and first dorsal interosseous. He was taken immediately to the OR for repair. PROCEDURE: The patient was taken to the OR. General anesthesia was administered, a tourniquet was applied, and the wound was explored. The common digital nerve to the thumb was identified and found to be divided at the level just proximal to the first metacarpal. The digital nerve to the radial aspect of the index finger was also divided. The abductor pollicis and the first dorsal interosseous tendons were then repaired with 3-0 Vicryl to the fascia. Following this, both digital nerves were repaired by using interrupted 9-0 Nylon, suturing epineurium to epineurium. When completed, the wound was thoroughly irrigated with saline solution and the skin was closed with interrupted Ethilon. A dorsal splint was applied to the thumb and remains in IP flexion at about 30 degrees and slight adduction. Tourniquet time totaled 190 minutes. Be sure to list the codes, one code per box, in the correct sequence, from top to bottom, and in the proper row. Capitalization, punctuation, and spacing can impact whether or not your answer is correct. Follow coding best practices. Please list modifiers with the code they relate to as necessary. Include a hyphen in between the code and the modifier. Example Procedure: 43846-74 or for Anesthesia: 00797-P2. NOTE: The CPT Changes: An Insider's View; CPT Assistant and Clinical Examples are not considered symbols or notations for this exercise. Determine the most accurate anesthesia code(s) and modifier(s), if appropriate. The number of spaces provided does not indicate the number of codes required to accurately report this encounter . Anesthesia code(s) and any applicable modifier(s) 01810-P1

Explanation Anesthesia Code: Where should you begin to look up the code in the coding manual - Alphabetic Index What is the key term - Anesthesia What type of procedure - Repair of digital nerve What is the anatomical site - Hand What is the laterality - Right Begin to code the encounter Did you verify the code in the numerical listing - Yes Is there a symbol for this code - No Is there additional notation(s) - No Do you need to add a physical status modifier - Yes If so what is the physical status modifier - P1 Do you need a qualifying circumstance code - No Did you check the guidelines - Yes Did you code to the highest level of specificity - Yes What is the correct anesthesia code - 01810-P1 Overall Feedback: 01810-P1:Index>anesthesia>hand>on nerves, muscles, tendons, fascia, and bursae of forearm, wrist, and hand Physical status modifier P1: Normal healthy patient

Martha Gantt, a 76-year-old female with a history of hypertension and diabetes mellitus, is brought into the OR for Dr. Brunson to perform a corneal transplant. Dr. Williams, the anesthesiologist, administers the anesthesia. NOTE: The CPT Changes: An Insider's View; CPT Assistant and Clinical Examples are not considered symbols or notations for this exercise. What is the principal anesthesia code? 00144-P3-AA What is the second anesthesia code? 99100

Explanation Anesthesia Code: Where should you begin to look up the code in the coding manual - CPT Alphabetic Index What is the key term - Anesthesia What type of procedure - Corneal transplant Who provides the anesthesia services - Anesthesiologist Begin to code the encounter Did you verify the code in the numerical listing - Yes Is there a symbol for this code - No If so what does the symbol mean - Does not apply Is there additional notation(s) - No If so does the notation(s) apply - Does not apply Do you need to add a physical status modifier - Yes If so what is the physical status modifier - P3 Do you need a HCPCS Level II modifier - Yes If so what is the HCPCS Level II modifier - AA Do you need a qualifying circumstance code - Yes If so what is the qualifying circumstance code - 99100 Did you check the guidelines - Yes Did you code to the highest level of specificity - Yes What is the correct anesthesia code - 00144-P3-AA What is the correct qualifying circumstances code - 99100 Overall Feedback: 00144-P3-AA: Index>anesthesia>corneal transplant>P3 99100: Anesthesia for patient of extreme age, younger than 1 year and older than 70 Physical status modifier P3: Patient with severe systemic disease (hypertension and diabetes mellitus) Modifier AA: Anesthesia services performed personally by anesthesiologist

Gerry Sherman, a healthy 28-year-old male, plays professional basketball and is given anesthesia by Dr. Wallace before having a diagnostic arthroscopy of his right knee by Dr. Hook. NOTE: The CPT Changes: An Insider's View; CPT Assistant and Clinical Examples are not considered symbols or notations for this exercise. What is the principal anesthesia code? 01382-P1

Explanation Anesthesia Code: Where should you begin to look up the code in the coding manual - CPT Alphabetic Index What is the key term - Anesthesia What type of procedure - Diagnostic arthroscopy What is the anatomical site - Knee Begin to code the encounter Did you verify the code in the numerical listing - Yes Is there a symbol for this code - No If so what does the symbol mean - Does not apply Is there additional notation(s) - No If so does the notation(s) apply - Does not apply Do you need to add a physical status modifier - Yes If so what is the physical status modifier - P1 Do you need a qualifying circumstance code - No If so what is the qualifying circumstance code - Does not apply Did you check the guidelines - Yes Did you code to the highest level of specificity - Yes What is the correct anesthesia code - 01382-P1 Overall Feedback: 01382-P1: Index>anesthesia>arthroscopic procedure>knee>P1 Physical status modifier P1: Normal healthy patient

Dr. Billingsworth administered anesthesia to Ralph Skipper, a 7-month-old male requiring a hernia repair in the lower abdomen. Dr. Sims, the neonatologist, noted that, without the surgery, Ralph was not expected to survive. NOTE: The CPT Changes: An Insider's View; CPT Assistant and Clinical Examples are not considered symbols or notations for this exercise. What is the principal anesthesia code? 00834-P5

Explanation Anesthesia Code: Where should you begin to look up the code in the coding manual - CPT Alphabetic Index What is the key term - Anesthesia What type of procedure - Hernia repair What is the anatomical site - Lower abdomen What is the age of the patient - 9 months Begin to code the encounter Did you verify the code in the numerical listing - Yes Is there a symbol for this code - No If so what does the symbol mean - Does not apply Is there additional notation(s) - Yes If so does the notation(s) apply - Yes Do you need to add a physical status modifier - Yes If so what is the physical status modifier - P5 Do you need a qualifying circumstance code - No If so what is the qualifying circumstance code - Does not apply Did you check the guidelines - Yes Did you code to the highest level of specificity - Yes What is the correct anesthesia code - 00834-P5 Overall Feedback: 00834-P5: Index>anesthesia>hernia repair>abdomen>lower>younger than age 1 year>P5 Physical status modifier P5: A moribund patient who is not expected to survive without the operation

Dr. Hanh administers anesthesia so that Dr. Lindholm can perform a diagnostic lumbar puncture on Keith Franklin, a 56-year-old male. Over the course of the last year, Keith, a construction worker, has developed essential hypertension, which is currently controlled by diet. This lumbar puncture is to confirm the suspected diagnosis of bacterial meningitis. NOTE: The CPT Changes: An Insider's View; CPT Assistant and Clinical Examples are not considered symbols or notations for this exercise. What is the principal anesthesia code? 00635-P2

Explanation Anesthesia Code: Where should you begin to look up the code in the coding manual - CPT Alphabetic Index What is the key term - Anesthesia What type of procedure - Lumbar puncture Begin to code the encounter Did you verify the code in the numerical listing - Yes Is there a symbol for this code - No If so what does the symbol mean - Does not apply Is there additional notation(s) - No If so does the notation(s) apply - Does not apply Do you need to add a physical status modifier - Yes If so what is the physical status modifier - P2 Do you need a qualifying circumstance code - No If so what is the qualifying circumstance code - Does not apply Did you check the guidelines - Yes Did you code to the highest level of specificity - Yes What is the correct anesthesia code - 00635-P2 Overall Feedback: 00635-P2: Index>anesthesia>lumbar puncture>P2 Physical status modifier P2: a mild systemic disease (hypertension under control)

Dr. Solington brought Howard Chen, a 10-month-old male, into the OR for repair of his complete transposition of the great arteries under cardiopulmonary bypass. Pump oxygenation was used. Howard was not expected to survive without the surgery. Dr. Misher, the anesthesiologist, administered the anesthesia. NOTE: The CPT Changes: An Insider's View; CPT Assistant and Clinical Examples are not considered symbols or notations for this exercise. What is the principal anesthesia code? 00561-P5-AA

Explanation Anesthesia Code: Where should you begin to look up the code in the coding manual - CPT Alphabetic Index What is the key term - Anesthesia What type of procedure - Repair of complete transposition of the great arteries What is the anatomical site - Heart What is the age of the patient - 9 months old What else do we know about it - With pump oxygenation Who provides the anesthesia services - Anesthesiologist Begin to code the encounter Did you verify the code in the numerical listing - Yes Is there a symbol for this code - No If so what does the symbol mean - Does not apply Is there additional notation(s) - Yes If so does the notation(s) apply - Yes Do you need to add a physical status modifier - Yes If so what is the physical status modifier - P5 Do you need a HCPCS Level II modifier - Yes If so what is the HCPCS Level II modifier - AA Do you need a qualifying circumstances code - No If so what is the qualifying circumstances code - Does not apply Did you check the guidelines - Yes Did you code to the highest level of specificity - Yes What is the correct anesthesia code - 00561-P5-AA Overall Feedback: 00561-P5-AA: Index>anesthesia>heart>pericardial sac and great vessels of the chest; with pump oxygenator, younger than age 1 year Physical status modifier P5: A moribund patient who is not expected to survive without the operation Modifier AA: Anesthesia services performed personally by anesthesiologist

Carlton Dazquez, a 17-year-old male, was in a go-kart accident and fractured his upper arm 3 months ago. Today, Dr. Hytower operated on him to repair the malunion of his humerus. Dr. Murphy administered the anesthesia. Carl is otherwise healthy. NOTE: The CPT Changes: An Insider's View; CPT Assistant and Clinical Examples are not considered symbols or notations for this exercise. What is the principal anesthesia code? 01744-P1-AA

Explanation Anesthesia Code: Where should you begin to look up the code in the coding manual - CPT Alphabetic Index What is the key term - Anesthesia What type of procedure - Repair of malunion What is the anatomical site - Humerus Begin to code the encounter Did you verify the code in the numerical listing - Yes Is there a symbol for this code - No If so what does the symbol mean - Does not apply Is there additional notation(s) - No If so does the notation(s) apply - Does not apply Do you need to add a physical status modifier - Yes If so what is the physical status modifier - P1 Do you need a HCPCS Level II modifier - Yes If so what is the HCPCS Level II modifier - AA Do you need a qualifying circumstance code - No If so what is the qualifying circumstance code - Does not apply Did you check the guidelines - Yes Did you code to the highest level of specificity - Yes What is the correct anesthesia code - 01744-P1 Overall Feedback: 01744-P1-AA: Index>anesthesia>humerus>repair of nonunion or malunion of humerus Physical status modifier P1: Normal healthy patient

Dr. Elliston is preparing to perform a ventriculography with burr holes on Daniel Ewing, a 12-year-old male, who fell off the monkey bars onto a cement floor yesterday. Dr. Hallbeck administers the anesthesia. Daniel is otherwise healthy. NOTE: The CPT Changes: An Insider's View; CPT Assistant and Clinical Examples are not considered symbols or notations for this exercise. What is the principal anesthesia code? 00214-P1

Explanation Anesthesia Code: Where should you begin to look up the code in the coding manual - CPT Alphabetic Index What is the key term - Anesthesia What type of procedure - Ventriculography with burr holes Begin to code the encounter Did you verify the code in the numerical listing - Yes Is there a symbol for this code - No If so what does the symbol mean - Does not apply Is there additional notation(s) - No If so does the notation(s) apply - Does not apply Do you need to add a physical status modifier - Yes If so what is the physical status modifier - P1 Do you need a qualifying circumstance code - No If so what is the qualifying circumstance code - Does not apply Did you check the guidelines - Yes Did you code to the highest level of specificity - Yes What is the correct anesthesia code - 00214-P1 Overall Feedback: 00214-P1: Index>anesthesia>ventriculography>P1 Physical status modifier P1: Normal healthy patient

Regina Weyeneth, a healthy 23-year-old female, was given an epidural during labor, with the expectations of a vaginal delivery. After a time, Dr. Bedenbaugh, her obstetrician, determined that the labor was obstructed and notified the hospital staff, that they would have to do a cesarean (c-section). NOTE: The CPT Changes: An Insider's View; CPT Assistant and Clinical Examples are not considered symbols or notations for this exercise. What is the principal anesthesia code? 01967-P1 What is the second anesthesia code? 01968-P1

Explanation Primary Anesthesia Code: Where should you begin to look up the code in the coding manual - CPT Alphabetic Index What is the key term - Anesthesia What type of procedure - Child birth Type of first of delivery attempt - Vaginal What else do we know about the encounter - Resulted in a c-section Begin to code the encounter Did you verify the code in the numerical listing - Yes Is there a symbol for this code - No If so what does the symbol mean - Does not apply Is there additional notation(s) - No If so does the notation(s) apply - Does not apply Do you need to add a physical status modifier - Yes If so what is the physical status modifier - P1 Do you need a qualifying circumstance code - No If so what is the qualifying circumstance code - Does not apply Did you check the guidelines - Yes Did you code to the highest level of specificity - Yes What is the correct anesthesia code - 01967-P1 Second Anesthesia Code: Where should you begin to look up the code in the coding manual - CPT Alphabetic Index What is the key term - Anesthesia What type of procedure - Child birth What was the final type of delivery - C-section What else do we know about the encounter - First attempted vaginally Begin to code the encounter Did you verify the code in the numerical listing - Yes Is there a symbol for this code - Yes If so what does the symbol mean - Add-on code Is there additional notation(s) - Yes If so does the notation(s) apply - Yes Do you need to add a physical status modifier - Yes If so what is the physical status modifier - P1 Do you need a qualifying circumstance code - No Did you check the guidelines - Yes Did you code to the highest level of specificity - Yes What is the correct second anesthesia code - 01968-P1 Overall Feedback: 01967-P1: Index>anesthesia>childbirth>vaginal delivery>P1 01968-P1: Index>anesthesia>childbirth>cesarean delivery Physical status modifier P1: Normal healthy patient

Trisha Moultrie brought her 3-year-old daughter, Tamara, into the emergency room with a deep laceration of her scalp above her right ear, measuring 2.25 cm. Tamara was distraught, crying, and combative, kicking at the physician and the nurse as they attempted to clean the wound. At the recommendation of Dr. White, Trisha held Tamara in her lap, while the physician administered 1 mg of Versed, IM. Once the sedation took effect, Dr. White was able to perform a layered repair of the laceration while the nurse monitored Tamara's vital signs. The entire procedure took 25 minutes. Code the moderate sedation only. NOTE: The CPT Changes: An Insider's View; CPT Assistant and Clinical Examples are not considered symbols or notations for this exercise. What is the principal anesthesia code? 99151 What is the second anesthesia code? 99153

Explanation Principal Anesthesia Code: Where should you begin to look up the code in the coding manual - CPT Alphabetic Index What is the key term - Sedation What type - Moderate What is the age of the patient - 4-years-old How much time was spent - 25 minutes - Initial 15 minutes Begin to code the encounter Did you verify the code in the numerical listing - Yes Is there a symbol for this code - Yes If so what does the symbol mean - Modifier 51 exempt Is there additional notation(s) - No If so does the notation(s) apply - Does not apply Do you need to add a physical status modifier - No If so what is the physical status modifier - Does not apply Do you need a qualifying circumstance code - No If so what is the qualifying circumstance code - Does not apply Did you check the guidelines - Yes Did you code to the highest level of specificity - Yes What is the correct anesthesia code - 99151 Second Anesthesia Code: Where should you begin to look up the code in the coding manual - CPT Alphabetic Index What is the key term - Sedation What type - Moderate What is the age of the patient - 4 years old How much time was spent - 25 minutes - additional 10 minutes Begin to code the encounter Did you verify the code in the numerical listing - Yes Is there a symbol for this code - Yes If so what does the symbol mean - Add-on Code Is there additional notation(s) - No If so does the notation(s) apply - Does not apply Do you need to add a physical status modifier - No If so what is the physical status modifier - Does not apply Do you need a qualifying circumstance code - No If so what is the qualifying circumstance code - Does not apply Did you check the guidelines - Yes Did you code to the highest level of specificity - Yes What is the correct anesthesia code - 99153 Overall Feedback: 99151: Index>sedation>moderate>younger than age 5 years>initial 15 minutes 99153: Index>sedation>moderate>younger than age 5 years>additional 10 minutes

WESTON HOSPITAL 629 Healthcare Way • SOMEWHERE, FL 32811 • 407-555-6541 PATIENT: TURNER, CHARLES ACCOUNT/EHR #: TURNCH001 DATE: 10/01/22 Attending Physician: Renee O. Bracker, MD S: This 27-year-old male was brought to the ED by ambulance after he was found unconscious on the living room floor. He regained consciousness within several minutes but complained of a severe headache and nausea. Pt states that the last thing he remembers he was on a ladder, changing a light bulb. He believes he lost his balance trying to reach too far and fell, hitting his head on the end-table. O: Ht 5'10", Wt 195 lb., R 16. Head: Scalp laceration on the right posterior parietal bone. Bruise indicates trauma to this area. Eyes: PERRLA. Neck: Neck muscles are tense; there is minor pain upon rotation of the head. Musculoskeletal: All other aspects of the shoulders, arms, and legs are unremarkable. X-rays of skull, two views, and soft tissue of the neck are all benign. A: Concussion P: MRI to rule out subdural hematoma Repair laceration and bandage Be sure to list the codes, one code per box, in the correct sequence, from top to bottom, and in the proper row. Capitalization, punctuation, and spacing can impact whether or not your answer is correct. Follow coding best practices. Please list modifiers with the code they relate to as necessary. Include a hyphen in between the code and the modifier. Example Procedure: 43846-74 or for Anesthesia: 00797-P2. NOTE: The CPT Changes: An Insider's View; CPT Assistant and Clinical Examples are not considered symbols or notations for this exercise. Determine the most accurate E/M code(s) and modifier(s), if appropriate. The number of spaces provided does not indicate the number of codes required to accurately report this encounter. CPT code(s) and any applicable modifier(s) 99281

Explanation Principal Procedure: Where should you begin to look up the code in the coding manual - Alphabetic Index What is the key term - Evaluation and management What is the location of the encounter - ED Is the patient new or established - New Do you need to meet 3 of the 3 key components - Yes What is the level of history - Problem focused What is the level of the examination - Problem focused What is the level of medical decision making - Straightforward complexity What else do we know about it - Diagnosed with a concussion Begin to code the encounter Did you verify the code in the numerical listing - Yes Is there a symbol for this code - No Is there additional notation(s) - No Do you need to add a modifier - No Did you check the guidelines - Yes Did you code to the highest level of specificity - Yes What is the correct procedure code - 99281 Overall Feedback: 99281: Index>evaluation and management>ED>new or established patient Problem-focused history Problem-focused examination MDM of straightforward complexity

PRADER, BRACKER, & ASSOCIATES A Complete Health Care Facility 159 Healthcare Way • SOMEWHERE, FL 32811 • 407-555-6789 PATIENT: BROMWELL, BRANDON ACCOUNT/EHR #: BROMBR001 DATE: 10/18/22 Attending Physician: Oscar R. Prader, MD S: Matthew is a 9-month-old male brought in today by his mother. I last saw this patient at his regular 6-month checkup. He has been irritable lately and is tugging at his right ear. Brandon has been running a low-grade fever since yesterday. There has been no cough. Pt has a history of problems with his ears and sinuses. O: Ht 25", Wt 26 lb., R 20, T 101.3. HEENT: Purulent nasal discharge, yellow-green in color, is noted. Right TM is erythematous unilaterally, bulging, and with purulent effusions. Oropharynx is nonerythematous without lesions. One tooth on the bottom. Tonsils are unremarkable. Neck: Neck is supple with good range of motion (ROM). Positive cervical adenopathy. Lungs: Clear. Heart: Regular rate and rhythm without murmurs. A: Acute suppurative otitis media, right side P: Rx Augmentin 40 mg/kg divided tid 10 days Bed rest, lots of fluids Follow-up prn or if no improvement in 10 days Be sure to list the codes, one code per box, in the correct sequence, from top to bottom, and in the proper row. Capitalization, punctuation, and spacing can impact whether or not your answer is correct. Follow coding best practices. Please list modifiers with the code they relate to as necessary. Include a hyphen in between the code and the modifier. Example Procedure: 43846-74 or for Anesthesia: 00797-P2. NOTE: The CPT Changes: An Insider's View; CPT Assistant and Clinical Examples are not considered symbols or notations for this exercise. Determine the most accurate E/M code(s) and modifier(s), if appropriate. The number of spaces provided does not indicate the number of codes required to accurately report this encounter. CPT code(s) and any applicable modifier(s) 99213

Explanation Principal Procedure: Where should you begin to look up the code in the coding manual - Alphabetic Index What is the key term - Evaluation and management What is the location of the encounter - Office Is the patient new or established - Established patient What is the level of history - Medically appropriate history What is the level of the examination - Medically appropriate examination What is the level of medical decision making - Low complexity What else do we know about it - Diagnosed with acute suppurative otitis media, right side Begin to code the encounter Did you verify the code in the numerical listing - Yes Is there a symbol for this code - Yes Is there additional notation(s) - No Do you need to add a modifier - No Did you check the guidelines - Yes Did you code to the highest level of specificity - Yes What is the correct procedure code - 99213 Overall Feedback: 99213: Index>evaluation and management>office or other outpatient services>established patient Medically appropriate history Medically appropriate examination MDM of low complexity

PRADER, BRACKER, & ASSOCIATES A Complete Health Care Facility 159 Healthcare Way • SOMEWHERE, FL 32811 • 407-555-6789 PATIENT: HENSLEY, ERNEST ACCOUNT/EHR #: HENSER001 DATE: 09/29/22 Attending Physician: Benjamin L. Johnston, MD Referring Physician: Oscar R. Prader, MD S: Pt is a 35-year-old male, referred by Dr. Prader for a consultation regarding a sore on his left temple, at the hairline. Pt states he is very involved in water sports. He knows the importance of sunscreen; however, he does not always remember to put it on. He has not had any dermatologic concerns prior to this. Patient states that his skin is occasionally dry and that he has adult onset acne. O: Ht 6'1", Wt 225 lb., R 17, T 98.6. After an examination of the skin along the hairline, as well as the rest of the face and neck, a culture is taken of the lesion. The pathology report confirms a malignant melanoma of the skin of the scalp. A: Malignant melanoma, scalp P: 1. Discuss surgical and pharmaceutical options for treatment 2. Report sent to Dr. Prader Be sure to list the codes, one code per box, in the correct sequence, from top to bottom, and in the proper row. Capitalization, punctuation, and spacing can impact whether or not your answer is correct. Follow coding best practices. Please list modifiers with the code they relate to as necessary. Include a hyphen in between the code and the modifier. Example Procedure: 43846-74 or for Anesthesia: 00797-P2. NOTE: The CPT Changes: An Insider's View; CPT Assistant and Clinical Examples are not considered symbols or notations for this exercise. Determine the most accurate E/M code(s) and modifier(s), if appropriate. The number of spaces provided does not indicate the number of codes required to accurately report this encounter. CPT code(s) and any applicable modifier(s) 99242

Explanation Principal Procedure: Where should you begin to look up the code in the coding manual - Alphabetic Index What is the key term - Evaluation and management What is the type of service - Outpatient consultation Do you need to meet 3 of the 3 key components - Yes What is the level of history - Expanded problem focused What is the level of the examination - Expanded problem focused What is the level of medical decision making - straightforward complexity What else do we know about it - diagnosed with malignant melanoma, scalp Begin to code the encounter Did you verify the code in the numerical listing - Yes Is there a symbol for this code - Yes Is there additional notation(s) - No Do you need to add a modifier - No Did you check the guidelines - Yes Did you code to the highest level of specificity - Yes What is the correct procedure code - 99242 Overall Feedback: 99242: Index>evaluation and management>consultation>office or other outpatient consultation>new or established patient Expanded problem-focused history Expanded problem-focused examination MDM of straightforward complexity

WESTON HOSPITAL 629 Healthcare Way • SOMEWHERE, FL 32811 • 407-555-6541 PATIENT: LEAMAN, HESTER ACCOUNT/EHR #: LEAMHE001 DATE: 10/01/22 Attending Physician: Renee O. Bracker, MD This 18-month-old female is being admitted to the pediatric critical care. Mother claims onset of symptoms was sudden. She states that she rushed the child to the ED immediately. Child is unresponsive. Respiration is shallow. B/P 85/60 mmHg, T 102. Complete blood workup ordered: CBC with diff, tox screen, bilirubin, and basic metabolic panel. IV fluids to keep hydrated. Await test results. Be sure to list the codes, one code per box, in the correct sequence, from top to bottom, and in the proper row. Capitalization, punctuation, and spacing can impact whether or not your answer is correct. Follow coding best practices. Please list modifiers with the code they relate to as necessary. Include a hyphen in between the code and the modifier. Example Procedure: 43846-74 or for Anesthesia: 00797-P2. NOTE: The CPT Changes: An Insider's View; CPT Assistant and Clinical Examples are not considered symbols or notations for this exercise. Determine the most accurate E/M code(s) and modifier(s), if appropriate. The number of spaces provided does not indicate the number of codes required to accurately report this encounter. CPT code(s) and any applicable modifier(s) 99471

Explanation Principal Procedure: Where should you begin to look up the code in the coding manual - Alphabetic index What is the key term - Evaluation and management What is the location of the encounter - Pediatric critical care Do you need to meet 3 of the 3 key components - Does not apply What the age of the patient - 18 months Begin to code the encounter Did you verify the code in the numerical listing - Yes Is there a symbol for this code - No Is there additional notation(s) - No Do you need to add a modifier - No Did you check the guidelines - Yes Did you code to the highest level of specificity - Yes What is the correct procedure code - 99471 Overall Feedback: 99471: Index>evaluation and management>pediatric critical care>initial inpatient pediatric critical care, per day, for evaluation and management of a critically ill infant or young child, 29 days through 24 months of age

Zena Awtrey, a 58-year-old female, sees Dr. Lunden for the first time for a variety of medical problems. She was diagnosed 5 years ago with insulin-dependent diabetes mellitus with complicating eye and renal problems. In addition, she suffers from hypertensive heart disease with episodes of congestive heart failure. Her peripheral vascular disease has worsened, and she can walk only a block before being crippled with extreme leg pain. The patient reports that a new problem has surfaced: throbbing headaches with radiating neck pain. Dr. Lunden and Zena thoroughly discuss her health concerns and issues. In order to manage and investigate the multiplicity of problems, Dr. Lunden takes a complete PFSH. A complete review of systems (ROS) is performed and a medically appropriate examination is completed. Dr. Lunden has to take a multitude of factors into consideration, as the patient's problems are highly complex. NOTE: The CPT Changes: An Insider's View; CPT Assistant and Clinical Examples are not considered symbols or notations for this exercise. What is the principal procedure code? 99205

Explanation Principal Procedure: Where should you begin to look up the code in the coding manual - CPT Alphabetic Index What is the key term - Evaluation and management What is the location of the encounter - Office Is the patient new or established - New patient What is the level of history - Medically appropriate history What is the level of the examination - Medically appropriate examination What is the level of medical decision making - High complexity What else do we know about it - Diagnosed with insulin-dependent diabetes mellitus Begin to code the encounter Did you verify the code in the numerical listing - Yes Is there a symbol for this code - Yes If so what does the symbol mean - Telemedicine Is there additional notation(s) - Yes If so does the notation(s) apply - Does not apply Do you need to add a modifier - No If so what is the modifier - Does not apply Did you check the guidelines - Yes Did you code to the highest level of specificity - Yes What is the correct procedure code - 99205 Overall Feedback: 99205: Index>evaluation and management>office or other outpatient services>new patient Medically appropriate history Medically appropriate examination MDM of high complexity

Dr. Harrington provided care plan oversight services for Verniece Dantini, one of her patients at the Bracker Assisted Living Center. It took her 20 minutes. NOTE: The CPT Changes: An Insider's View; CPT Assistant and Clinical Examples are not considered symbols or notations for this exercise. What is the principal procedure code? 99339

Explanation Principal Procedure: Where should you begin to look up the code in the coding manual - CPT Alphabetic Index What is the key term - Evaluation and management What is the type of service - Care plan oversight services What is the location - Assisted Living Center Do you need to meet 3 of the 3 key components - Does not apply What is the total time frame - 20 minutes Begin to code the encounter Did you verify the code in the numerical listing - Yes Is there a symbol for this code - No If so what does the symbol mean - Does not apply Is there additional notation(s) - No If so does the notation(s) apply - Does not apply Do you need to add a modifier - No If so what is the modifier - Does not apply Did you check the guidelines - Yes Did you code to the highest level of specificity - Yes What is the correct procedure code - 99339 Overall Feedback: 99339: Index>evaluation and management>care plan oversight services>15-29 minutes

PRADER, BRACKER, & ASSOCIATES A Complete Health Care Facility 159 Healthcare Way • SOMEWHERE, FL 32811 • 407-555-6789 PATIENT: SARGENT, ALEXANDER ACCOUNT/EHR #: SARGAL001 DATE: 10/25/22 Attending Physician: Renee O. Bracker, MD S: This 85-year-old male is seen today at Northside Assisted Living Center, where he has been living for the last 6 months. The last time I saw this patient was right before he moved into the center. Nurse Thomas states that he has been complaining of mild abdominal pain and some discomfort upon urination. Other than this issue, he has been well and stable. O: Ht 5′6.5″, Wt 145 lb., R 18, P 73, BP 137/81. Abdomen is unremarkable. No masses or rigidity noted. A: Suspected bladder infection P: Order written for UA to rule out bladder infection. Be sure to list the codes, one code per box, in the correct sequence, from top to bottom, and in the proper row. Capitalization, punctuation, and spacing can impact whether or not your answer is correct. Follow coding best practices. Please list modifiers with the code they relate to as necessary. Include a hyphen in between the code and the modifier. Example Procedure: 43846-74 or for Anesthesia: 00797-P2. NOTE: The CPT Changes: An Insider's View; CPT Assistant and Clinical Examples are not considered symbols or notations for this exercise. Determine the most accurate E/M code(s) and modifier(s), if appropriate. The number of spaces provided does not indicate the number of codes required to accurately report this encounter. CPT code(s) and any applicable modifier(s) 99334

Explanation Principal Procedure: Where should you begin to look up the code in the coding manual - CPT Alphabetic Index What is the key term - Evaluation and management What is the type of service - Domiciliary or rest home Do you need to meet 3 of the 3 key components - No, only 2 of the 3 key components must meet or exceed stated requirements What is the level of history - Problem focused What is the level of the examination - Problem focused What is the level of medical decision making - Straightforward complexity Is the patient new or established - Established Begin to code the encounter Did you verify the code in the numerical listing - Yes Is there a symbol for this code - No Is there additional notation(s) - No Do you need to add a modifier - No Did you check the guidelines - Yes Did you code to the highest level of specificity - Yes What is the correct procedure code - 99334 Overall Feedback: 99334: Index>evaluation and management>domiciliary or rest home>established patient Problem-focused history Problem-focused examination MDM of straightforward complexity

Tom Seihill, a 23-year-old male, was admitted into the hospital 2 days ago for bronchitis. While in the hospital, Tom requested that his family physician, Dr. Selbiger, perform a circumcision, so Dr. Selbiger called in Dr. Wacker, a urologist, for a consultation. Dr. Wacker discussed the request with Tom and took a brief history and performed a limited genitalia examination. Afterward, Dr. Wacker made a straightforward decision and recommended that Raymond have the surgical procedure done at a later date as an outpatient procedure. Code for Dr. Wacker's services. NOTE: The CPT Changes: An Insider's View; CPT Assistant and Clinical Examples are not considered symbols or notations for this exercise. What is the principal procedure code? 99251

Explanation Principal Procedure: Where should you begin to look up the code in the coding manual - CPT Alphabetic Index What is the key term - Evaluation and management What is the type of service - Inpatient consultations Do you need to meet 3 of the 3 key components - Yes, 3 of the 3 key components must meet or exceed stated requirements What is the level of history - Problem focused What is the level of the examination - Problem focused What is the level of medical decision making - Straightforward complexity What else do we know about it - Patient was admitted for bronchitis Begin to code the encounter Did you verify the code in the numerical listing - Yes Is there a symbol for this code - Yes If so what does the symbol mean - Telemedicine Is there additional notation(s) - No If so does the notation(s) apply - Does not apply Do you need to add a modifier - No If so what is the modifier - Does not apply Did you check the guidelines - Yes Did you code to the highest level of specificity - Yes What is the correct procedure code - 99251 Overall Feedback: 99251: Index>evaluation and management>consultation>inpatient consultation>new or established. Problem-focused history Problem-focused examination MDM of straightforward complexity

Petula Carter, a 4-day-old female, currently weighs 2,000 grams and requires intensive cardiac and respiratory monitoring. This is her third day in the NICU, and Dr. Wadhwa comes in to do his E/M of her condition. NOTE: The CPT Changes: An Insider's View; CPT Assistant and Clinical Examples are not considered symbols or notations for this exercise. What is the principal procedure code? 99479

Explanation Principal Procedure: Where should you begin to look up the code in the coding manual - CPT Alphabetic Index What is the key term - Evaluation and management What is the type of service - Low birth weight infant Do you need to meet 3 of the 3 key components - Does not apply What else do we know about it - Subsequent care Current weight - 2,000 grams Begin to code the encounter Did you verify the code in the numerical listing - Yes Is there a symbol for this code - No If so what does the symbol mean - Does not apply Is there additional notation(s) - No If so does the notation(s) apply - Does not apply Do you need to add a modifier - No If so what is the modifier - Does not apply Did you check the guidelines - Yes Did you code to the highest level of specificity - Yes What is the correct procedure code - 99479 Overall Feedback: 99479: Index>evaluation and management>low birth weight infant>subsequent intensive care, per day, for the evaluation and management of the recovering low birth weight infant, 1,500-2,500 grams

Raymond Catertell, a 23-year-old male, is the son of two alcoholics. Dr. Lowen spends 40 minutes with him providing risk factor reduction behavior modification techniques to help him avoid becoming an alcoholic himself. NOTE: The CPT Changes: An Insider's View; CPT Assistant and Clinical Examples are not considered symbols or notations for this exercise. What is the principal procedure code? 99403

Explanation Principal Procedure: Where should you begin to look up the code in the coding manual - CPT Alphabetic Index What is the key term - Preventive medicine What is the type of service - Counseling Do you need to meet 3 of the 3 key component - Does not apply Is it individual or group - Individual What else do we know about it - Intervention What is the time frame - 45 minutes Begin to code the encounter Did you verify the code in the numerical listing - Yes Is there a symbol for this code - No If so what does the symbol mean - Does not apply Is there additional notation(s) - No If so does the notation(s) apply - Does not apply Do you need to add a modifier - No If so what is the modifier - Does not apply Did you check the guidelines - Yes Did you code to the highest level of specificity - Yes What is the correct procedure code - 99403 Overall Feedback: 99403: Index>preventive medicine>counseling>individual>intervention>new or established patient>approximately 45 minutes

Premier Life & Health Insurance Company required David Harrison, a 39-year-old male, to get Dr. Dijohn, his regular physician, to complete a certificate confirming that David's current disability prevents him from working at his regular job and makes him eligible for disability insurance. NOTE: The CPT Changes: An Insider's View; CPT Assistant and Clinical Examples are not considered symbols or notations for this exercise. What is the principal procedure code? 99455-32

Explanation Principal Procedure: Where should you begin to look up the code in the coding manual - CPT Alphabetic index What is the key term - Evaluation and management What is the type of service - Work-related and/or medical disability evaluation Do you need to meet 3 of the 3 key component - Does not apply Begin to code the encounter Did you verify the code in the numerical listing - Yes Is there a symbol for this code - No If so what does the symbol mean - Does not apply Is there additional notation(s) - No If so does the notation(s) apply - Does not apply Do you need to add a modifier - No If so what is the modifier - Does not apply Did you check the guidelines - Yes Did you code to the highest level of specificity - Yes What is the correct procedure code - 99455-32 Overall Feedback: 99455-32: Index>evaluation and management>work-related and/or medical disability Evaluation ~ append modifier -32 because it is a mandated encounter.

Dr. Anderson works in a very small town in Ohio and travels up to 200 miles to see his patients in the surrounding rural areas. His patient Brenda Viard gave birth at her home the previous day to a 6-lb 3-oz baby girl, Alice Rose. Dr. Anderson sees Alice Rose for the first time today, does a complete history and exam, and prepares her medical chart. Alice Rose is a healthy newborn. NOTE: The CPT Changes: An Insider's View; CPT Assistant and Clinical Examples are not considered symbols or notations for this exercise. What is the principal procedure code? 99461

Explanation Principle Procedure: Where should you begin to look up the code in the coding manual - CPT Alphabetic index What is the key term - Evaluation and management What is the type of service - Newborn care Do you need to meet 3 of the 3 key component - Does not apply What else do we know about it - Initial care Begin to code the encounter Did you verify the code in the numerical listing - Yes Is there a symbol for this code - No If so what does the symbol mean - Does not apply Is there additional notation(s) - No If so does the notation(s) apply - Does not apply Do you need to add a modifier - No If so what is the modifier - Does not apply Did you check the guidelines - Yes Did you code to the highest level of specificity - Yes What is the correct procedure code - 99461 Overall Feedback: 99461: Index>evaluation and management>newborn care>initial care, per day, for evaluation and management of normal newborn infant seen in other than a hospital or birthing center

ANYTOWN ANESTHESIOLOGY ASSOCIATES 241 MAIN STREET • ANYTOWN, FL 32711 • 407-555-1234 PATIENT: HAMMOND, NEIL ACCOUNT/EHR #: HAMMNE001 DATE: 10/21/22 Preoperative DX: C5-C6 and C6-C7 herniated nucleus pulposus Postoperative DX: Same Procedure: C5-C6 and C6-C7 anterior cervical diskectomy and fusion with cadaver bone and plate Attending Physician: Oscar R. Prader, MD Anesthesia: General endotracheal Anesthesiologist: Eric Keist, MD INDICATIONS: The patient is a 35-year-old male with a history of neck and arm pain. MRI scan showed disk herniation at C5-C6 and C6-C7. The patient failed conservative measures and was subsequently set up for surgery. Patient has been diagnosed with DM/HTN, which is well under control. PROCEDURE: The patient was taken to the OR. The patient was induced, and an endotracheal tube was placed. A Foley catheter was placed. The patient was given preoperative antibiotics. The patient was placed in slight extension. The left neck was prepped and draped in the usual manner. A linear incision was made above the C6 vertebral body. The platysma was divided. Dissection was continued medial to the sternocleidomastoid to the prevertebral fascia. The longus colli were cauterized and elevated. The C5-C6 disk space was addressed first. A retractor was placed. A large anterior osteophyte was removed with a large Leksell and drill. Distraction pins were then placed. The disk space was drilled out. Large bone spurs were drilled posteriorly. The posterior longitudinal ligament was removed. A free fragment was removed from beneath the ligament. The dura was visualized. A piece of bank bone was measured and slightly countersunk. The C6-C7 disk space was then addressed. Distraction pins were placed. A large anterior osteophyte was removed with a large Leksell and drill. The disk space was drilled out. Large bone spurs were drilled posteriorly. The Kerrison punch was used to remove the posterior longitudinal ligament. The dura was visualized. One piece of bank bone was in the C5, one in the C6, and two in the C7 vertebral bodies. The locking screws were tightened. The wound was irrigated. A drain was placed. The platysma was approximated with simple interrupted Vicryl. The dressing was applied. The patient was placed in a soft collar. The patient tolerated the procedure without difficulty. All counts were correct at the end of the case. The patient was extubated and transferred to recovery. Be sure to list the codes, one code per box, in the correct sequence, from top to bottom, and in the proper row. Capitalization, punctuation, and spacing can impact whether or not your answer is correct. Follow coding best practices. Please list modifiers with the code they relate to as necessary. Include a hyphen in between the code and the modifier. Example Procedure: 43846-74 or for Anesthesia: 00797-P2. NOTE: The CPT Changes: An Insider's View; CPT Assistant and Clinical Examples are not considered symbols or notations for this exercise. Determine the most accurate anesthesia code(s) and modifier(s), if appropriate. The number of spaces provided does not indicate the number of codes required to accurately report this encounter. Anesthesia code(s) and any applicable modifier(s) 00600-P2

Explanation Anesthesia Code: Where should you begin to look up the code in the coding manual - Alphabetic Index What is the key term - Anesthesia What is the anatomical site - Cervical spine and spinal cord Begin to code the encounter Did you verify the code in the numerical listing - Yes Is there a symbol for this code - No Is there additional notation(s) - Yes Do you need to add a physical status modifier - Yes If so what is the physical status modifier - P2 Do you need a qualifying circumstance code - No Did you check the guidelines - Yes Did you code to the highest level of specificity - Yes What is the correct anesthesia code - 00600-P2 Overall Feedback: 00600-P2:Index>anesthesia>spine and spinal cord>cervical Physical status modifier P2: Patient with mild systemic disease

Howard Shires, a 78-year-old male, was diagnosed with advanced Alzheimer's disease about 1 year ago and has been in this facility for approximately 10 months. He was seen today by the nursing facility's physician, Dr. Bowyer, over concern of the development of urinary and fecal incontinence, as well as a number of other medical problems that have appeared to increase in severity. In addition to the detailed interval history, the physician spoke with family members and the nursing staff. Then, Dr. Bowyer reviewed the patient's record to create an extended history necessary for an extended review of systems (ROS). Dr. Bowyer performed a comprehensive physical exam to assess all body systems. Afterward, he wrote all new orders due to the dramatic change in the patient's physical and mental condition. A new complex treatment plan was created. NOTE: The CPT Changes: An Insider's View; CPT Assistant and Clinical Examples are not considered symbols or notations for this exercise. What is the principal procedure code? 99310

Explanation Principal Procedure: Where should you begin to look up the code in the coding manual - CPT Alphabetic Index What is the key term - Evaluation and management What is the type of service - Nursing Facility Do you need to meet 3 of the 3 key components - No, only 2 of the 3 key components must meet or exceed stated requirements What is the level of history - Comprehensive interval What is the level of the examination - Comprehensive What is the level of medical decision making - High complexity What else do we know about it - Patient was admitted for bronchitis Begin to code the encounter Did you verify the code in the numerical listing - Yes Is there a symbol for this code - Yes If so what does the symbol mean - Telemedicine Is there additional notation(s) - No If so does the notation(s) apply - Does not apply Do you need to add a modifier - No If so what is the modifier - Does not apply Did you check the guidelines - Yes Did you code to the highest level of specificity - Yes What is the correct procedure code - 99310 Overall Feedback: 99310: Index>evaluation and management>nursing facility>subsequent care Comprehensive interval history Comprehensive examination MDM of high complexity