Coding: Medicine Ch. 20
An 18-year-old ESRD patient is receiving dialysis services and has had two face-to-face visits with her physician for 25 days. On the 26th day she is admitted to the hospital for inpatient management without a complete assessment. She remains in the hospital until the end of the month. Code for the physician services for the 25 days.
90969 x 25 Rationale: Code 90969 describes ESRD related services for dialysis less than a full month of service per day, for patients 12-19 years of age. This was not a full month of ESRD related services and; 90969 is reported per day with 25 units, 1 unit for each day. See the example in CPT® under End-Stage Renal Disease Services. In the CPT® Index, look for End Stage Renal Disease Services/Less Than a Full Month.
A pregnant female is Rh negative and at 28 weeks gestation. The child's father is Rh positive. The mother is given an injection of a high-titer Rho (D) immune globulin, 300 mcg, IM. What CPT® and ICD-10-CM codes are reported?
90384, 96372, O36.0130, Z3A.28 Rationale: When a mother is Rh negative and the father is Rh positive, the fetus is generally Rh positive, and fetal hemolytic anemia may develop in the fetus. In the CPT® Index look for Immune Globulins/Rho (D) and you are directed to code range 90384-90386. A full dose is 300 mcg. Code 90384 is reported. According to the guidelines for Immune Globulins an administration code is also reported. In the CPT® Index look for Immune Globulin Administration/Injection directing you to 96372. The administration code for intramuscular injection is 96372. In the ICD-10-CM Alphabetic Index look for Rh (factor)/incompatibility, immunization or sensitization/affecting management of pregnancy NEC/anti-D antibody which directs you to O36.01-. Tabular List shows seven characters are needed to complete the code. The 6 th character 3 is used to indicate the patient is in her 3 rd trimester. The 7 th character 0 is used to indicate this is a single gestation. Next look for Pregnancy/weeks of gestation/28 directing you to Z3A.28.
A diabetic patient visited a neighborhood clinic to receive influenza and pneumonia immunizations. The patient received the influenza, trivalent (IIV3) spilt virus 0.5mL and pneumococcal polysaccharide vaccine, 23-valent (PPSV23). Select the appropriate procedure codes for this service.
90658, 90732, 90471, 90472 Rationale: The patient received two vaccines: influenza and pneumonia. Each is charged separately. In the CPT® Index, look for Vaccines and Toxiods/Influenza/for Intramuscular Use. A review of the code choices indicates 90658 is the correct code. For the pneumonia vaccine look in the index for Vaccines/and Toxoids/Pneumococcal/ 23-valent (PPSV23). Code 90471 describes injection of one vaccine. The add-on code 90472 describes each additional vaccine. Add-on codes (+) may not be reported independently, but are a composite of the basic code. In the CPT® Index look for Administration/Immunization One Vaccine/Toxoid and Administration/ Immunization/Each Additional/Vaccine/Toxoid.
A therapist in a residential care facility works with a nonverbal autistic child, age 4. In this session the therapist uses drawing paper and washable markers. The therapist sat with the child and began to draw on a sheet of paper. She gave paper and markers to the child and encouraged the child to draw. The psychotherapy session lasted 30 minutes.
90832, 90785, F84.0 Rationale: Psychotherapy session with was performed lasting 30 minutes. In the CPT® Index look for Psychotherapy/Individual Patient. Review the codes, code 90832 is the correct code to report. Art therapy is frequently used when working with children who are unable to verbalize well or not at all. It may give insight to thought processes through the expressions captured in the artwork. Art therapy is considered individual psychotherapy. In the CPT® Index look up Psychotherapy/Interactive Complexity you are directed to code range 90785. Code selection is based on time and whether a medical evaluation and management was performed. Code 90785 is an add-on code and for this case is reported with 90832 per instructions at the beginning of this section. Time is not a factor with 90785. The child is currently autistic and does not communicate verbally. In the ICD-10-CM Alphabetic Index look for Autism, autistic (childhood) (infantile) which directs you to F84.0. Since an autism spectrum is not defined, the correct diagnosis code is F84.0. Verification in the Tabular List confirms code selection.
A teenager has been chronically depressed since the separation of her parents 1 year ago and moving to a new city. Her school grades continued to slip and she has not made new friends. She has frequent crying episodes and is no longer interested in her appearance. She has attended the community mental health center and participates in group sessions. Recently her depression exacerbated to the point inpatient admission was required. The provider diagnosed adjustment disorder with emotional and conduct disturbances. Due to the length of the depression and no real improvement, the provider discussed electroconvulsive therapy with her mother. After discussing benefits and risks, the mother consented to the procedure. What CPT® and ICD-10-CM codes are reported for the electroconvulsive therapy?
90870, F43.25 Rationale: In the CPT® Index look for Electroconvulsive Therapy which directs you to 90870. For the diagnosis, in the ICD-10-CM Alphabetic Index look for Disorder/adjustment/with/conduct disturbance/with emotional disturbance and you are directed to F43.25. F43.25 includes disturbances of conduct, so F43.24 is not reported separately. Verification in the Tabular List confirms code selection.
A patient had several panic attacks at work disturbing her coworkers. She had been unable to explain any particular reason for her behavior. Her employer requested she be referred for counseling. After several sessions, her psychiatrist provided reports for her primary care provider and her insurer about her status and prognosis. What CPT® and ICD-10-CM codes are reported for the preparation of the report?
90889, F41.0 Rationale: The psychiatrist has prepared a report about her psychiatric status, history and current progress for other individuals, agencies, or insurance carriers. In the CPT® Index look for Psychiatric Treatment/Report Preparation and you are directed to code 90889. By definition in the code, this is not used for legal or consultative purposes. Panic attacks not defined are reported as F41.0. In the ICD-10-CM Alphabetic Index look for Attack, attacks/panic. Verification in the Tabular List confirms code selection.
A patient with hypertensive end stage renal failure, stage 5, and secondary hyperparathyroidism is evaluated by the provider and receives peritoneal dialysis. The provider evaluates the patient once before dialysis begins. What CPT® and ICD-10-CM codes are reported?
90945, I12.0, N18.6, Z99.2, N25.81 Rationale: In the CPT® Index look for Dialysis/Peritoneal which directs you to codes 90945, 90947, 4055F (an outcomes measurement code). The peritoneal dialysis with one provider evaluation is reported with 90945. In the ICD-10-CM guideline I.C.9.a.2 codes from category I12 is assigned when both hypertension and a condition from the chronic kidney disease codes N18 are both present. In the ICD-10-CM Alphabetic Index look for Hypertension, hypertensive/kidney/stage 5 chronic disease (CKD) or end stage renal disease (ESRD) which directs you to I12.0. The instructions in the ICD-10-CM guidelines and in the Tabular List for code I12.0 indicate to use an additional code to identify the stage of CKD. In the Alphabetic Index look for Disease, diseased/kidney/chronic/stage 5 leading to N18.5. In the Tabular List, according to the Excludes1 note below N18.5 when the patient has stage 5 CKD but requires dialysis it is reported with N18.6. Coding note under N18.6 states to use an additional code to identify the dialysis status with code Z99.2. Look for Status/Dialysis (hemodialysis) (peritoneal) which directs the coder to Z99.2. The patient also has secondary hyperparathyroidism reported with N25.81. Look in the Alphabetic Index for Hyperparathyroidism/secondary (renal). Verification in the Tabular List confirms code selection.
A 49 year-old patient had several episodes of esophageal reflux and underwent a gastroesophageal reflux test to measure the pH balance (a measure of the degree of acidity or alkalinity). The test was performed with a mucosal attached capsule. The provider provided an interpretation and report. The provider stated the diagnosis as gastroesophageal reflux. What CPT® and ICD-10-CM codes are reported?
91035, K21.9 Rationale: In the CPT® Index look for Acid Reflux Test/Esophagus. The provider measured the pH balance and used a mucous capsule, which attaches the electrode to the mucous in the esophagus which is reported with code 91035. Catheter placement of the electrode is becoming rare with the development of the mucous attaching capsule.In the ICD-10-CM Alphabetic Index look for Reflux/gastroesophageal. The diagnosis code for gastroesophageal reflux without esophagitis is K21.9. Reflux is regurgitation of gastric contents into the mouth, caused by incompetence of the lower esophageal sphincter. Verification in the Tabular List confirms code selection.
A 55 year-old patient had several episodes of fecal incontinence. A colonoscopy had been performed one year ago with normal results. Anorectal manometry was performed to determine the pressure on the sphincter muscles. The test indicated a mild relaxation of the sphincter. Biofeedback training was prescribed. What CPT® and ICD-10-CM codes are reported?
91122, K62.89, R15.9 Rationale: In the CPT® Index look for Manometry/Anorectal and you are directed to 91122. Biofeedback training is not reported since it was prescribed but not performed.The diagnosis of relaxation of anal sphincter is reported with K62.89. In the ICD-10-CM Alphabetic Index look for Relaxation/anus (sphincter). Verification in the Tabular List shows an instructional note to code also any fecal incontinence. In the Alphabetic Index look for Incontinence/feces directing you to R15.9. Verify code selection in the Tabular List.
A 15 year-old underwent placement of a cochlear implant 1 year ago. It now needs to be reprogrammed. What CPT® code is reported for the reprogramming?
92604 Rationale: Cochlear implants differ from hearing aids; they bypass the damaged part of the ear. The use of a cochlear implant involves relearning how to hear and react to sounds. In the CPT® Index look for Cochlear Device/Programming which directs you to codes 92602, 92604. The code selection is based on the age of the patient and whether it is the initial programming or subsequent reprogramming. Code 92604 describes subsequent reprogramming for a patient age 7 or older.
A patient with coronary atherosclerosis underwent a PTCA in the left anterior descending and in the first diagonal of the LD. What CPT® code(s) is/are reported?
92920-LD, 92921-LD Rationale: PTCA stands for percutaneous transluminal coronary angioplasty. In the CPT® Index look for PTCA directing you to see Percutaneous Transluminal Angioplasty. Under Percutaneous Transluminal Angioplasty/Artery/Coronary. Code 92920 is used for the main coronary artery which is the left anterior descending. The add-on code 92921 is used to report the PTCA to a branch off of the left anterior descending - the first diagonal.
A patient was brought to the emergency department in cardiac arrest. The physician immediately initiated CPR. What CPT® code is reported for CPR?
92950 Rationale: Medical personnel usually begin cardiopulmonary resuscitation (CPR) which provides artificial breathing and chest compressions for a person in cardiac arrest. In the CPT® Index you can look for either CPR or Cardiopulmonary Resuscitation or Resuscitation/Cardiopulmonary. All indexed items direct you to code 92950.
A cardiologist provided an interpretation and report of an EKG. What CPT® code is reported?
93010 Rationale: In the CPT® Index look for EKG and you are directed to see Electrocardiography. For Electrocardiography/Evaluation. Codes 93000, 93010. 93000 includes the 12 lead EKG in addition to the interpretation and report. The provider only provided the interpretation and report making 93010 the correct code choice. Modifier 52 to report reduced services is not appropriate because there are codes that can specifically report each component.
A patient with atrial fibrillation had a dual lead pacemaker implanted 1 year ago. Today she returns to the provider's office for evaluation of function of the device by analyzing and reviewing the parameters stored comparing it to current readings. It was determined minor adjustments and reprogramming were needed. What CPT® code is reported?
93280 Rationale: In the CPT® Index look for Pacemaker and you are directed to See Cardiac Assist Devices. In the CPT® Index look for Cardiac Assist Devices/ Pacemaker System/Device and Evaluation. The elements included in the service are described in the Programming device evaluation (in person) guidelines, listed under Cardiovascular Monitoring Services - Implantable and Wearable Cardiac Device Evaluations. You can find these guidelines in CPT® just before code 93280. Code 93280 is the correct code for a dual lead pacemaker, with adjustments, in person.
A 5 week-old infant shows signs of fatigue after eating and has poor weight gain. He is suspected to have a congenital heart defect. The neonatologist ordered a transthoracic echocardiogram (TTE). TTE is showing a shunt between the right and left ventricles. The neonatologist read and interpreted the study and indicated the patient has a ventricular septal defect (VSD). What are the CPT® and ICD-10-CM codes for the TTE read?
93303-26, Q21.0 Rationale: In the CPT® Index look for Echocardiography/Transthoracic/Congenital Cardiac Anomalies which directs you to 93303, 93304. Code selection is based on whether it is a complete study, follow up or limited study. This is a complete study therefore code 93303 the correct code choice. Since we are only reporting reading and interpretation of the report, a modifier 26 is appended. In ICD-10-CM Alphabetic Index look for Defect, defective/ventricular septal which directs you to Q21.0. Verification in the Tabular List confirms code selection.
A patient with chronic myeloid leukemia (CML), BCR/ABL-positive has an implanted access port for delivery of chemotherapy. The device needs to be irrigated before receiving treatment. What ICD-10-CM and CPT® codes are reported for the irrigation?
96523, C92.10 Rationale: In the CPT® Index look for Irrigation/Venous Access Device. Report code 96523 for irrigation of an implanted venous access device. In the ICD-10-CM Alphabetic Index look for Leukemia/chronic myeloid, BCR/ABL-positive and you are directed to C92.1-. In the Tabular List the 5 th character of 0 is used to indicate there is no mention of having achieved remission.
A baby was born with a ventricular septal defect (VSD). The provider performed a right heart catheterization and transcatheter closure with implant by percutaneous approach. What codes are reported?
93581, Q21.0 Rationale: In the CPT® Index look for Septal Defect/Closure/Ventricular. Reading the descriptions code 93581 describes percutaneous transcatheter closure of a congenital ventricular septal defect using an implant. There is a parenthetical note under code 93581 stating that the right heart catheterization is included in this procedure and not to report code 93530 with code 93581.VSD is a congenital condition (present at birth). In the ICD-10-CM Alphabetic Index look for Defect/ventricular septal which refers you to Q21.0. Verification in the Tabular List confirms code selection.
A post-MI (myocardial infarction) patient has been receiving cardiac rehabilitation. At this session the provider evaluates the patient, determines he shows satisfactory progress and may increase his normal daily activities. Continuous EKG is not used at this session. What CPT® code is reported?
93797 Rationale: In the CPT® Index look for Rehabilitation/Cardiac. Code 93797 describes the provider services for cardiac rehabilitation when continuous EKG monitoring is not utilized at the encounter.
A patient visits her physician complaining of severe left lower leg pain and numbness. The left lower leg is pale compared to the right lower leg. There is no known injury. The physician evaluates for a possible blood clot before considering treatment. The physician orders a stat duplex scan of the arteries of the left leg . The scan indicates no evidence of a clot. Select the appropriate CPT® code for reporting this service.
93926 Rationale: Code 93926 describes duplex scan, limited or unilateral study, of the lower extremity arteries, including digits. Pain and discoloration were present in the lower left leg, the only extremity scanned. In the CPT® Index, look for Duplex Scan/Arterial Studies/Lower Extremity.
A 70 year-old patient with chronic obstructive asthma is brought to the urgent care center with increased wheezing and coughing. The provider initiated an albuterol inhalation treatment, one dose, delivered by nebulizer. After treatment, the patient's exacerbation was somewhat improved but the provider determined a second treatment was necessary. What codes are reported?
94640, 94640-76, J7609 x 2, J44.1 Rationale: In the CPT® Index look for Inhalation Treatment/for Airway Obstruction/Pressured or Nonpressured which directs you to 94640. Inhalation treatment was given therapeutically in treating the acute airway obstruction. Two treatments were given so code 94640 is reported twice. Under code 94640 there is a parenthetical instruction stating to use modifier 76 if more than one inhalation treatment is performed on the same date. Because treatment is in the office (urgent care is considered office treatment), the provider will also bill for the medication used. In this case, it is albuterol. In the HCPCS Level II codebook go to the Table of Drugs and Biologicals and look for Albuterol, unit dose form which directs you to J7609, J7613. J7609 is reported for albuterol per dose. Two doses were given reporting J7609 x 2. For the diagnosis in the ICD-10-CM Alphabetic Index look for Asthma/chronic obstructive/with exacerbation (acute) directing you to J44.1. There is no mention of status asthmaticus, but exacerbation is mentioned. The diagnosis code is J44.1. Verification in the Tabular List confirms code selection.
A 5 year-old is brought in to see an allergist for generalized urticaria. The family just recently visited a family member that had a cat and dog. The mother wants to know if her son is allergic to cats and dogs. The child's skin was scratched with two different allergens. The provider waited 15 minutes to check the results. There was a flare up reaction to the cat allergen, but there was no flare up to the dog allergen. The provider included the test interpretation and report in the record.
95004 x 2 Rationale: In the CPT® Index look for Allergy Tests/Skin Tests/Allergen Extract. Code selection is based on the method of testing performed. Code 95004 describes the scratch test with allergenic extracts. The test is reported twice for the number of substances that were tested.
A patient who has had two recent seizures underwent a 3-hour continuous EEG recording, without video. The physician interpreted the study and documented a report in the patient's medical record. What CPT® code is reported?
95705 Rationale: In the CPT® Index look for EEG directing you to See Electroencephalography (EEG). Look for Electroencephalography (EEG)/Recording/Detection. The patient had a 3 hour continuous EEG without use of video which the physician interpreted, not an EEG technologist. The correct code to report is 95717.
A qualified genetics counselor is working with a child who has been diagnosed with fragile X syndrome. After extensive research about the condition, she meets with the parents to discuss the features of the disease and the child's prognosis. The session lasted 45 minutes. What CPT® and ICD-10-CM codes are reported?
96040, Q99.2 Rationale: In the CPT® Index look for Medical Genetics which directs you to 96040. The genetics counseling session is reported as face-to-face time per 30 minutes. Report 1 unit for the first 30 minutes. Since the remaining time is 15 minutes, it is not reported separately per the Medical Genetics and Genetic Counseling Services guidelines. Fragile X syndrome is a congenital chromosomal anomaly that may include mental retardation. In the ICD-10-CM Alphabetic Index look for Syndrome/fragile X. The condition is reported with code Q99.2. Verification in the Tabular List confirms code selection.
A patient needs a renal transplant. The patient has been on dialysis and is awaiting a suitable donor. A clinical psychologist meets with the patient to assess the patient's ability to comply with the requirements and drug regimen if a donor match is found. The session lasts 2 hours. What is the correct code for this service?
96156 Rationale: Code 96156 describes the health behavior assessment or re-assessment.. The encounter lasted two hours, but the code is not a time-based code and should only be billed with a quantity of 1. In the CPT® Index, look for Evaluation and Management/Health Behavior/Assessment.
A patient underwent a knee arthroplasty (joint replacement) and now requires physical therapy to learn to walk with the artificial joint. The therapist evaluates the patient and documents a brief history and exam, and initiates therapeutic exercises and gait training. The clinical decision making is of low complexity. The exercises are for 45 minutes and the gait training is 15 minutes at this session. Code the evaluation and therapeutic services.
97161-GP, 97110-GP X 3, 97116-GP Rationale: The therapist evaluates the patient and problem at the first visit and determines a treatment plan. Gait training will be necessary and will likely increase in time at subsequent therapy sessions. Code 97161 is reported for an uncomplicated condition with low clinical decision making. In the CPT® Index, look for Physical Medicine/Therapy/Occupational Therapy/Evaluation/Physical Therapy. Code 97110 is for the exercises. In the CPT® Index, look for Physical Medicine/Therapy/Occupational Therapy/Procedures/Therapeutic Exercises. And 97116 for the gait training. In the CPT® Index, look for Physical Medicine/Therapy/Occupational Therapy/Procedures/Gait Training. Report three units for the exercises to cover 45 minutes.
An anorexic patient is experiencing signs of severe dietary deficiency and electrolyte imbalance. She will need medical nutrition therapy to treat these symptoms. The provider spends 30 minutes with the patient to discuss the seriousness of her eating disorder and the necessity of nutrition therapy. What is the code for this initial assessment?
97802 x 2 Rationale: Code 97802 describes the initial medical nutrition assessment interview per 15 minutes of face-to-face time. Report two units for the 30-minute session. In the CPT® Index, look for, Nutrition Therapy/Initial Assessment.
A patient sustained a neck strain as a driver in an automobile accident, losing control, hydroplaning and hitting a tree off the highway which caused the car to overturn. He has continued to have neck pain and stiffness. He sees a chiropractor who assesses the patient and manipulates his neck. The diagnosis is neck strain. What CPT® and ICD-10-CM codes are reported for the chiropractor?
98940, S16.1XXA, V47.0XXA Rationale: In the CPT® Index look for Manipulation/Chiropractic. The neck is the cervical spine and code selection is based on the number regions treated. In this case, 1 region is treated making 98940 is the correct code choice.In the ICD-10-CM Alphabetic Index look for Strain/cervical or Strain/neck and you are directed to code S16.1-. The Tabular List shows seven characters are needed to complete the code. X is used as a placeholder for the 5 thand 6 th characters. A is the 7 th character for the initial encounter receiving active treatment. Next, report the external cause. The patient was the driver in a non-collision vehicle accident when he lost control of the car. Look in the ICD-10-CM External Cause of Injuries Index for Accident/car which states to see Accident, transport, car occupant. Look for Accident/transport/car occupant/driver/collision (with)/stationary object/nontraffic. When referring to the Tabular List, subcategory code V47.0 is used and it shows seven characters are needed to complete this code. X is used as the 5 th and 6 thcharacters and A, initial encounter, is used for the 7 thcharacter.
A patient receives manipulations in the cervical, thoracic and lumbar spine by a Chiropractor. What is the correct code for this service?
98941 Rationale: Three regions of the spine were manipulated. Code 98941 describes manipulation of 3-4 regions. In the CPT® Index, look for Manipulation/Chiropractic.
A diabetic patient who has not been successful managing his diet meets personally with a Registered Dietician for one hour to develop a diet plan. What is the correct code for this service?
98960 x 2 Rationale: Code 98960 describes face-to face education and training with one patient for 30 minutes. Report two units for one hour. In the CPT® Index, look for Special Services/Individual Education/Self-management.
A patient ingested a toxic substance and was administered ipecac in the Emergency Department to empty the stomach. What is the correct code for this service?
99175 Rationale: Code 99175 describes administration of Ipecac to induce emesis for emptying the stomach. In the CPT® Index, look for Ipecac Administration/for Poisoning.
A provider has ordered de-ironing by therapeutic phlebotomy to be performed weekly. The patient is diagnosed with hemochromatosis and therapeutic phlebotomy is used to avoid irreversible tissue damage. One unit of blood is removed weekly. What CPT® and ICD-10-CM codes are reported for each weekly visit treatment?
99195, E83.119 Rationale: In the CPT® Index look for Phlebotomy/Therapeutic and you are directed to 99195. The codes are reported once per encounter. In the ICD-10-CM Alphabetic Index look for Hemochromatosis and without further information you are directed to E83.119. Verification in the Tabular List confirms code selection.
A 64 year-old patient came to the emergency department complaining of chest pressure. The provider evaluated the patient. Appropriate initial management was continued by the ED provider who contacted the cardiologist on call in the hospital. Admission to the cardiac unit was ordered. No beds were available in the cardiac unit and the patient was held in the ED. The cardiologist left the ED after completing the evaluation of the patient and had interpreted the findings of an EKG that indicated signs of acute cardiac damage. Several hours passed and the patient was still in the ED. During an 80-minute period, the patient experienced acute breathing difficulty, increased chest pain, arrhythmias and cardiac arrest. The patient was managed by the ED provider during this 80-minute period. Included in the ED provider management were endotracheal intubation and CPR to restore the patient's breathing and circulation for 20 minutes. CPR was unsuccessful, the patient was pronounced dead after a total of 44 minutes critical care time, exclusive of other separately billable services. What CPT® codes are reported by the ED provider?
99291-25, 31500, 92950 Rationale: Only one E&M code is reportable per provider per day. The patient never left the emergency department. The first part of the encounter did not meet critical care, although the second part did meet critical care. In the CPT® Index look for Critical Care Services. Use code 99291 for 44 minutes of critical care. The Critical Care Services guidelines list services that are included in Critical Care time. Additional services performed not included in the listing are reported separately. In the CPT® Index look for Insertion/Endotracheal Tube/Emergency Intubation which directs you to 31500. In the CPT® Index look for CPR. Report cardiopulmonary resuscitation with code 92950.
A patient was discharged recently from the hospital following a colon resection with colostomy. A nurse makes a home visit to assist with the patient's colostomy. What is the correct code for this visit?
99505 Rationale: Code 99505 describes a home care visit from a nonphysician practitioner to manage stomas and ostomies. In the CPT® Index, look for Home Services/Stoma Care.
CASE 1 Pre-procedure Diagnosis: Asthma Post-procedure Diagnosis: Asthma (Post procedural diagnosis used for coding.) Procedure: Psychophysiological Therapy Biofeedback The patient returned to clinic with daily diary documenting home peak flow readings and asthma symptoms. Diary was assessed and discussed with patient. Patient reports reduced dosing with inhaled steroids and fewer asthmatic episodes. Lungs and respiratory resistance assessed. Lungs clear, no wheezes or rhonci noted. (Psychophysiological training.) HRV biofeedback was performed using a physiograph. (Biofeedback documentation.) ECG data were collected from the left arm and right leg, and were digitized at 510 Hz. EEG biofeedback equipment attached and baroreflex gain was assessed with beat-to-beat BP recordings and digitized at a rate of 252 samples per second. The sensor was placed on the participant's right middle finger, and the hand was elevated on a table to approximately the level of the heart. Respiratory system impedance (Zrs) (between 2 and 32 Hz with 2-Hz increments) was measured using a pseudorandom noise forced oscillation system. It was presented in 40 2-second bursts spaced equally throughout In order to minimize the effects of possible partial glottal closure during exhalation, each burst was triggered by the beginning of an inhalation. Post procedure, Inspirometer readings were recorded. Asthma symptoms were scored with the patient. Biofeedback procedure lasted approximately 28 minutes. (Biofeedback time.) The patient is to return to clinic in two weeks with daily diary. It is expected the patient will continue with reduced regiment and asthmatic episodes. What are the CPT® and ICD-10-CM codes reported? CPT® code: [a] ICD-10-CM code: [b]
Specified Answer for: a 90875 Specified Answer for: b J45.909
CASE 2 Performed in the office Pre-procedure Diagnosis: Gastro-esophageal reflux disease (GERD), Heartburn Post-procedure Diagnosis: GERD (Post procedure diagnosis used for coding.) Procedure: Esophageal pH monitoring with Bravo pH Capsule (Acid reflux testing) Patient was placed in supine position on examining bed, IV moderate sedation was administered. Visualization of esophagus with anatomic markers located during endoscopy. Endoscopy was removed and the Bravo pH Capsule delivery system was passed into the esophagus using the oral passage until the attachment site was obtained at approximately 5cm proximal to the upper margin of the LES. The external vacuum pump was activated pulling the adjacent esophageal mucosa into the fastening well. Vacuum gauge at 600 mm Hg and held for 10 seconds. The plastic safety guard on handle was then removed and the activation button was depressed and turned attaching the pH capsule to the esophageal wall. (Placement of electrode placement.) The activation button on handle was then twisted 90 degrees and re-extended, releasing the pH capsule. Esophagoscopy was repeated to verify capsule attachment. Prior to procedure, the Bravo pH capsule was activated and calibrated by submersion in pH buffer solutions. The patient tolerated the procedure well and was transferred into the recovery room. The patient returned to the office two days later for download of the recording. The information was analyzed and interpreted. What are the CPT and ICD-10-CM codes reported? CPT® code: [a] ICD-10-CM code: [b]
Specified Answer for: a 91035 Specified Answer for: b K21.9
CASE 3 Pre-procedure Diagnosis: Sleep Apnea Post-procedure Diagnosis: Obstructive sleep apnea Procedure: Overnight Sleep Study 35-year-old patient in Hospital Sleep Lab for attended, overnight polysomnogram. (Polysomnogram performed.) Patient oriented to room and changed into overnight clothing and brought into lab by patient. Latency to sleep onset slightly prolonged at 32.3 minutes. During the first 82 minutes of sleep, 80 obstructive apneas were manifested (Respiratory Effort). The lowest SpO2 during the non-supplemented sleep period was 73% (Oxyhemoglobulin saturations (SPO2)). CPAP was then applied at 5 cm H2, and sequentially titrated to a final pressure of 18 cm H2O. The Apnea-hypopnea index (AHI) changed from 60 events/hr to 4 events/hr. SpO2 increased to 90%. The sleep study with and without CPAP shows severe obstructive sleep apnea with improvement with CPAP settings at 18 cm H20. Based on the improved SpO2 levels with CPAP, it is recommended this patient use a BIPAP machine during sleep hours due to obstructive sleep apnea events. What are the CPT® and ICD-10-CM codes reported? CPT® code: [a] ICD-10-CM code: [b]
Specified Answer for: a 95808 Specified Answer for: b G47.33
CASE 4 Pre-procedure Diagnosis: Excessive Daytime Sleepiness, Snoring, Epworth Score 18 Post-procedure Diagnosis: Sleep Study Procedure: Polysomnogram, attended 25-year-old patient underwent overnight polysomnogram with the recording of EEG(Parameter 1.), EOG(Parameter 2.), submental and anterior tibialis EMG(Parameter 3.), respiratory effort(Parameter 4.), nasal and oral airflow(Parameter 5.), EKG(Parameter 6.), continuous pulse oximetry(Parameter 7.). Total time in bed of 386 minutes and a total of sleep time of 221 minutes. The sleep latency was 24 minutes and the REM sleep latency was 18 minutes. Throughout the night, the patient had a total of 256 episodes of arousals and 6 awakenings. Sleep efficiency was 56%. No apparent parasomnia noted. The average oxygen saturation was reported to be 95% with the lowest saturation being 84%. There were no periodic leg movements for an index of 0.0 and cardiac arrhythmias were not present. Impression: Mild sleep apnea(Post-procedure diagnosis.) What are the CPT® and ICD-10-CM codes reported? CPT® code: [a] ICD-10-CM code: [b]
Specified Answer for: a 95810 Specified Answer for: b G47.30
CASE 5 Pre-procedure Diagnosis: Analysis of Vagal Nerve Stimulator (VNS), epilepsy with history of seizures Post-procedure Diagnosis: Analysis of Vagal Nerve Stimulator (VNS), epilepsy with history of seizures(Post procedural diagnosis) Procedure: Vagal Nerve Stimulator Analysis(VNS analysis) Patient here for VNS implant analysis with possible adjustments. The programming head was placed over the implanted neurostimulator located within the patient's neck-left side. Impedance was verified insuring parameters within normal limits. Parameters charted on flowchart within medical record. Operating status of neurostimulator reflects on. Estimated time for analysis/interrogation was 20 minutes in duration. Patient denies questions at this time. Will repeat analysis in three months. What are the CPT® and ICD-10-CM codes reported? CPT® code: [a] ICD-10-CM codes: [b], [c]
Specified Answer for: a 95970 Specified Answer for: b Z46.2 Specified Answer for: c G40.909
CASE 6 Pre-procedure Diagnosis: Aortic insufficiency; hypertension Post-procedure Diagnosis: Borderline Left Ventricular Hypertrophy, Mild Aortic Insufficiency, Left ventricular Ejection Fraction 80% Procedure: 2D with M-mode Echocardiogram with pulsed continuous wave with spectral display and Doppler color flow mapping Patient positioned in supine position on exam table. Echocardiogram proceeded without incidence. Findings: Borderline left ventricular hypertrophy. Mild aortic insufficiency. Left ventricular ejection fraction 80%. What are the CPT® and ICD-10-CM codes reported? CPT® code: [a] ICD-10-CM codes: [b], [c]
Specified Answer for: a 93306 Specified Answer for: b I51.7 Specified Answer for: c I35.1
CASE 7 Pre-procedure Diagnosis: Persistent Right and Left Leg pains; Extensive varicose vein disease Post-procedure Diagnosis: Varicose vein disease with inflammation, venous insufficiency, leg pains due to varicose veins Procedure: Peripheral Vascular Duplex Ultrasound Evaluation of the Venous Anatomy of the Lower Extremities Patient's right and left leg venous anatomy was examined in the standing position utilizing a B-Mode Duplex ultrasound machine with a 12 MHz probe. The focus was to determine the location and flow characteristics of both the deep and superficial venous systems. The evaluations included dynamically focused gray-scale and color imaging supplemented by Doppler spectroanalysis. Valsalva maneuver as well as calf and thigh compressions were performed to determine the patency and direction of blood flow, the exact paths of venous reflux in the major venous trunks, tributaries, and perforator veins. Ultrasonic mapping included images of major deep veins of the leg, saphenofemoral junction, the great saphenous vein above and below the knee, and the short saphenous vein system below the knee. Measurements and flow characteristics were obtained and listed on venous map in chart. Bilaterally, the great saphenous veins were absent beginning at the saphenofemoral junction, due to previous surgery. Noted was venous reflux and enlargement of neovascular and tributary portions of the vein systems in the upper and lower legs. Abnormalities and associated perforator veins were documented on venous map in chart. The internal diameters of the leg varicosities varied to 5 and 3.8mm in diameter, bilaterally. No evidence of deep venous reflux or thrombosis noted within the femoral, popliteal, gastroncnemius, or posterior tibial vessels. Photocopies were taken of the venous abnormalities and are included in the medical record. Findings: Varicose vein disease with inflammation Venous insufficiency Leg pains due to varicose veins What are the CPT and ICD-10-CM codes? CPT Code: [a] ICD-10-CM codes: [b], [c], [d]
Specified Answer for: a 93970 Specified Answer for: b I83.11 Specified Answer for: c I83.12 Specified Answer for: d I83.813
CASE 9 Pre-procedure Diagnosis: Palpable Pulsating Abdominal Mass Post-procedure Diagnosis: AAA Procedure: Abdominal Aorta Duplex Ultrasound by ultrasound technician The patient was placed on the examining table in a supine position. Conductive gel was applied to the abdomen. The transducer was gently moved over the abdomen. An aortic mass was identified within the inferior aorta at approximately the 3.2 cm mark. Measurements were marked and recorded. Anterior-posterior measurement equaled 4.8 cm and transverse measurement equaled 5.7 cm. Report views and results were given to the ER physician caring for the patient by the radiologist who interpreted the ultrasound. What are the CPT® and ICD-10-CM codes reported? CPT® code: [a] ICD-10-CM code: [b]
Specified Answer for: a 93979-26 Specified Answer for: b I71.4
CASE 8 Pre-procedure Diagnosis: Extensive keratosis lesions of left anterior neck Post-procedure Diagnosis: keratosis lesions left anterior neck Procedure: Blue Light Photodynamic Therapy with topical skin sensitizing agent Patient here for photodynamic therapy. Verbal instruction of procedure given to patient with patient verbalizing understanding. Patient positioned self in supine position on exam table. Safety goggles applied to eyes, noting patent seal and full coverage of ocular orbital areas. Application of topical Levulan® Kerastick® applied to left anterior neck keratosis lesions. Blue light lamp adjusted to reflect on left anterior neck. Phototherapy duration: 15 minutes. Post procedure skin was slightly reddened, no swelling noted. Post-procedure instructions were discussed with patient. Patient to return to office in eight weeks for assessment and possible repeat treatment. Procedure performed by the physician. What are the CPT® and ICD-10-CM codes reported? CPT codes: [a], [b] ICD-10-CM code: [c]
Specified Answer for: a 96573 Specified Answer for: b J7308 Specified Answer for: c L57.0
CASE 10 10-Year-old established patient presents today for well child check with mother with complaints of frequent urination during the day. The patient has two sisters and sees dad sporadically. Lives in a smoke free environment. One dog, one rabbit. Denies dysuria, abdominal pain, or rashes, all other systems are reviewed and negative. Patient going into 4th grade with good grades. No parental concerns. Patient cooperates but does tend to back talk. Doing well on Concerta Exam General: Normal Head: Normal Eyes: Normal Ears: Normal Nose: Normal Mouth/throat: Normal Neck: Normal Abdomen: Normal Rectal: Not examined Genitals: Normal Skin: 3mm papule on dorsal R hand without disruption of creases Urinalysis: Ketones, nitrite, leukocytes normal; trace blood, low specific gravity. Counseled patient on the use of seat belts, bicycle/skate helmets, gun safety, water/sun safety. Assessment: Well Child Check, ADHD, Wart, Frequent Urination Refill Concerta 18mg PO q AM Wart cleansed with alcohol. Histofreeze x 25 seconds was performed to destroy the wart. Varicella Vaccine #2 administered without any complications. What are the CPT® and ICD-10-CM Codes? CPT® Codes: [a], [b], [c], [d], [e] ICD-10-CM Codes: [f], [g], [h], [i], [j]
Specified Answer for: a 99393-25 Specified Answer for: b 17110 Specified Answer for: c 90471 Specified Answer for: d 90716 Specified Answer for: e 81002 Specified Answer for: f Z00.121 Specified Answer for: g F90.9 Specified Answer for: h B07.9 Specified Answer for: i R35.0 Specified Answer for: j Z23
A patient with bilateral sensory hearing loss is fitted with a digital, binaural, behind the ear hearing aid. What HCPCS Level II and ICD-10-CM codes are reported?
V5261, Z46.1, H90.3 Rationale: In the HCPCS Level II Index look for Hearing aid/Binaural/Digital/BTE referring you to V5261. The purpose of the visit is the fitting of the hearing aid. Look in the ICD-10-CM Alphabetic Index for Fitting (and adjustment) (of)/hearing aid directing you to Z46.1. The condition necessitating the hearing aid is bilateral sensory hearing loss. In the Alphabetic Index, look for Deafness/sensorineural/bilateral which directs you to H90.3. Verification in the Tabular List confirms code selection.
What ICD-10-CM code is reported when a flu vaccine is administered?
Z23 Rationale: In the ICD-10-CM Alphabetic Index look for Vaccination (prophylactic)/encounter which refers you to Z23. Verification in the Tabular List confirms Z23 is for an encounter for immunization. This code is nonspecific as to the type of vaccination that is given. The type of vaccination given (i.e. influenza, MMR, DPT) will be specified by the CPT® or HCPCS codes.
