CPT Coding Practice/Review

A patient is diagnosed with osteochondroma of the right clavicle. The surgeon excises the tumor.

23140-RT

The surgeon performed a closed reduction of a scapular fracture.

23575

Closed reduction of proximal humerus fracture, right.

23605-RT

Repair of medial collateral ligament of right elbow using local tissue.

24345-RT

ORIF (screws) for a fracture of the left humeral shaft.

24515-LT

A patient with a previously implanted pacing cardioverter-defibrillator now requires repositioning of the lead.

33215

The surgeon creates a new skin pocket to relocate a pacemaker.

33222

The surgeon creates a new skin pocket to relocate the pacemaker.

33222

The existing pacemaker pulse generator was removed, and a new dual lead generator was inserted. The existing leads were attached to the new generator.

33228

The patient requires a new pacemaker battery. The surgeon removes the old pacemaker generator and inserts a new dual chamber generator.

33228

The patient was diagnosed with severe aortic stenosis. Through a percutaneous incision in the leg (transfemoral), the surgeon performed a TAVR.

33361

The surgeon performed an open mitral valve replacement with cardiopulmonary bypass.

33430

A surgeon performed a triple coronary artery bypass using an autologous saphenous vein.

33512

A CABG procedure was performed. The surgeon bypassed three coronary artery sites by grafting the left internal mammary artery (LIMA), and one site was treated by grafting the greater saphenous graft to the obtuse marginal from the aorta.

33535, 33517

Repair of patent ductus arteriosus by division (18-year-old patient)

33824

The surgeon repairs a ruptured aneurysm of the splenic artery.

35112

A surgeon performs an axillary-brachial thromboendarterectomy with patch graft.

35321

The surgeon created a femoral-popliteal artery bypass using a vein graft.

35556

Catheter placement into brachiocephalic artery (first-order)

36215

A 34-year-old patient had a PICC line inserted with no imaging.

36569

45-year-old patient has a peripherally central venous catheter inserted under ultrasound guidance.

36573

Complete replacement of tunneled centrally inserted central venous catheter with subcutaneous port; replacement performed through original access site (45-year-old patient)

36582

The surgeon replaces the peripherally inserted central venous catheter (PICC) through same access.

36584

Operative Note Diagnosis: End-stage renal disease Procedure: Creation of left forearm arterial venous fistula The patient was prepped and draped in the usual manner. An incision was made over the radial artery and cephalic vein. Each was dissected free to create an anastomosis.

36821

Operative Note: Diagnosis: Thrombosis of right AV (Gore-Tex) graft Procedure: A transverse incision was made in order to complete a thrombectomy of the graft. Because the balloon catheter could not be passed, it was elected to perform an arteriotomy for removal of the thrombus. The area was irrigated and the incision was closed.

36831

Open revision of AV fistula with thrombectomy, patient receiving hemodialysis.

36833

Percutaneous thrombectomy of forearm AV graft that was inserted for dialysis treatment.

36904

A surgeon performs a percutaneous transluminal angioplasty on the left femoral-popliteal artery for a patient with peripheral artery disease.

37224-LT

A patient was seen for surgical treatment of an occlusion of the femoral artery, left. Percutaneously under guidance, the surgeon inserted a catheter to perform an atherectomy (lower extremity revascularization)

37225-LT

Percutaneous transcatheter placement of stent in femoral artery.

37226

Dr. Tin completed a repair of a ruptured spleen with removal of part of the spleen. Select the appropriate CPT code for these procedures.​

38115

Tom Tighter has extensive swelling in a lymph node in the left inguinal region, and he also has a fever. He is diagnosed with an abscess of a deep inguinal lymph node. Dr. Gon performed an extensive drainage of the abscess. Select the correct CPT code for the procedure.​

38305

Select the appropriate CPT code for the following procedure. Suturing of thoracic duct via thoracic approach

38381

Using the CPT manual, select the appropriate code for the following procedure. Cervical lymphadenectomy

38724

Mrs. Teech was diagnosed with cancer that involves the axillary lymph nodes. Dr. Smith performed a complete axillary lymphadenectomy. Select the appropriate CPT code for the procedure.​

38745

Using the CPT manual, select the appropriate code for the following procedure. Preoperative and postoperative diagnosis: Mass in mediastinum Procedure: Open exploration of the mediastinum with biopsy Pathology: Pending The patient was prepped, and an incision was made low in the front of the neck. The sternomastoid muscles and the cranial vessels were visualized and were pulled to the side. The trachea and thyroid were drawn to the center, exposing the space behind the esophagus. A mass was seen, and a biopsy was taken. Penrose drains were placed. The incision was closed with sutures. Minimal blood loss occurred. The patient was sent to the recovery room in satisfactory condition.

39000

elect the appropriate CPT code for the following procedure. Biopsy of mediastinum via mediastinoscopy

39401

Using the CPT manual, select the appropriate code for the following report. Patient age: 4 days old Preoperative and postoperative diagnosis: Diaphragmatic hernia Procedure: Hernia repair The patient was prepped and draped in the usual fashion. A transabdominal incision was made, and the herniated stomach was visualized. The stomach was returned to the appropriate position in the abdominal cavity. The hernia sac was cut away and removed. Sutures were placed in the diaphragm to narrow the enlarged opening. A chest tube was inserted. The abdomen was closed. Drains were placed, and the wound was sutured. The patient tolerated the procedure and was sent to the recovery room in stable condition.

39503

Review the range of CPT codes 40810 through 42836. what is the correct code assignment for an excision of a mucosal lesion of the vestibule of the mouth with a complex repair?

40814

Review the range of CPT codes 42820 through 42836. What is the correct code assignment for a 4-year-old patient who had a tonsillectomy and an adenoidectomy?

42820

The patient suffered a perforation of the pharynx wall from a bottle cap. The surgeon performed a suture repair of the wound.

42900

Flexible esophagoscopy, inserted in the mouth, with biopsy of a small lesion in the esophagus and a snare removal of a polyp from another area of the esophagus.

43202, 43217

The surgeon performed an esophagoscopy (flexible, transoral) for removal of a polyp via hot biopsy forceps

43216

A patient was taken to the endoscopy suite. The flexible endoscope was passed from the mouth into the esophagus and continued into the stomach and into the duodenal bulb. Based on this documentation, what CPT code would be selected to represent this procedure?

43235

EGD (transoral) with removal of a piece of a chicken bone.

43247

The physician performs an EGD (flexible, transoral) for removal of a coin.

43247

Operative Note Diagnosis: Gallstone pancreatitis and biliary tree obstruction Procedure: ERCP with sphincterotomy Indications: The patient has gallstone pancreatitis, and an ultrasound showed a dilated common duct with stones.

43262

ERCP with removal of biliary stent.

43275

The surgeon performed a laparoscopic repair of paraesophageal hernia.

43281

Procedure Performed: Partial distal gastrectomy with gastrojejunostomy

43632

Laparoscopic gastirc bypass and Roux-en-Y gastroenterostomy performed for obesity.

43644

Laparoscopic gastric bypass and Roux-en-y gastroenterostomy performed for obesity.

43644

Percutaneous replacement of gastrostomy tube requiring debridement of granulation tissue to insert the new tube.

43763

The patient is morbidly obese with a BMI of 37. Procedure performed: Laparoscopic vertical sleeve gastrectomy.

43775

Laparoscopic removal of a portion of the jejunum with anastomosis.

44202

Patient has a diagnosis of acute aappendicitis, and the surgeon performs a laparoscopic appendectomy.

44970

Patient has the diagnosis of acute appendicitis, and the surgeon performs a laparoscopic appendectomy.

44970

Flexible sigmoidoscopy with laser removal of polyp in the rectum.

45346

Colonoscopy with removal of polyp with a saline-left technique followed by a hot snare excision.

45381, 45385-59

The physician performed a colonoscopy that extended from the anus to the cecum and used a snare to remove a polyp of the transverse colon.

45385

The surgeon performed an excision of five external tags of the anus.

46230

A patient is diagnosed with papillomas of the anus. Using cryosurgery, the surgeon removes the three papillomas.

46916

Infrared coagulation of internal hemorrhoids.

46930

Laparoscopic removal of a portion of the liver.

47379

Initial herniorrhaphy for repair of an inguinal hernia and a unilateral hydrocelectomy of the spermatic cord (4-year-old patient)

49500

Initial repair of strangulated ventral hernia requiring mesh (49-year-old patient)

49561, 49568

Umbilical reducible herniorrhaphy (4-year-old patient).

49580

The patient had a laparoscopic incisional herniorrhaphy for a recurrent reducible hernia. The repair included insertion of mesh.

49656

The surgeon performed a carpal tunnel release (median nerve) on the left and right wrist. What modifier would be used with CPT code 64721?

50

Percutaneous nephrostolithotomy for basket extraction of 1.5 cm stone

50080

Percutaneous needle biopsy of the kidney

50200

Under CT guidance, a percutaneous needle core biopsy of the kidney mass was performed.

50200 Biopsy, kidney

Excision of a perinephric cyst.

50290

Patient underwent left kidney transplant, including backbench standard preparation of living donor renal allograft. Kidney was obtained from a living donor.

50365, 50320, 50325

The surgeon aspirates the cyst of the kidney with the use of a percutaneous needle

50390

The surgeon aspirates the cyst of the kidney with the use of a percutaneous needle.

50390

Patient underwent injection procedure for ureterogram, new access.

50430

The surgeon performs a laparoscopic ablation of a renal cyst.

50541

The surgeon performs a laparoscopic nephrectomy with partial ureterectomy.

50546

Patient underwent renal endoscopy through established nephrostomy, with biopsy.

50555

Patient underwent extracorporeal shock wave lithotripsy on the left side to pulverize kidney stones.

50590-LT

Under direct visualization, the surgeon performs a drainage ureterotomy.

50600

Patient had a ureterolysis, with repositioning of ureter for retroperitoneal fibrosis.

50715

Code for a patient recieving a simple uroflowmetry.

51736

Patient presented for capsule endoscopy of the GI tract. The ileum was not visualized. What modifier is used with CPT code 91110?

52

A cystourethroscope was passed through the urethra and urinary bladder to examine the urethra, bladder, and ureteral openings. No other procedure was preformed.

52000

Performed a cystoscopy with resection of a 4.0 cm bladder tumor. The procedure concluded with a steroid injection into the urethral stricture.

52235, 52283-59

Cystoscopy to remove small stones from the patient's upper right ureter and another stone lodged in the middle left ureter. Both stones were manipulated back into the kidney with subsequent placement of double J ureteral stents in each ureter.

52330-50, 52332-50

Patient has a ureteral stricture. Performed a cystoscopy with ureteroscopy and laser treatment of the stricture.

52344

The surgeon performed a cystoscopy with ureteroscopy for laser treatment of a stricture of the ureteropelvic junction

52345

A cystourethroscopy with ureteroscopy was performed to remove a calculus lodged in the left ureter.

52352-LT

Cystoscopy, left ureteroscopy with laser lithotripsy.

52353

An arthroscopic meniscectomy of the knee was planned for a patient. During the procedure, the scope was inserted but the patient went into respiratory distress and the procedure was terminated. What CPT modifier would be appended to the CPT code (29880) for the physician's services?

53

Female patient presents for a total urethrectoy, including cystostomy.

53210

Patient is undergoing a urethroplasty, first stage, to repair stricture.

53400

Patient underwent subsequent dilation of urethral stricture by passage of sound or urethral dilator

53601

What modifier can be used to indicate that two surgeons were required to perform a procedure?

62

A surgeon performed an esophageal dilation (43453) on a four-week-old newborn that weighed 3.1 kg. What CPT modifier would be appended to CPT code to describe this special circumstance?

63

A 45-year-old male is brought to the endoscopy suite for diagnostic EGD. Patient is prepped. After moving the patient to the procedure room, and prior to initiation of sedation, he develops significant hypotension, and the physician cancels the procedure. What modifier is used with CPT code 43253?

73

What does CPT stand for?

Current Procedural Terminology

The surgeon performed a tenolysis, extensor tendon of the right index finger (26445). What HCPCS Level II modifier should be appended to the CPT code?

F6

If documentation supports removal of excess breast tissue in a male (gynecomastia), what guidence is provides in the note under code 19303?

For breast tissue removed for breast-size reduction for gynecomastia, use 19300

Fine needle aspiration biopsy of a cyst of a thyroid nodule under fluoroscopic guidance.

10007

Surgical exploration of stab wound of chest with included coagulation of blood vessels and enlargement of the wound.

20101

Open treatment with internal fixation of three rib fractures.

21811

What modifier is used when a surgical procedure took a great deal of extra work and time due to complexity of case?

22

Posterolateral fusion of L4-L5 with local bone graft.

22612, 20936

Video-assisted thoracic surgery (VATS) with resection of bleb with pleurodesis.

32655

Thorascopy (VATS) with resection of upper left lobe of the lung.

32663

Operative Report Diagnosis: Left thigh abscess. Procedure: Incision and drainage of left thigh abscess. Indications: An otherwise healthy 2-year-old male presented with progressive swelling, redness, and pain of the upper left thigh area. The area in question on the left thigh now has a fluctuant center, and incision and drainage is indicated. Description of Procedure: With the patient in the supine position under general anesthesia, the upper anterior left leg was prepped with Betadine and draped in a sterile fashion. We used an 18-gauge needle and a small syringe to aspirate grossly purulent grayish material from the center of the fluctuant area, and this was sent for aerobic and anaerobic routine bacterial culture. We then made a small transverse incision directly through the area, entering a cavity and obtaining a substantial amount of additional purulent material. We gently probed the area and broke up any loculations. The abscess appeared to be quite superficial and did not extend grossly beyond the subcutaneous tissues. It did extend laterally to the edge of the indurated area, and we opened our incision very slightly towards that lateral area to make sure that the area was adequately drained. The wound was irrigated with saline, and then packed open with ¼-inch strip gauze. The area was dressed with a 4 × 4 and wrapped with a Kerlix. The patient tolerated the procedure well and was taken to the recovery room in stable condition.

10060

Operative Note: After local anesthesia was administered, the site was cleansed and an incision was made in the center of the sebaceous cyst. The cyst was drained and irrigated with a sterile solution. Diagnosis: sebaceous cyst of back.

10060 Incision and Drainage, Cyst, Skin

In the clinic, the physician performed a simple incision and drainage of a pilonidal cyst

10080

The surgeon performs debridement down to and including the fascia of the abdominal wall due to necrotizing fascitis.

11005

A patient had a mesh inserted during an inguinal hernia repair. Two years later, the patient presented for removal of the infected mesh and debridement of the necrotic tissue. The physician performed a debridement of the wound, including the fascia, and removed the mesh.

11005 Debridement, skin, infected 11008 Removal, mesh, abdominal wall

Patient has a diagnosis of a decubitus ulcer of the leg. The surgeon debrided the necrotic tissue (10 sq. cm) that extended down to and included part of the muscle.

11043 Debridement, Muscle

A wedge of tissue was biopsied from a mass on the patient's back. The sample was sent to pathology for analysis. In addition, another lesion of the arm was shaved with a scalpel for biopsy.

11106 Biopsy, skin lesion, incisional 11103 Biopsy, skin lesion, tangential

The surgeon performed a punch biopsy of the right upper chest skin lesion and an incisional skin biopsy of a lesion of the neck.

11106, 11105

With the use of electrocauterization, the physician removed 18 skin tags from the patient's neck and shoulders

11200, 11201

Operative Procedure: Shaving of a 0.75 cm pyogenic granuloma of the neck removed in total.

11306 Lesion, Skin, Shaving

Shaving of 1.5 cm epidermal lesion, scalp

11307

A surgeon reports that the patient has a 2.5 cm basal cell carcinoma of the chin. The excision required removal of 0.5 cm margins around the lesion.

11644 Lesion, Skin, Excision, Malignant

Complete excision of nail and matrix, right great toe.

11750-T5 Nails, removal

Intermediate, layered closure of 2.0 cm laceration of right forearm, and intermediate closure of 2.5 cm laceration of elbow.

12032 Wound, repair, arms, intermediate

A patient is seen in the Emergency Department after an accident. A 4.0 cm deep wound of the upper arm (located in area of non-muscle fascia) required a layered closure and a 1.0 cm superficial laceration of the left cheek was repaired.

12032, 12011-59

A patient is seen in the Emergency Department after an accident. A 4.0 cm deep wound of the upper arm (located in area of non-muscle fascia) required a layered closure and a 1.0 cm superficial laceration of the left cheek was repaired.

12032, 12011-59 Wound, Repair, Arms, (intermediate and simple). Terms "deep, non-muscle fascia" and "layered" documents an intermediate closure. Superficial indicates a simple repair.

A patient was treated for multiple wounds of the right forearm, hand and knee. The physician sutured the following: simple repair, 2.5 cm forearm; intermediate repair, 1.5 cm hand; simple repair 2.0 cm knee.

12041-59 Wound, repair, hands, intermediate 12002 Wound, repair, arms and legs, simple (sum of repairs)

The surgeon performed a tubed pedicle flap from the forehead to cover the defect on the nose.

15576

A surgeon performed a tubed pedicle flap from the forehead to cover the defect on the nose.

15576 Pedicle Flap, formation

Debridement and dressing of first-degree (partial-thickness) burn of the index finger.

16020 Burns, dressings

With the use of a YAG laser, the surgeon removed a 2.0 cm giant congenital melanocytic nevus of the leg. Pathology confirmed that the lesion was premalignant.

17000 Lesion, Skin, Destruction, Premalignant

What is the correct CPT code assignment for laser removal of three (3) nevi of the arm (size approximately 2.0 cm, 1.5 cm, 0.5 cm)?

17110

The surgeon fulgurates a 0.5 cm superficial basal cell carcinoma of the back.

17260 Lesion, Skin, Destruction, Malignant

Electrosurgical fulguration was used to remove a 2.0 cm squamous cell carcinoma of the hand.

17272 Skin, destruction, malignant lesion

Operative Note: Patient seeking treatment for a cyst of right breast. A 21-gauge needle was inserted into the cyst. The white, cystic fluid was aspirated and the needle withdrawn. Pressure was applied to the wound and the site covered with a bandage.

19000 Breast, Cyst, Puncture Aspiration

Bilateral total mastectomy with reconstruction using double-pedicle TRAM.

19303-50 Mastectomy, simple, complete 19369-50 Reconstruction, breast, transverse rectus abdominis myocutaneous

A 35-year-old patient is seen in the physician's office for his yearly physical (CPT code 99395—Preventive Medicine E/M). During the exam, the patient requests that the physician remove a mole on his shoulder. What CPT modifier would be appended to the 99395 to explain that the E/M service was unrelated to excision of the mole?

25

Closed reduction of right radial shaft fracture.

25505

Operative Note Preoperative Diagnosis: Painful left wrist Postoperative Diagnosis: Closed distal radial fracture Operation: Closed reduction of left wrist Under satisfactory general anesthesia the patient was placed in supine position. The hand was secured with traction. The fracture was reduced and the alignment was checked with imaging.

25605

The surgeon performed a percutaneous tenotomy of the left hand, second digit and third digit.

26060-F1, 26060-F2

The patient was seen in the ED with a staple embedded in the left index finger. An automatic staple gun impaled a staple into the DIP joint. A 1% lidocaine digital block was performed, and incision was made into the joint and the staple was removed with no complications. He was told to watch for any red streaks, swelling, pain or pus.

26080

Excision of enchondroma of finger

26210

I&D of hematoma of the thigh.

27301

Removal of splinter embedded deep in the left knee.

27372-LT

The patient is seen in the outpatient surgery department for a comminuted right supracondylar femoral fracture. An open reduction and internal fixation of the right supracondylar femur fracture was performed.

27511-RT

Lengethening of Achilles' tendon.

27685

Excision of bone cyst, toe (third digit of left foot)

28108-T2

Closed reduction of two metatarsal fractures of left foot.

28475-LT, 28475-LT

Metatararsophalangeal arthrodesis, great toe.

28750

Patient has the diagnosis of wet gangrene of the right great toe. The physician performs an amputation of the metatarsophalangeal joint with removal of the right great toe.

28820

Arthroscopy of left shoulder with rotator cuff repair.

29827-LT

Arthroscopy of the right wrist with complete synovectomy.

29845-RT

The surgeon performed an arthroscopy of the right knee with medial meniscectomy.

29881-RT

Partial excision of inferior turbinate.

30130

A patient is seen in the Emergency Department for epistaxis. Physician performs an anterior packing of left nasal passage.

30901

A patient is seen in the Emergency Department for epistaxis. Physician performs an anterior packing of left nasal passage.

30901-LT

Diagnostic maxillary sinusoscopy, bilateral.

31233-50

A physician performs a bilateral nasal endoscopy with polypectomy.

31237-50

Surgeon performs an endoscopic anterior ethmoidectomy.

31254

A patient was diagnosed with squamous cell carcinoma of the larynx. The surgeon performed a supraglottic laryngectomy with radical neck dissection to remove the metastasis to the lymph nodes.

31368

With the use of an operating microscope, the surgeon performs a direct laryngoscopy for removal of a piece of a toothpick.

31531

Direct laryngoscopy with stripping of vocal cords.

31540

The surgeon performed a thoracoscopy for a therapeutic wedge resection of the lung.

32666

Operative Report Preoperative Diagnosis: Chronic laryngitis with polypoid disease Postoperative Diagnosis: Same Procedure: Laryngoscopy with removal of polyps After adequate premedication, the 60-year-old female patient was taken to the operating room and placed in supine position. The patient was given a general oral endotracheal anesthetic with a small endotracheal tube. The Jako laryngoscope was then inserted. There were noted to be large polyps on both vocal cords, essentially obstructing the glottic airway when the tube was in place. The polyps appeared larger on the right cord. Using the straight-cup forceps, the polyps were removed from the left cord first. The polyps were removed from the right cord up to the anterior commissure. There was very minimal bleeding noted. This opened up the airway extremely well. The patient was extubated and sent to recovery in good condition.

31540

The patient has a history of persistent hoarseness. The surgeon performed a flexible laryngoscopy to evaluate the larynx.

31575

Flexible laryngoscopy with removal of lesion using microdebrider.

31578

Flexible bronchoscopy with cell washigs, brushings, and biopsy.

31623, 31625

Bronchoscopy with multiple transbronchial lung biopsies taken of the right upper lobe.

31628

Bronchoscopy with EBUS-guided transbronchial sampling of two mediastinal lymph nodes.

31652

Physician removes an indwelling tunneled pleural catheter with cuff.

32552

Percutaneous drainage of pleural cavity via indewelling catheter, with imaging.

32557

Patient is seen in a radiology clinic for an x-ray of the arm (73090). The films are sent to another radiologist (not affiliated with the clinic) to interpret and write the report. What HCPCS Level II modifier would be appended to the CPT code for the services of the radiology clinic?

TC