Download 1 Answers to Odd-Numbered Section and Chapter Review

1
Answers to Odd-Numbered Section and Chapter Review
Exercises
for
Medical Coding Certification Exam Preparation:
A Comprehensive Guide
First Edition
Cynthia L. Stewart, CPC, CPC-H, CPMA, CPC-I, CCS-P
Cynthia L. Ward, CPC, CPC-H, CPMA, CEMC, CCC
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distribution in any manner. This document may not be copied, scanned, duplicated, forwarded, distributed, or posted on a
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Copyright © 2014 by The McGraw-Hill Companies, Inc. All rights reserved. Printed in the United States
of America. Except as permitted under the United States Copyright Act of 1976, no part of this
publication may be reproduced or distributed in any form or by any means, or stored in a database or
retrieval system, without prior written permission of the publisher.
All brand or product names are trademarks or registered trademarks of their respective companies.
CPT five-digit codes, nomenclature, and other data are copyright ©2013 American Medical Association.
All rights reserved. No fee schedules, basic unit, relative values or related listings are included in CPT.
The AMA assumes no liability for the data contained herein.
CPT codes are based on CPT 2013.
ICD-9-CM codes are based on ICD-9-CM 2013.
ICD-10-CM codes are based on ICD-10-CM 2013.
All names, situations, and anecdotes are fictitious.
They do not represent any person, event, or medical record.
The Internet addresses listed in the text were accurate at the time of publication. The inclusion of a
website does not indicate an endorsement by the authors or McGraw-Hill, and McGraw-Hill does not
guarantee the accuracy of the information presented at these sites.
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distribution in any manner. This document may not be copied, scanned, duplicated, forwarded, distributed, or posted on a
website, in whole or part.
3
CONTENTS
In this Answer Key
The answer key includes answers and rationales for the the odd-numbered end-of-section exercises, as
well as the end-of-chapter exercises, including Using Terminology, Checking Your Understanding, and
Applying Your Knowledge
Unit One: Fundamental Coding Guidelines
Chapter 1: The Certified Professional Coder
Chapter 2: Foundations of ICD-9-CM
Chapter 3: Foundations of ICD-10-CM
Chapter 4: ICD Chapter-Specific Guidelines
Chapter 5: Foundations of CPT
Unit Two: Coding for Evaluation and Management, Anesthesia, and Surgery Section
Chapter 6: Evaluation and Management
Chapter 7: Anesthesia
Chapter 8: Surgery Section
Unit Three: Coding for Surgical Procedures on Integumentary, Musculoskeletal, Respiratory, and
Cardiovascular/Lymphatic Systems
Chapter 9: Surgery Section: Integumentary System
Chapter 10: Surgery Section: Musculoskeletal System
Chapter 11: Surgery Section: Respiratory System
Chapter 12: Surgery Section: Cardiovascular and Lymphatic System
Unit Four: Coding for Surgical Procedures on Digestive, Urinary, Male and Female Reproductive
Systems, Maternity Care, Nervous System, and Eyes, Ears, and Endocrine System
Chapter 13: Surgery Section: Digestive System
Chapter 14: Surgery Section: Urinary System and Male Reproductive System
Chapter 15: Surgery Section: Female Reproductive System and Maternity Care and Delivery
Chapter 16: Surgery Section: Nervous System
Chapter 17: Surgery Section: Eyes, Ears, and Endocrine System
Unit Five: Coding for Radiology, Pathology/Laboratory, General Medicine, HCPCS Category II
and III, and Practice Management
Chapter 18: Radiology
Chapter 19: Pathology/Laboratory
Chapter 20: Medicine
Chapter 21: HCPCS Level II: Category II and Category III Codes
Chapter 22: Practice Management
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4
Chapter 1 – The Certified Professional Coder
Exercise 1.1
1. Describe the foundation of a coder’s role.
Ans: The answers may vary but basically should discuss the ability to interpret, translate, and submit
correctly the data about the patient encounter onto a CMS-1500 form for reimbursement
Feedback: Coding and billing language is used to assist physician offices, hospitals, patients, third-party
administrators, and insurance companies in understanding why the patient was seen and what services,
procedures, or supplies were provided for the patient and in identifying and submitting the claim as codes.
Exercise 1.2
1. What are some of the consequences of not submitting a clean claim the first time the
claim is submitted to the payer?
Ans: Delay of revenue in the Accounts receivable (A/R) cycle due to increased adjudication periods and
more staff time spent researching, correcting, and resubmitting the claim. Also potential loss due to
failure to comply with claim filing limits.
Feedback: Correcting such errors is costly to medical practices, as they result in more days of revenue in
the accounts receivable (A/R) cycle due to longer adjudication periods and more staff time spent
researching, correcting, and resubmitting the claims.
As the patient record may not be altered, errors identified must be corrected so that an auditor can
recognize both the error and the correction. All corrections or additions to the medical record
(addendums) must be dated and legibly signed or initialed.
Exercise 1.3
1. List three reasons to become a certified coder.
Ans: 1) Increased value to the practice
2) Aid the practice in maintaining coding and billing compliance with federal and state regulations and
contracted payer policies.
3) Career advancement
Feedback: One reason for becoming credentialed is the increased opportunity for employment.
According to findings of the Bureau of Labor Statistics, employers prefer to hire credentialed medical
coders rather than noncredentialed coders, thereby increasing the chances of employment for CPCs.
Exercise 1.4
1. What is the length of the CPC exam and how many questions are included?
Ans: Five hours and forty minutes and 150 questions
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distribution in any manner. This document may not be copied, scanned, duplicated, forwarded, distributed, or posted on a
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Feedback: The Certified Professional Coder (CPC) exam is a grueling 150-question exam that thoroughly
tests the coder’s ability within a medical coding subset. As there are multiple versions of this exam, of
which any may be administered during examination, the examinee must be prepared to demonstrate her or
his knowledge and ability across all code sets: ICD, CPT, and HCPCS Level II codes.
Regardless of the exam version, the time allowed for completing the exam is 5 hours and 40 minutes.
Exercise 1.5
1. What are two of the major factors that can affect a coder’s successful completion of the
CPC exam?
Ans: Time and test taking anxiety
Feedback: Occasionally, coders go into the CPC exam very well versed on the subject matter but fail the
exam. One of the more common reasons for this is text anxiety: Some students will begin the exam feel
ready, look at the first question, and forget what they had learned due to panic and fear. Running out of
time during the test is a major reason for failing the test.
Chapter One Review
Using Terminology
1. C
AAPC
7. I
Medical coding
3. A
CPC
9. E
Payer language
5. J
Clean claim
Feedback: N/A
Checking Your Understanding
1. The CPC exam has ___________questions and is _________________ in length.
Ans: B. 150 hours, 40 minutes
Feedback: The Certified Professional Coder (CPC) exam is a grueling 150-question exam that thoroughly
tests the coder’s ability within a medical coding subset. As there are multiple versions of this exam, of
which any may be administered during examination, the examinee must be prepared to demonstrate her or
his knowledge and ability across all code sets: ICD, CPT, and HCPCS Level II codes.
Regardless of the exam version, the time allowed for completing the exam is 5 hours and 40 minutes.
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distribution in any manner. This document may not be copied, scanned, duplicated, forwarded, distributed, or posted on a
website, in whole or part.
6
3. The “language” that is used by insurance carriers and includes terms such as noncovered
services, unbundling, and duplicate claim is called:
Ans: D. Payer language
Feedback: Payer language comprises terms such as noncovered services, medical necessity, compliance
language, and unbundling.
5. Certified coders, on average, earn ______________ more than noncertified coders.
Ans: B. 20 percent
Feedback: Certified coders, on average, earn 20 percent more than noncertified coders and often continue
their education, becoming office managers, billing managers, consultants, auditors, and educators.
7. A diagnosis may not receive direct treatment during an encounter but the physician still has to
consider this diagnosis when determining treatment for other conditions. This is a definition of:
Ans: B. Medically managed
Feedback: Medically managed: A diagnosis which may not receive direct treatment during an encounter
but which the provider has to consider when determining treatment for other conditions.
9. Which books are required for the CPC exam?
Ans: D. All of these
Feedback: The CPC exam is an “open code-book” exam. This means approved current year coding
manuals (CPT, HCPCS, and ICD) may be used during the exam.
Applying Your Knowledge
1. Explain how coding is like translating a language and how realizing this can help a coder
pass the CPC exam.
Ans: Medical coding is a form of translating provider documentation and medical terminology into codes
that illustrate the procedures and services performed by medical professionals. The Certified Professional
Coder (CPC) exam is designed to test the coder’s skill in translating this information accurately and
completely so that the provider is reimbursed correctly, fairly, and within compliance guidelines.
Feedback: Coding and billing language is used to assist physician offices, hospitals, patients, third-party
administrators, and insurance companies in understanding why the patient was seen and what services,
procedures, or supplies were provided for the patient and in identifying and submitting the claim as codes.
3. Explain which test-taking tips you think will be most beneficial to you in preparing for
the CPC exam.
Ans:
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 Take a mock/practice test a few months before the actual test.
 Use resources available to practice specific areas of weakness as identified by the mock/practice test,
such as ICD or compliance.
 Form a study group among your peers.
 Know the ICD, CPT and HCPCS books and know how to locate and use them.
 Take a second mock/practice test within a month before the CPC Exam.
 Again using resources available, practice any areas of weakness identified by the second mock/practice
test.
 Go over the guidelines in both the ICD and CPT thoroughly the week of the exam.
 Listen to the proctor carefully and follow all instructions.
 Leave nothing blank
Feedback: Here are some tips that will help you improve your test-taking skills:
Take a mock/practice test a few months before the actual test.
Use available resources to practice specific areas of weakness identified by the mock/practice test, such as
ICD or compliance.
Form a study group among your peers.
Know the ICD, CPT, and HCPCS books, and know how to locate codes and use them. Memorization of
the guidelines is not required; however, the more you know without having to reference this information
during the exam, the better for time management.
Practice exam time management.
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distribution in any manner. This document may not be copied, scanned, duplicated, forwarded, distributed, or posted on a
website, in whole or part.
8
Chapter 2 – Foundations of ICD-9-CM
Exercise 2.1
1. Explain the differences between the three volumes of the ICD-9-CM manual.
Ans: The ICD-9-CM is published in a two or three volume set. The two volume set is used by
providers to identify why the service or procedure was provided. The three volume set is used
exclusively by facilities to identify both why the service or procedure was provided and what
service or procedure was provided. Volume 1 is also known as the tabular portion of the ICD-9CM and contains the codes and the full description (nomenclature) of each code. To ease the
process of coding for the coder, this volume appears after Volume 2. Volume 2, also known as
the index of the ICD-9-CM contains an alphabetic listing of main terms identifying the patient’s
condition, injury, sign or symptom. Sub terms follow the main term in a graduated indented
format and allow for further clarification of the patient’s condition thus allowing the coder to
drill down to a more accurate code prior to looking up the code in Volume 1.
Feedback: N/A
Exercise 2.2
1. Explain the difference between the abbreviations NEC and NOS.
Ans: NEC - Not elsewhere classified. There is not a more specific code provided in the ICD-9CM manual. In this case the provider documentation is more specific in its description of the
patient’s condition than the ICD-9-CM allows for in the code description.
NOS - Not otherwise specified. This is the equivalent of “unspecified”. This abbreviation is to
be used only when there is not enough information in the documentation to provide a more
specific code.
Feedback: N/A
3. What must be present for the coder to report an additional code?
Ans: The provider documentation must provide the additional information needed to accurately
report the additional code.
Feedback: N/A
Exercise 2.3
Underline the main term in each diagnostic statement, follow the bulleted steps and
determine the appropriate ICD-9-CM code.
1. Capsular congenital cataract
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Feedback: cataract, congenital, capsular or sub capsular
3. Laceration of the forearm
Feedback: laceration (see also wound, open, by site); wound, open, forearm
Exercise 2.4
1. ICD-9-CM chapter-specific guidelines for Chapter 2 include which type of guidelines?
Ans: These guidelines include general, history of, administration of chemotherapy,
complications and sequencing instructions for neoplasms.
Feedback: N/A
3. ICD-9-CM chapter-specific guidelines for Chapter 17 include which type of guidelines?
Ans: Injuries, fractures, burns, adverse effects, poisoning, and toxic effects instructions are
included in these guidelines.
Feedback: N/A
Exercise 2.5
1. Explain the difference between a first-listed diagnosis and a principal diagnosis.
Ans: First-listed diagnosis (reason for the visit) is used for provider/outpatient coding. Principal
diagnosis (reason for admission after study) is used for facility coding.
Feedback: N/A
3. When may a chronic condition be coded?
Ans: Chronic conditions may be coded if the chronic condition affects the treatment or
management of the presenting condition.
Feedback: N/A
Exercise 2.6
1. Briefly discuss the importance of translating the medical record into accurate coding
data, and explain why it is important to have a thorough knowledge of anatomy, medical
terminology, and pathophysiology.
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distribution in any manner. This document may not be copied, scanned, duplicated, forwarded, distributed, or posted on a
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10
Ans: There can be many answers to this but they should all include the importance of linking the
medical necessity for the service or procedure provided for the patient encounter.
Feedback: N/A
Chapter Two Review
Using Terminology
1. I
Acute
9. A
NEC
3. C
Main term
11. L
Symptom
5. O
Slanted brackets
13. E
Manifestation
7. N
Includes
15. D
NOS
Feedback: N/A
Checking Your Understanding
1. This abbreviation is next to an ICD-9-CM code when a more appropriate code is not
provided elsewhere in the manual.
Ans: B. Not elsewhere classified
Feedback: There is not a more specific code provided in the ICD-9-CM manual. In this case the
provider documentation is more specific in its description of the patient’s condition than the
ICD-9-CM allows for in the code description.
3. Which of the following, when noted in the Alpabetic List or Tabular List, instructs the
coder on the mandatory sequencing of the etiology/manifestation?
Ans: A. Slanted brackets
Feedback: In ICD-9-CM, the slanted bracket punctuation marks are used to identify the
mandatory sequencing of etiology/manifestation coding.
5. According to the diagnostic outpatient guidelines, which of the following best fits the
guidelines for the use of signs and symptoms?
Ans: B. They are reported only when a diagnosis has not been confirmed and reported by the
provider.
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distribution in any manner. This document may not be copied, scanned, duplicated, forwarded, distributed, or posted on a
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11
Feedback: Signs and symptoms are acceptable for reporting when a diagnosis has not been
confirmed and reported by the provider.
7. Which of the following are important aspects of a coder’s being able to translate
provider documentation?
Ans: D. All of these
Feedback: The documentation should prove medical necessity for the service or procedure
provided for the patient encounter.
9. What is the term for a condition due to an underlying disease or condition?
Ans: A. Manifestation
Feedback: Etiology is the cause of the disease or condition.
Applying Your Knowledge
1. Discuss the main steps that a coder needs to follow when translating a provider’s
documentation and determining the appropriate code using the ICD-9-CM manual.
Ans: After reading the provider documentation thoroughly, the coder should follow these steps:
1. Determine the main term(s) from the documentation.
2. Locate the main term in the Alphabetic Index (Volume 2).
3. Identify and review any subterms listed below the main term in the Alphabetic Index. Then
identify in the provider’s documentation the subterm that further defines and supports the level
of specificity of the condition as documented.
4. Review all notes listed in the Alphabetic Index and Tabular List.
5. Verify the code identified in the Alphabetic Index by checking it in the Tabular List (Volume
1).
6. Determine the code to the highest degree of specificity (use a fourth or fifth digit if required).
Be sure to read all of the instructional notes that exist for the chapter, section, and category of
ICD-9-CM code(s) that you are choosing, as these guidelines supersede the chapter-specific
guidelines found in the official coding guidelines of the ICD-9-CM manual.
Feedback: N/A
3. Explain the difference between includes and excludes and the importance each plays in
determining the correct ICD-9-CM code.
Answer:
Excludes The ICD-9-CM manual provides a list of conditions, diseases, and injuries that are not included
in the code being considered in the tabular (Volume 1). The condition, disease, or injury being coded is
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website, in whole or part.
12
located elsewhere in the ICD-9-CM manual. Excludes notes may be found at the beginning of a chapter,
section, or category or directly below the code. The placement of an excludes note identifies the range of
codes to which the note applies.
Includes notes further clarify the code or category being considered by providing definitions or examples
of conditions included in the code. Although includes notes are not found at the four- and five-digit code
levels, inclusion terms may be found at these levels that aid the coder by providing synonyms of the
diagnostic statement being coded.
Feedback: N/A
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distribution in any manner. This document may not be copied, scanned, duplicated, forwarded, distributed, or posted on a
website, in whole or part.
13
Chapter 3 – Foundations of ICD-10-CM
Exercise 3.1
1. What is the function of a sub term?
Ans: Subterms follow the main term in a graduated indented format and allow for further clarification of
the patient’s condition thus allowing the coder to drill down to a more accurate code prior to looking up
the code in the tabular listing.
Feedback: N/A
Exercise 3.2
1. Explain with and without in ICD-10-CM.
Ans: The distinction between these codes is identified by the statement of “with” when the
condition or complication is present and “without” when the condition or complication is not
present. The ICD-10-CM conventions indicate that the default between with and without codes
is always without. This means that if the documentation is unclear or does not state that the
complication or comorbidity listed in the code description is present with the condition the
“without” code is to be listed.
Feedback: N/A
Exercise 3.3
1. Explain default codes and their function in ICD-10-CM coding.
Ans: The ICD-10-CM identifies codes which are either unspecified or most often used with a condition as
default codes. These codes are located directly behind the bolded main term and should only be used if
the provider’s documentation provides no additional detail regarding the patient’s condition or disease.
Feedback: N/A
3. Explain placeholders and their function in ICD-10-CM coding.
Ans: The structure of ICD-10-CM codes is unique in requiring that the 7th character extender must always
be in the 7th character place in the code. In ICD-10-CM complete codes may be 3, 4 or 5 characters. ICD10-CM uses placeholder character(s) to extend these codes through the 6th character. Using placeholder
“x” in the 4th, 5th, or 6th character place when needed allows the 7th character extender to remain in the 7th
character placement.
Feedback: N/A
Exercise 3.4
1. Which guidelines are specific to Chapter 21 in ICD-10-CM?
Ans: ICD-10-CM Chapter 21 specific guidelines cover coding for patient encounters for reasons other
than illness or injury such as inoculations, vaccinations, contact or suspected exposure to disease, patient
status, family or personal history of a medical condition, screening, observation, aftercare or follow up,
and routine and administrative examinations.
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distribution in any manner. This document may not be copied, scanned, duplicated, forwarded, distributed, or posted on a
website, in whole or part.
14
Feedback: N/A
3. Which guidelines are specific to Chapter 10 in ICD-10-CM?
Ans: Chronic Obstructive Pulmonary Disease (COPD), asthma, bronchitis and respiratory failure
instructions and code sequencing are included in these guidelines.
Feedback: N/A
Exercise 3.5
1. Explain coding to the highest level of specificity in ICD-10-CM.
Ans: Refers to the use of 4th, 5th , 6th characters and 7th character extenders when required.
Feedback: Coding to the highest level of specificity in ICD-10-CM refers to the use of fourth, fifth, and
sixth characters and seventh-character extenders when required.
3. When may a chronic condition be coded?
Ans: Chronic conditions may be coded if the chronic condition affects the treatment or management of
the presenting condition.
Feedback: N/A
Exercise 3.6
1. Briefly discuss the importance of translating the medical record into accurate coding data and
why it is important to have a thorough knowledge of anatomy, medical terminology, and
pathophysiology.
Ans: Answers will vary but should include medical necessity and linking the ICD-10-CM to the service
or procedure provided to the patient.
Feedback: The service or procedure provided to the patient should be documented to prove medical
necessity.
Chapter Three Review
Using Terminology
1. I
Acute
11. L Symptom
3. C
Main term
13. E Manifestation
5. O
Square brackets
15. D NOS
7. N
Includes
17. Q Placeholder
9. A
NEC
19. S Extender
Feedback: N/A
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distribution in any manner. This document may not be copied, scanned, duplicated, forwarded, distributed, or posted on a
website, in whole or part.
15
Checking Your Understanding
1. This abbreviation is next to an ICD-10-CM code when a more appropriate code is not provided
elsewhere in the manual.
Ans: B. NEC (Not Elsewhere Classified)
Feedback: NOS is not otherwise specified and DEF is used to state a definition of the term or terms used.
3. Which of the following, when noted in the Alphabetic Index or Tabular List, instructs the coder
on the mandatory sequencing of the etiology/manifestation?
Ans: D. Square brackets
Feedback: ICD-10-CM does not use the slanted bracket. The square bracket instructs the coder of the
mandatory sequencing of the etiology/manifestation.
5. According to the diagnostic outpatient guidelines, which of the following best fits the guidelines
for the use of signs and symptoms?
Ans: B. They are reported only when a diagnosis has not been confirmed and reported by the provider.
Feedback: Per the diagnostic outpatient guidelines they are reported only when a diagnosis has not been
confirmed and reported by the provider. Refer to Official ICD-10-CM Guidelines for Coding and
Reporting, Section IV.
7. Which of the following are important aspects of a coder being able to translate provider
documentation?
Ans: D. All of the choices are important aspects.
Feedback: Important aspects of a coder’s being able to translate provider documentation are: ensuring the
proper ICD-10-CM code is chosen, being able to stay within compliance guidelines, and linking the
medical necessity of the encounter to the service provided.
9. The way the condition due to the underlying disease or condition presents itself is:
Ans: A. Manifestation
Feedback: The way the condition due to the underlying disease or condition presents itself is the
manifestation. This is the same for ICD-9-CM and ICD-10-CM.
Applying Your Knowledge
1. Discuss the main steps that a coder needs to follow when translating a provider’s documentation
and determining the appropriate code using the ICD-10-CM manual.
Ans: After reading the provider documentation thoroughly, the coder should follow these steps:
1) Determine the main term(s) from the documentation.
2) Locate the main term(s) in the Alphabetic Index.
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distribution in any manner. This document may not be copied, scanned, duplicated, forwarded, distributed, or posted on a
website, in whole or part.
16
3) Identify and review any subterms listed below the main term in the Alphabetic Index. Then
identify in the provider’s documentation the subterm that further defines and supports the level of
specificity of the condition as documented.
4) Review all notes listed in the Alphabetic Index and Tabular List.
5) Verify the code identified in the Alphabetic Index by checking it in the Tabular List.
6) Determine the code to the highest degree of specificity (use up to seven characters if required).
Feedback: N/A
3. Explain the difference between includes and Excludes 1 and Excludes 2 and the importance each
plays in determining the correct ICD-10-CM code.
Ans: Includes - further clarifies the code or category by providing definition or examples of conditions
included in the code
Excludes 1 - Provides a list of conditions, diseases, or injuries which are not included in the code being
considered in the tabular listing. This condition, disease, or injury is located elsewhere in the ICD-9-CM
manual and the excludes note identifies this range of codes.
Excludes 2 - The includes and excludes instructional notes help the coder to code accurately, efficiently,
and within compliance guidelines.
Feedback: N/A
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distribution in any manner. This document may not be copied, scanned, duplicated, forwarded, distributed, or posted on a
website, in whole or part.
17
Chapter 4 – ICD Chapter-Specific Guidelines
Exercise 4.1
1. What supersedes the chapter-specific guidelines?
Ans: Guidelines and direction provided in the tabular list at the chapter, section, and code level
supersede chapter specific guidelines.
Feedback: A complete listing of the chapter-specific coding guidelines is located in the ICD-9-CM
Official Guidelines for Coding and Reporting, Section I, C, Chapter-Specific Guidelines.
The chapter-specific guidelines are more specific and detailed than the general coding guidelines.
However, the guidelines and directions provided in the Tabular List at the chapter, section, and code
levels supersede the chapter-specific guidelines.
Exercise 4.2
Code the following diagnostic statements:
1. An HIV-positive patient presents to the orthopedist for distal shaft fracture of the left
radius.
Ans: 813.42, V08
Feedback: N/A
3. Nurse Jaci is seen by the occupational health provider for testing after exposure to an
HIV-positive patient by accidental needle stick.
Ans: V73.89
Feedback: N/A
Exercise 4.3
Code the following:
1. Sepsis with acute renal failure due to E. coli following gastric bypass.
Ans: 539.81, 038.42, 995.92, 584.9
Feedback: Reference Chapter 1 specific guidelines in the ICD-9-CM and ICD-10-CM manuals
for the appropriate sequencing of sepsis due to postprocedural infection. The tendency will be to
use 997.49 as the complication code, be sure and read the exclude notes.
3. The patient was admitted to the hospital for streptococcal pneumonia. On day 2 of
admission, patient symptoms include tachycardia and labs confirm leukocytosis. Physician
is queried and confirms sepsis.
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18
Ans: 038.2, 995.91
Feedback: N/A
Exercise 4.4
Code the following:
1. Biopsy of a suspicious mass of the lower outer quadrant of the right breast in a 42-yearold female with a maternal history of malignant breast cancer.
Ans: 611.72, V16.3
Feedback: 239.3 would not be used since there is an instructional note with category 239 stating
the term mass, unless otherwise stated, is not to be regarded as a neoplastic growth.
3. Radiation therapy for an occipital lobe lesion is provided for astocytic glioma of
unknown origin.
Ans: V58.0, 198.3, 199.1
Feedback: Reference chapter specific guidelines for sequencing when the encounter is for
radiation therapy.
Exercise 4.5
1. A poorly controlled type I DM patient is seen and has elevated ketone levels. The
physician query confirms a diagnosis of ketoacidosis.
Ans: 250.13
Feedback: The fifth digit “3” informs the payer that the patient’s diabetes is type I and
uncontrolled as stated in the documentation.
3. The endocrinologist provides a 3-month recheck for a DM patient. The patient had
managed DM with diet; however, for past 4 months the patient has required insulin for
adequate control.
Ans: 250.00, V58.67
Feedback: N/A
Chapter Four Review
Using Terminology
Answers:
1. B
MRSA
7. H
Sepsis
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19
3. I
Metastases
5. A
Secondary diabetes mellitus
9. C
Severe sepsis
Feedback: N/A
Checking Your Understanding
1. The medical record states diabetic proliferate retinopathy in a patient with controlled
type 1 diabetes. This is coded as:
Ans: B. 250.51, 362.02
Feedback: The fifth digit of 1 indicates Type I diabetes that is controlled, thus eliminating
answers a and c. ICD-9-CM code 250.51 has a notation to use additional code to further
delineate retinopathy. Code 362.02 is enclosed in slanted brackets in the index indicating the
sequence of the code.
3. A patient who is 32 weeks’ pregnant is admitted because of an HIV related illness. The
patient spent 3 days in the hospital and was sent home in stable condition. The baby was
not delivered during this hospital stay. The codes for this are:
Ans: D. 647.83, 042
Feedback: 647.63 codes to infectious and parasitic condition in the mother, other viral diseases
for conditions classifiable to 042. The fifth digit of 3 is used to indicate this is an antepartum
condition. Refer to chapter specific guidelines for sequencing instructions for pregnancy and
HIV.
5. A 70-year-old male is brought to the operating room for a biopsy of the pancreas. A
wedge biopsy is performed and the specimen sent to pathology. The report comes back
immediately indicating that malignant cells are present in the specimen. The code for this
case is:
Ans: C. 157.9
Feedback: Using the neoplasm table the coder would find 157.9 as a primary malignant
neoplasm of the pancreas.
7. Which of the following is not considered a type of diabetes?
Ans: C. Hypertensive diabetes
Feedback: Type I diabetes mellitus sometimes is called insulin-dependent diabetes or juvenile
diabetes. Non-insulin dependent diabetes mellitus is the same as Type II diabetes mellitus.
Gestational diabetes is only present when a female is pregnant. With gestational diabetes, after
delivery the blood sugars stabilize again. If they don’t then the patient is diagnosed with either
Type I or Type II diabetes.
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20
9. The patient is being admitted for a sprained coccyx due to a fall off a roof. The patient
also has been diagnosed with AIDS. This is coded as:
Ans: A. 847.4, 042
Feedback: The encounter was for a condition not related to HIV; the reason for the encounter is
coded first and the HIV positive second. This is per the chapter specific guidelines for HIV.
Applying Your Knowledge
CASE STUDY
Clinical information Patient has a history of breast cancer with left lumpectomy and radiation 4
years ago. Chest CT shows multiple pulmonary nodules.
Specimen submitted Left lower-lobe lung mass.
Gross description Received, labeled with the patient’s name and “lung Bx,” are seven white to
gray needle biopsy cylinders measuring 1.5 x 1.0 x 0.1 cm in aggregate.
Microscopic and final diagnosis Lung, left lower lobe, needle biopsy: Adenocarcinoma,
consistent with breast primary.
1. Which is (are) the correct code(s) for this case?
Ans: B. 197.0, 174.9
Feedback: The reason for the biopsy was to determine the disease related to the lung mass, so the primary
diagnosis is the carcinoma of the lung which is metastatic with the breast cancer being the primary site.
The metastatic lung cancer is coded first.
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21
Chapter 5 – Foundations of CPT
Exercise 5.1
1. Explain linkage in reference to CPT and ICD coding.
Ans: Supporting the medical necessity of the CPT code with the ICD code(s) is also referred to
as linkage on the claim form submitted to payers.
For example: A visit for management of benign hypertension and removal of six skin tags. To
support medical necessity for each of these services, a different distinct diagnosis code would
need to be linked to each.
Feedback: The CPT manual is used to complete the story of the patient’s encounter or visit.
While the ICD manual tells why the visit occurred, the CPT manual tells what was provided to
the patient during the encounter. Medical necessity requires that the diagnosis, or the why,
support the service or procedure provided, or the what.
Backing up the necessity of the CPT code with the condition documented as the medical reason
for the service or procedure is known as supporting the medical necessity of the service.
Exercise 5.2
1. List the six main sections of the CPT manual.
Answer:
1. Evaluation and Management
2. Anesthesia
3. Surgery
4. Radiology
5. Pathology/Laboratory
6. Medicine
Feedback: The six main sections of the CPT manual are: Evaluation and Management,
Anesthesia, Surgery, Radiology, Pathology/Laboratory, and General Medicine
3. Who is responsible for the annual CPT updates?
Ans: American Medical Association (AMA) is responsible for the annual updates of the CPT
manual.
Feedback: Each update occurs in the third quarter of each year for use beginning January 1 of the
year immediately following the update.
Exercise 5.3
1. Explain the concept of separate procedure.
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Ans: CPT includes a number of codes for services or procedures which, though they may be
performed alone, when performed with a more extensive procedure or service of the same site
are considered a part of the more extensive procedure or service and are therefore not separately
reportable.
Feedback: These codes are designated as Separate Procedures and are identified by the term
(separate procedure) within the description of the code.
3. Explain the function of a parenthetical note in CPT coding.
Ans: Parenthetical notes provide additional information regarding the code being reviewed by
the coder. These notes may inform the coder that the service or procedure described by the code
or codes being reviewed are a part of or included in the work of the code for the service or
procedure code listed in the parenthetical note. These notes also indicate when an additional
code or codes may be needed to capture additional work not included in the code being
reviewed.
Feedback: Parenthetical notes (coding notes enclosed in parentheses) are located directly below
the code or code range to which the note applies.
Exercise 5.4
1. List the major steps in locating an appropriate CPT code.
Answer:
1. Determine the main term(s) and subterm(s) from the documentation.
2. Locate the main term and subterm in the alphabetic index.
3. Determine any modifying circumstances that require the use of a modifier.
4. Verify the code identified in the alphabetic index by checking it in the appropriate
section of CPT.
5. Review all section-specific instructional notes and guidelines.
6. Determine the CPT code that represents the service or procedure provided to the patient, along
with appropriate modifiers.
Be sure to read all of the instructional notes that exist for the main sections and subsections of
CPT.
Feedback: The coder should begin by reading the provider documentation thoroughly to
determine the service or procedure provided to the patient. Then the coder should follow the
steps as outlined in the answer above.
Exercise 5.5
1. Explain the purpose of a modifier.
Ans: The purpose of a modifier is to continue to tell the patient’s story by showing that the
service or procedure performed was altered in some way. The CPT code does not change, just
the telling of the story.
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23
Feedback: There are several types of modifiers that need to be used in order to translate
completely the service or procedure provided to the patient.
3. A 54-year-old patient presents to the office for their annual visit. The patient has no
complaints. During the exam, the physician determines that the patient’s blood pressure
has continued to remain elevated over the past three months and the provider prescribes
medication. The coder reports 99396 for the preventive medicine visit. Is it appropriate to
also code for the office visit? If so, is a modifier needed, and which one would be
appropriate?
Ans: Yes, modifier 25 would be appended to the evaluation and management (office visit) code.
Feedback: The guidelines in the CPT manual before codes 99381-99397 instruct the coder in the
use of modifier 25 with a preventive medicine visit.
Exercise 5.6
1. Why is accurate translation of the patient encounter important to both the provider and
the patient?
Ans: This accurate translation of the medical record into codes is important to the provider as
well as the patient. This story decides reimbursement, creates an insurance profile for the
patient, and gathers statistical and research data.
Feedback: It is important to the patient because it creates an insurance profile for the patient.
Chapter Five Review
Using Terminology
Answers:
1. D
Bullet
9. J
Null zero
3. A
Eponym
11. I
Semicolon
5. F
Parenthetical notes
13. L Triangle
7. G
Moderate sedation
Feedback: N/A
Checking Your Understanding
Identify the main term in each diagnostic statement and the main section and subsection of
the CPT in which the code would appear.
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24
1. CT scan of the abdomen
Ans: Main term = CT scan; Section = Radiology; Subsection = Diagnostic Radiology
Feedback: N/A
3. Excision of tendon sheath of the palm
Ans: Main Term = Excision; Section = Surgery; Subsection = Musculoskeletal
Feedback: N/A
5. Patient is seen in the office for 2-week follow-up visit for hypertension
Ans: Main Term = Office Visit; Section = Evaluation and Management; Subsection = Office or
Other Outpatient Services
Feedback: N/A
Choose the most appropriate answer for each of the following questions.
7. A patient is sent to the radiology department with an indication of abdominal pain. A
KUB is ordered. The coder inputs data that is then transferred to line 21 of the CMS-1500
form, showing ICD-9-CM 789.01 (abdominal pain RUQ), or ICD-10-CM R10.11, and line
24 field C, showing CPT 74000. The coder has demonstrated which of the following:
Ans: C. linkage
Feedback: The diagnosis code for abdominal pain shows the medical necessity for the KUB and
correctly identifying this on lines 21 and 24 show the linkage between the diagnosis and
procedure code.
9. Identify the appendix to be consulted for examples of levels of office visits.
Ans: D. Appendix C - Clinical Examples of Evaluation and Management Services
Feedback: Appendix C, Clinical Examples of Evaluation and Management Services, should be
consulted for examples of levels of office visits.
11. Which statement is not true about HCPCS Level II codes?
Ans: B. Level II HCPCS codes are 5-digit numeric codes.
Feedback: Level I HCPCS codes are 5-digit numeric codes; Level II are alpha and numeric.
13. Determine the full description of code CPT 33244.
Ans: B. Removal of single- or dual-chamber pacing cardioverter-defibrillator electrode(s) by
transvenous extraction.
Feedback: Removal of single- or dual-chamber pacing cardioverter-defibrillator electrode(s) is
the description of the code above 33243 to the left of the semi-colon.
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25
This part of the description becomes part of the description of code 33244 with the phrase by
transvenous extraction completing the description
15. In which section of the CPT manual would code 0176T, transluminal dilation of
aqueous outflow canal; without retention of device stent, be located?
Ans: D. Category III
Feedback: Category III codes are T codes.
Applying Your Knowledge
1. The patient had a pacemaker inserted with atrial and ventricular lead placements. This
procedure was coded as 33249 and 33217. Determine whether the codes are correct. If they
are incorrect, what code or codes should have been reported and what translation errors
were made?
Ans: The correct code would be 33208. Code 33249 is for an implantable cardioverter
defibrillator and the record clearly stated a pacemaker was inserted. There would be only one
code, 33208, since this code includes the placement of the generator and the electrodes (leads) so
a separate code for lead placement would not be reported.
Feedback: The pacemaker placed is a dual chamber since the record stated there were both atrial
and ventricular leads placed.
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26
Chapter 6 – Evaluation and Management
Exercise 6.1
1. Explain the three R’s needed to support a consultation code.
Ans: The service must be in the form of a written request to the consulting physician asking them to
render an opinion and supply a written report to the requesting physician.
Feedback: The three R’s can be summarized as follows: The service must be in the form of a written
request to the consulting physician asking that physician to render an opinion and supply a written report
to the requesting physician.
3. Explain CPT’s definition of a critical illness or injury.
Ans: CPT defines a critical illness or injury as one that acutely impairs one or more vital organ systems
and there is a high probability of life threatening deterioration.
Feedback: The patient can be in a critical care unit, such as ICU or CCU, and not be designated as
critically ill. A patient can also be in a setting other than a critical care unit and be designated as critically
ill. It is not the setting but the condition that defines critical care.
Exercise 6.2
1. Define new patient and established patient.
Ans: New patient: One who has not received face-to-face services from the physician/qualified
healthcare professional or another physician/qualified healthcare professional of the exact same specialty
and subspecialty in the same group within the past 3 years. Established patient: One who has received
face-to-face services from the physician/ qualified healthcare professional or another physician/qualified
healthcare professional of the exact same specialty and subspecialty in the same group within the past 3
years.
Feedback: N/A
3. List the four steps that can lead the coder to the appropriate range of E/M codes for the patient
encounter.
Ans:
1) Determine the patient’s chief complaint.
2) Identify the place of service or setting of the encounter.
3) Identify the kind of service.
4) Identify the status of the patient.
Feedback: N/A
Exercise 6.3
1. When is time a key factor?
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Ans: Time can be a key factor, for the codes within this section requiring either three or two key
components, when 50% or more of the visit is spent on counseling and coordination of care.
Feedback: The documentation must state the total time of the visit and the amount of time spent on
counseling and coordination of care.
3. List the three key components of an E/M service.
Ans:
History
Examination
Medical Decision Making
Feedback: N/A
Exercise 6.4
1. What year’s E/M documentation guidelines are followed for the CPC exam?
Ans: 1995 guidelines
Feedback: The 1995 documentation guidelines are followed for the CPC exam, and the determination of
the three key components is based on these guidelines in this textbook.
3. What determines the overall risk for the table of risk subelement for medical decision making?
Ans: In this element the highest level in any one subelement (presenting problem, diagnostic procedure,
or management option) determines the overall risk.
Feedback: N/A
Exercise 6.5
1. Which modifier informs the payer that an unrelated E/M service was provided by the same
physician during a postoperative period?
Ans: Modifier 24
Feedback: Modifier 24 – Unrelated E/M service by the same physician during a postoperative period
3. Which modifier allows for a preoperative visit to be reported separately from the global surgical
package?
Ans: Modifier 57
Feedback: If the decision for surgery was made during the visit the same day as the surgery or the day
before the surgery.
Chapter Six Review
Using Terminology
Ans:
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28
1. B
Chief complaint
9. E
Medical decision making (MDM)
3. G
Emergency department
11. A
Outpatient
5. K
Established patient
13. N
Preventive care
7. M
History of present illness (HPI)
Feedback: N/A
Checking Your Understanding
Complete each sentence with the most appropriate term or terms.
1. It is not the setting but the _____________________that defines critical care.
Ans: Condition
Feedback: It is not the setting but the condition that defines critical care.
3. CPT code 99221 is found under the subheading __________________in the E/M section of the
CPT manual.
Ans: Inpatient Care Services
Feedback: CPT code 99221 is found in the subheading inpatient care services in the E/M section of the
CPT manual.
5. A patient presents to the office for their annual visit and has no signs or symptoms. An
appropriate code would be chosen from the _________________ section.
Ans: Preventive Medicine
Feedback: A patient presents to the office for their annual visit and has no signs or symptoms. An
appropriate code would be chosen from the Preventive Medicine section.
Choose the most appropriate answer for each of the following questions.
7. The physician observes that the patient’s throat is red and swollen. Which key-component
element is this an example of?
Ans: B. Ears, nose, mouth, and throat organ system
Feedback: In this statement the physician examined (observed) the patient’s throat, which would make it
an organ system within the physical exam component.
9. A provider documents spending 35 minutes in the morning and 65 minutes in the afternoon
providing clinical care for a patient. CPT code(s) ________ would be reported.
Ans: B. 99291, 99292
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Feedback: Total time spent -100 minutes. Time spent with critically ill patient does not have to be
continuous. 99291 is first 30-74 minutes, 99292 each additional 30 minutes. The grid in the CPT manual
shows 75-104 minutes would be coded 99291 and 99292.
11. The patient calls the office and asks the cardiologist for a “consultation” regarding his chest
pain. The patient is seen, and the physician determines that his chest pain is due to heartburn and
sends a report to the patient’s family physician. The cardiologist’s office reports this visit as a
consultation, using codes from range 99241-99245. One of the three “Rs” is missing and therefore
the appropriate code range 99201-99205 should be reported. Which “R” is missing?
Ans: A. request
Feedback: The request must come from a provider - this request was from the patient
13. The patient states that her pain occurs upon exertion. Which subelement of the history of
present illness (HPI) is this an example of?
Ans: B. context (What is happening or happened when the present illness or injury occurred?)
Feedback: Timing is defined as: when do the signs and or symptoms occur?
Associated signs and symptoms is defined as: other factors occurring which are related to or affect the
present illness or injury
Severity is defined as: descriptors such as mild, moderate, severe or the use of the pain scale
15 . A 30-year-old male patient is seen in the office. He is a returning patient who has not been
seen for 4 years by the physician. The patient states that he has been having chronic back pain for
several months. The physician performs an expanded, problem-focused history and exam. The
physician prescribes medication and asks to see the patient in 3 weeks. The medical decisionmaking is low. What is the appropriate CPT code?
Ans: A. 99202
Feedback: This is a new patient in the office, so 99212 and 99242 are eliminated right away since they are
codes for established patient and office consultation.
Applying Your Knowledge
1. Using the techniques described in this chapter, work through the following case study to
determine the appropriate E/M code.
A 17-year-old year old high school student presents with his mother, complaining of a sore throat which
began three days ago. He denies any fever or chills but does state that he feels tired and weak. The
patient has been seen for frequent bouts of sore throat in the last year.
Physical Exam:
Neck: supple
General appearance- no acute distress
Vitals: 98.6, 80, 120/75
HEENT: pharynx is clear; throat is mildly red and swollen
Lungs: normal respiratory effort
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30
Impression: viral URI
Plan: drink plenty of fluids, Tylenol as needed. rest, and return in a week if no improvement
Ans:
Chief Complaint = sore throat
Place of Service = office
Type of Service = office or other outpatient
Status = established
History Component = Expanded Problem Focused
HPI =Brief (2-9 sub elements); location = throat; duration = three days; associated signs and symptoms =
fever
ROS = Problem pertinent (1 sub element); constitutional = fever, chills
PFSH = Pertinent (1 sub element); social = student
Physical Exam Component = Expanded Problem Focused
Body Areas = Neck
Organ Systems = Constitutional, HEENT, respiratory
Medical Decision-Making Component = Straightforward
Number of Diagnoses and Management
Options = Established problem - worsening
Amount and Complexity of Data = None
Table of Risk = Low - over the counter drugs
Final CPT Code = 99213
ICD Code = 472.1 (sore throat, chronic)
Feedback: N/A
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31
Chapter 7 – Anesthesia
Exercise 7.1
1. Define the term anesthesia.
Ans: Anesthesia means without sensation.
Feedback: This loss of sensation can be partial or complete and can be achieved by different types of
anesthesia.
3. What is the anesthesia reimbursement formula?
Ans: B + T + M (basic unit + time + modifying factor [physical status modifier and qualifying
circumstance])
Feedback: N/A
Exercise 7.2
1. What is the function of a qualifying-circumstance modifier?
Ans: At times anesthesia may be provided under more challenging circumstances such as extreme patient
age, condition of patient or surgical procedure, or emergency situations when the patient’s medical history
or history of previous anesthesia response is not available prior to initiation of anesthesia. Qualifying
circumstance modifiers are used to indicate this type of information.
Feedback: Qualifying-circumstance modifiers are used to indicate information regarding challenging
circumstances such as extreme patient age, condition of patient or surgical procedure, or emergency
situations when the patient’s medical history or history of previous anesthesia response is not available
prior to initiation of anesthesia.
3. A 72-year-old patient is taken to the operating room for emergency surgery. The patient is
known to be diabetic. What physical-status modifier and qualifying-circumstance modifier, if any,
would be appended to this patient’s anesthesia code?
Ans: P2 and 99100
Feedback: P2 for mild systemic disease and 99100 for age since the patient is 72 and 99140 since this was
an emergency situation.
Exercise 7.3
1. What is the purpose of the anesthesia-specific modifiers?
Ans: Anesthesia-specific modifiers are used to identify circumstances regarding providers and the level
of service being provided, since they are reimbursed at different rates.
Feedback: At times anesthesia services may be provided by different levels of providers performing
different levels of service; for example, an anesthesiologist providing the services or a Certified
Registered Nurse Anesthetist (CRNA) acting under the direction of an anesthesiologist or providing the
service without medical direction.
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As providers and the level of service being provided are reimbursed at different rates, these modifiers are
used to identify these circumstances.
3. Which anesthesia-specific modifier identifies that the service was performed by the CRNA with
no medical direction or supervision?
Ans: QZ
Feedback: Use of modifier QZ identifies that the service was performed by the CRNA with no medical
direction or supervision.
Exercise 7.4
1. Define intubation.
Ans: Intubation is the placement of a flexible tube into the trachea to maintain an open airway or allow
for ventilation of the lungs during anesthesia.
Feedback: N/A
3. List the requirements of medical direction
Ans:
 Complete pre-anesthetic examination and evaluation
 Set the anesthesia plan
 Attend to patients during the most demanding procedures of the anesthesia plan
 Ensure any procedures that are not personally performed are performed by individuals
qualified to do so
 Monitor the course of anesthesia in frequent intervals
 Remain physically present and available for emergencies
 Provide indicated postoperative care
Feedback: N/A
Exercise 7.5
1. The only two types of anesthesia sedation services reported with an Anesthesia section code (CPT
codes beginning with “0”) are general and monitored anesthesia care (MAC). What is the key to
understanding when to report general anesthesia and when to report MAC?
Ans: Knowing whether or not the patient’s airway was managed during the anesthesia service.
Feedback: If the airway was managed by the anesthesiologist, the service is reported as general
anesthesia.
3. List some of the methods of airway management.
Ans: Endotracheal, through existing tracheostomy, or via a mask or nasal cannula.
Feedback: Methods of airway management include endotracheal, through existing tracheostomy, or via a
mask or nasal cannula.
Exercise 7.6
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1. List services that are considered part of the work of the anesthesia service and as such are not
coded separately.
Ans:




Preoperative and postoperative visit
General or regional anesthesia and patient care
Administration of fluids and/or blood
Usual monitoring services (e.g., ECG, temperature, blood pressure, oximetry, capnography,
and mass spectrometry)
Feedback: There are several procedures or services that might be performed and documented by the
provider of anesthesia services that, although they may have a distinct CPT code to identify them, are
considered part of the work of the anesthesia service and as such are not coded separately. (These include
the list above).
Chapter Seven Review
Using Terminology
1. L
Airway management
9. I
MAC
3. B
Base unit
11. M Moderate/conscious sedation
5. J
Emergency condition
13. E
Physical-status modifiers
7. N
General anesthesia
15. D
Time
Feedback: N/A
Checking Your Understanding
1. As it applies to anesthesia services, which of the following terms describes physician involvement
with and direction of anesthesia that is carried out by a qualified physician?
Ans: C. Medical direction
Feedback: Medical direction is the physician involvement with and direction of anesthesia that is carried
out by a qualified provider.
3. A 72-year-old normal, healthy patient presents to the operating room for a corneal transplant.
The anesthesiologist administers general anesthesia. Choose the appropriate codes the
anesthesiologist would report.
Ans: C. 00144, P1, 99100
Feedback: 00144 - Anesthesia for procedures on eye: corneal transplant; P1 for normal healthy patient;
99100 qualifying circumstance modifier for age older than 70.
00140, P3, 99100 is incorrect since it is specified as a corneal transplant, and P3 is for a patient with
severe systemic disease.
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34
65710, 00144, P1, 99100 is incorrect because it included 65710, which is the code the surgeon would
report.
00144, P1 is incorrect since it does not include the qualifying circumstance modifier.
5. Choose the appropriate description of when time begins and ends for anesthesia procedures.
Ans: B. Time begins when the anesthesiologist begins to prepare the patient for the induction of
anesthesia, and it ends when the anesthesiologist is no longer in personal attendance.
Feedback: This total time is then converted into units, typically 15 minutes equals 1 unit per ASA
recommendation, and added to the base units allotted for the surgical procedure.
Applying Your Knowledge
Case 1
The patient presents for anesthesia for open appendectomy needed for acute appendicitis (Base Units 6).
The patient is 19 and otherwise in good health. Under medical direction of Dr. Thames, the
anesthesiologist, the CRNA begins to prepare the patient for induction of endotracheal anesthesia at 7:45
a.m. The procedure is performed without incident, and patient is released to PACU at 9:05 a.m.
Answer the following questions.
CPT Coding for Anesthesia Services Only
1. What type of sedation is provided for this service?
Ans: Endotracheal, general
3. What is the surgical procedure and/or anatomic site of the procedure (subterm)?
Ans: Abdomen, intraperitoneal
ICD-9-CM Coding
1. What is the main diagnostic term for this patient’s condition?
Ans: Appendicitis
3. Are any additional signs, symptoms or conditions needed to complete this diagnosis?
Ans: No
Feedback: Appendicitis is confirmed diagnosis and the signs and symptoms would be inherent to the
condition.
Modifiers
1. What level of provider performed the service?
Ans: CRNA
3. What is the correct modifier to identify the provider and level of supervision for this service?
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35
Ans: QX
5. What is the correct physical-status modifier for this service?
Ans: P1
7. What is the qualifying-circumstance modifier for this service?
Ans: There is none
Units of Service
1. What is the number of base units assigned to this service?
Ans: 6
3. What is the total number of units listed on the claim for this anesthesia service?
Ans: 11
Feedback: N/A
Case 2
Following Dr. Thames’ anesthesiologist prescribed plan for a patient with type 2 diabetes mellitus not
well controlled, the CRNA intubates the patient at 8:58 a.m. The surgeon performs an excision of a
benign tumor on the olecranon process (Base Units 4). At 10:18 a.m. the patient is extubated and sent to
the PACU.
CPT Coding for Anesthesia Services Only
1. What type of sedation is provided for this service?
Ans: Endotracheal, general
3. What is the surgical procedure and/or anatomic site of the procedure (subterm)?
Ans: Elbow
ICD-9-CM coding
1. What is the main diagnostic term for this patient’s condition?
Ans: Tumor
3. Are any additional signs, symptoms, or conditions needed to complete this diagnosis?
Ans: Yes, Type II Diabetes Mellitus, not well controlled.
Feedback: This is a chronic condition that will affect the treatment and management of this patient.
Modifiers
1. What level of provider performed the service?
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Ans: CRNA
3. What is the correct modifier to identify the provider and level of supervision for this service?
Ans: QX
5. What is the correct physical-status modifier for this service?
Ans: P3
7. What is the qualifying-circumstance modifier for this service?
Ans: There is none
Units of Service
1. What is the number of base units assigned to this service?
Ans: 4
3. What is the total number of units listed on the claim for this anesthesia service?
Ans: 9
Feedback: N/A
Case 3
Using the information from Cases 1 and 2 above, provide the coding information needed to bill for Dr.
Thames’ services.
For Case 1:
CPT
Ans: 00840
ICD-9-CM
Ans: 540.9
Provider-of-service modifier
Ans: QK
Feedback: Refer back to the note at the beginning of the case studies: All anesthesia services in the
following cases are performed on the same day by Thames Anesthesiology Group which provided
services at General Medical Hospital.
Physical-status modifier
Ans: P1
Qualifying-circumstances modifier
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Ans: None
Total number of units
Ans: 11
For Case 2:
CPT
Ans: 01740
ICD-9-CM
Ans: 213.4; 250.02
Provider-of-service modifier
Ans: QK
Feedback: Refer back to the note at the beginning of the case studies : All anesthesia services in the
following cases are performed on the same day by Thames Anesthesiology Group which provided
services at General Medical Hospital.
Physical-status modifier
Ans: P3
Qualifying-circumstances modifier
Ans: None
Total number of units
Ans: 9
Feedback: N/A
Case 4
Arthroplasty right hip
DJD of right hip
After satisfactory anesthesia by Dr. Thames, the surgeon completed the arthroplasty of the right hip of
this 72-year-old male. Patient comorbidities include well-controlled type 2 DM and benign hypertension.
Both the head of the femur at the greater trochanter and the acetabulum were replaced during this
procedure (Base Units 8). Induction of the patient began at 11:02 a.m., and the patient was extubated and
sent to postanesthesia recovery at 1:48 p.m.
CPT Coding for Anesthesia Services Only
1. What type of sedation is provided for this service?
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Ans: Endotracheal, general
3. What is the surgical procedure and/or anatomic site of the procedure (subterm)?
Ans: Arthroplasty, Hip
ICD-9-CM Coding
1. What is the main diagnostic term for this patient’s condition?
Ans: Degenerative
Feedback: Index then tells the coder to see osteoarthritis.
3. Are any additional signs, symptoms or conditions needed to complete this diagnosis?
Ans: Yes, Type II Diabetes Mellitus, controlled and benign hypertension.
Feedback: These are chronic conditions that will affect the treatment and management of this patient.
Modifiers
1. What level of provider performed the service?
Ans: Anesthesiologist
3. What is the correct modifier to identify the provider and level of supervision for this service?
Ans: AA
5. What is the correct physical-status modifier for this service?
Ans: P2
7. What is the qualifying-circumstance modifier for this service?
Ans: 99100
Units of Service
1. What is the number of base units assigned to this service?
Ans: 8
3. What is the total number of units listed on the claim for this anesthesia service?
Ans: 19
Feedback: N/A
Case 5
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A 6-year-old boy presents to the OR for closed reduction of a distal ulnar fracture at 3:45. Dr. Thames
monitors the patient’s vital signs and respirations while on room air. The total time of the procedure is 48
minutes. (Base Units 3)
CPT Coding for Anesthesia Services Only
1. What type of sedation is provided for this service?
Ans: Monitored Anesthesia Care or MAC
3. What is the surgical procedure and/or anatomic site of the procedure (subterm)?
Ans: Arm, lower
ICD-9-CM Coding
1. What is the main diagnostic term for this patient’s condition?
Ans: Fracture
3. Are any additional signs, symptoms, or conditions needed to complete this diagnosis?
Ans: No
Modifiers
1. What level of provider performed the service?
Ans: Anesthesiologist
3. What is the correct modifier to identify the provider and level of supervision for this service?
Ans: QS
5. What is the correct physical-status modifier for this service?
Ans: P1
7. What is the qualifying-circumstance modifier for this service?
Ans: There are none
Units of Service
1. What is the number of base units assigned to this service?
Ans: 3
3. What is the total number of units listed on the claim for this anesthesia service?
Ans: 6
Feedback: N/A
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40
Chapter 8 – Surgery Section
Exercise 8.1
1. Explain the format of the Surgery section
Ans: The surgery section is broken into six subsections which are based on organ systems or body areas:
e.g.: integumentary, musculoskeletal.
Feedback: The Surgery section guidelines contain information and rules that pertain only to the Surgery
section, and, as with all other sections, knowing these guidelines and how to use them is one of the keys
to correct coding in the Surgery section.
3. Explain a laparoscopic procedure.
Ans: Scope is inserted into the abdominal cavity via an incision in the abdominal wall.
Feedback: Procedures or inspection of the outside of the organs contained within the abdominal cavity
such as colon, intestines, ovaries, fallopian tubes and uterus may be completed via this approach.
Exercise 8.2
1. Explain the use of modifier 57 in regard to the global surgical package.
Ans: As the global surgical period for major surgical procedures include the day prior to surgery the E/M
service which resulted in the decision for surgery completed the day before or the day of surgery must be
identified to the payer by appending the modifier -57 to the E/M code.
Feedback: N/A
3. How many postoperative days are typically allocated for minor and major procedures?
Ans: Minor procedure: 10 days Major procedure: 90 days
Feedback: Minor procedures typically have a 0- to 10-day post-op period, and major procedures typically
have post-op periods of 90 days or more. Additionally, major procedures have a 1 day pre-op included in
the surgery days
Exercise 8.3
1. What questions must a coder answer when determining whether the procedure was performed
as described by the nomenclature of the code or requires a modifier to define the variance from the
description?
Ans:



Was the procedure more difficult, time consuming, or required extra work on the part of the
surgeon such as unusual anatomy? If yes, append modifier 22
Was the procedure performed less than the procedure described by the code?
o If yes:
 Verify that the code is correct
 If correct, append modifier 52
Was procedure discontinued after anesthesia but prior to completion? If yes, append modifier 53.
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Feedback: N/A
3. What questions must a coder answer from the documentation to determine the appropriate use
of modifier 62, 80, or 81?
Ans:
 Did the surgeon have help from another surgeon or other appropriate person?
 Did each surgeon perform integral parts of the same procedure (i.e. approach and definitive
procedure)? If yes, append modifier 62
 Did the assist at surgery remain and assist during the entire procedure? If yes, append modifier 80
 Did the assist at surgery attend and assist for only a portion of the procedure? If yes, append
modifier 81
Feedback: N/A
Exercise 8.4
1. Explain the difference between the suffixes -ectomy, -otomy, and -ostomy.
Ans:
-ectomy = surgical removal by cutting
-otomy = cutting into or incising
-ostomy = surgically creating an artificial opening
Feedback: The suffixes-ectomy, -otomy, and –ostomy are different. -ectomy is defined as surgical removal
by cutting. -otomy is defined as cutting into or incising. -ostomy is defined as surgically creating an
artificial opening.
3. Identify another way that ”harvesting” of a vein or artery for CABG could be dictated in an
operative report.
Ans: “Harvesting” could also be dictated as “procurement” of vein or artery for CABG.
Feedback: Another way “harvesting” of a vein or artery for CABG could be dictated in an operative
report would be “procurement” of a vein or artery for CABG.
Exercise 8.5a
1. How much of the hip was replaced?
Ans: Total Hip Replacement
Feedback: The hip has two components, the femoral head and the acetabulum or hip socket. From the
note we can identify replacement of both of these components, confirming a total hip replacement: “the
acetabular component was done….” and “ head component was tapped onto the femoral stem”.
3. If this was a partial replacement or partial revision, what portion was replaced?
Ans: This is not relevant as it has been established that this is a total initial replacement of the left hip.
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5. Based on your review of the documentation, were any other procedures performed that should
be coded in addition to the primary procedure?
Ans: If yes, follow steps 1 through 5 for each additional procedure.
Feedback: N/A
Exercise 8.5b
1. Based on the operative report header, what is the preoperative diagnosis?
Ans: Degenerative joint disease
3. Review the documentation and determine whether the post-op diagnosis is supported in the body
of the report. Was the post-op diagnosis supported?
Ans: Yes, the documentation states “severe osteoarthritis was noted”.
5. Based on the answers from the documentation, what is the primary ICD-9-CM code for the
procedure in Case 8.1?
Ans: 715.95
Feedback: The fourth digit 9 shows that the condition was not specified as generalized or localized and
the fifth digit 5 shows the location as the pelvic region.
Exercise 8.5c
1. Based on the operative report header, what is the preoperative diagnosis?
Ans: Degenerative joint disease
3. Review the documentation, and determine whether the post-op diagnosis is supported in the body
of the report. Was the post-op diagnosis supported?
Ans: Yes, the documentation states “severe osteoarthritis was noted”.
5. Locate the code in the Tabular List and determine whether additional questions are needed to
further specify the diagnosis. Based on the information in the Tabular List, is additional
information needed to determine the appropriate diagnosis code?
Ans: No
7. Determine whether additional conditions are documented and should or should not be coded by
comparing each working diagnosis to the questions below, which are based on the ICD-10-CM
coding guidelines:
Is the condition, sign, or symptom an integral part of the primary (or other) condition coded?
Ans: No, neither are.
Does the condition require or affect patient care treatment or management?
Ans: Diabetes Mellitus – Yes, as this condition will need to be monitored during the healing as well as
impacts the patient’s ability to heal and increases the risk of infection as well as healing time.
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43
Feedback: This condition should be coded: E11.9
Hyperlipidemia – No, the presence of this condition does not affect management of this patient for this
procedure.
Feedback: N/A
Exercise 8.5d
1. Was the procedure performed different from that described by the nomenclature of the code?
Ans: No
3. Was the procedure performed in the global period of another procedure?
Ans: No
5. Did the surgeon have help from another surgeon or another appropriate person?
Ans: No
Feedback: N/A
Chapter Eight Review
Using Terminology
1. C
Approach
9. M
Laparoscopy
3. E
Closed procedures
11. P
Percutaneous
5. K
Endoscopy
13. D
Separate procedures
7. H
Global surgical package
15. L
-ostomy
Feedback: N/A
Checking Your Understanding
1. The Surgery section of CPT is divided into __________subsections based on _______________.
Ans: B. six; organ systems or body areas
Feedback: The Surgery section of CPT is divided into six subsections based on organ systems or body
areas.
3. Which of the following modifiers would be appropriate to use if each surgeon performed integral
parts of the same procedure?
Ans: C. modifier 62
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Feedback: Each surgeon performed integral parts of the same procedure (i.e. approach and definitive
procedure.
Modifier 80: the surgeon assisted at the surgery and remained and assisted during the entire procedure?
Modifier 81: the surgeon assisted at surgery and attended and assisted for only a portion of the procedure.
5. The process of using a scope inserted through a natural opening or stoma to examine the inside
of an organ or system (e.g., respiratory or gastrointestinal) is referred to as:
Ans: B. endoscopy
Feedback: The process of using a scope inserted through a natural opening or stoma to examine the inside
of an organ or system (e.g., respiratory or gastrointestinal) is referred to as endoscopy.
Applying Your Knowledge
Process 1: Procedural Coding (CPT)
1. What is the primary procedure?
Ans: Arthroscopy
3. Upon review of the all code choices identified in the index, what additional questions can be
determined?
Ans: Were autografts or transplantations completed?, was there infection present?, lateral release, foreign
bodies, synovectomy, shaving or debridement, arthroplasty, or meniscetomy? and which compartments?
Process 2: Diagnostic Coding (ICD)
ICD-9-CM Coding
1. Based on the operative report header, what is the preoperative diagnosis?
Ans: Possible torn medial meniscus
3. Is the post-op diagnosis supported?
Ans: Yes
Feedback: Documentation states “A tear was noted at the posterior horn of the medial meniscus”.
5. Based on the subterm choices, what question can be developed for this condition?
Ans: Anatomic location, old or current, and type of tear are the subterm choices which can be developed
for this condition.
7. Is the additional condition, sign, or symptom an integral part of the primary (or other) condition
coded?
Ans: No
9. Based upon the documentation, what is (are) the correct ICD-9-CM code(s) for this case?
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Ans: A. 836.0
Feedback: N/A
ICD-10-CM Coding
1. Based on the operative report header, what is the preoperative diagnosis?
Ans: Possible torn medial meniscus
3. Is the post-op diagnosis supported?
Ans: Yes
Feedback: Documentation states “A tear was noted at the posterior horn of the medial meniscus”.
5. Based on the subterm choices, what question can be developed for this condition?
Ans: Anatomic location, old or current and type of tear, laterality
7. Is any sign, symptom, or additional condition documented?
Ans: Yes, minimal erosion of the medial femoral condyle, and medial plateau.
9. Does the additional condition require or affect patient care, treatment, or management?
Ans: No
Feedback: N/A
Process 3: Adding Modifiers
1. Was the procedure performed different from that described by the nomenclature of the code?
Ans: No
3. Was the procedure performed in the global period of another procedure?
Ans: No
5. Did the surgeon have help from another surgeon or another appropriate person?
Ans: No
7. What modifier should be appended to the CPT code for this case?
Ans: B. LT
Feedback: N/A
Chapter 9 – Surgery Section: Integumentary System
Exercise 9.1
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1. In which layer of the skin are the sweat pores located?
Ans: The sweat pores are located in the epidermis.
Feedback: N/A
3. What is the function of melanocytes, and in which layer are they located?
Ans: Melanocytes give the skin its pigment and protect the skin’s DNA from the sun’s
ultraviolet light. Melanocytes are found in the epidermis of the skin.
Feedback: It is in the melanocytes that melanoma, a malignant neoplasm of the skin, begins its
formation.
Exercise 9.2
1. Explain the difference between inflammation and infection.
Ans: Infection is defined as an invasion of the body by a pathogenic organism while
inflammation is defined as a localized response to an injury or destruction of tissues.
Feedback: N/A
3. Discuss the guidelines concerning the coding of pressure ulcers.
Ans:
 To completely code the condition, two codes are needed; one to identify the site and one
to identify the stage.
 For pressure ulcers whose stage cannot be determined, assign code 707.25 Pressure ulcer,
unstageable in addition to the code for the site of the ulcer.
 Only one ICD-9-CM code is needed to identify bilateral pressure ulcers of the same
anatomic site and at the same stage.
 For pressure ulcers of different stages of the same bilateral site, (eg hip) assign one code
for the site and a separate code for each stage documented.
 Assign codes for each anatomic site and stage when multiple ulcers/sites are documented.
 Pressure ulcers documented as healing should be assigned both a code for the site and a
code for the stage of the ulcer documented. If the documentation does not provide the
stage of a healing ulcer, assign code 707.20 Pressure ulcer, stage unspecified.
 As the stage of a pressure ulcer may continue to evolve until healing begins, code the
stage to the highest stage reported.
Feedback: N/A
Exercise 9.3
1. The physician dictates the size of the lesion as 2 inches x 3 inches. Convert the inches to
centimeters.
Ans: Two inches = 2 x 2.54 = 5.08 centimeters. Three inches = 3 x 2.54 = 7.62 centimeters.
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47
Feedback: Coders must know that 1 inch (in.) equals 2.54 centimeters (cm) to be able to convert
inches to centimeters, as needed for CPT codes.
3. For coding a Z-plasty, which is an adjacent tissue transfer procedure, what is the
appropriate range of codes?
Ans: 14000-14350
Feedback: N/A
Exercise 9.4
1. Explain the difference between a simple incision and drainage and a complex I&D.
Ans: Simple I & D involves opening and draining the pus or cyst and leaving the site open to
heal on its own. Complex procedures require additional work such as placement of drains and
packing in addition to the work done in simple I & Ds.
Feedback: N/A
3. Describe the difference between excisional and nonexcisional debridement.
Ans: Excisional debridement is surgical removal or cutting away of tissue. Nonexcisional
debridement is brushing, irrigating, scrubbing, or washing of tissue, wet to dry dressing.
Feedback: N/A
5. List and define the six degrees of burns.
Ans: First-degree burns are limited to the epidermis and top layer of the dermis.
Second-degree burns extend beyond the epidermis and deeper into the dermis which results in
blistering and pain.
Third-degree burns involve all layers of the skin and the subcutaneous tissue and results in
destruction of the nerves.
Fourth-degree burns extend beyond the subcutaneous tissue involving the underlying structures
of muscle, tendon, and ligament but not through the bone.
Fifth- and Sixth-degree burns extend into the bone and beyond to the underlying organs,
typically resulting in the demise of the patient.
Feedback: ICD-9-CM and ICD-10-CM only reference first, second and third degree burns.
Exercise 9.5
1. Explain the function of a modifier when coding a procedure involving the
integumentary system.
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Ans: Modifiers used with the integumentary system function to let the payer know there were
multiple procedures performed, the procedure was a staged procedure, or the procedure was a
distinct procedural service.
Feedback: Multiple procedures = modifier 51; staged procedure = modifier 58; and distinct
procedural service = modifier 59.
Exercise 9.6
List other terms which could be used for the following in a physician dictation
Ans:
1. contusion, scrape, bruise
2. wound, cut, tear
3. procurement
4. zplasty, rotation flap, rearrangement
5. suture, revision, restore
6. transverse incision
7. bulla, pustule, vesicle
8. cicatrix, callus
9. furuncle, carbuncle
10. urticaria
Feedback: N/A
Chapter Nine Review
Using Terminology
Ans:
1.
J Adjacent tissue transfer
9.
B Inflammation
3.
E Debridement
11. L Laceration
5.
A Epidermis
13. C Paring
7.
O Incision and drainage
15. G Simple repair
Feedback: N/A
Checking Your Understanding
1. The ________layer, made up of living cells that continue to divide and work their way to
the surface, becoming keratin, is the deepest layer of the epidermis.
Ans: B
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Feedback: The basal layer, made up of living cells that continue to divide and work their way to
the surface, becoming keratin, is the deepest layer of the epidermis.
3. Which modifier would not be used with the codes in the integumentary subsection?
Ans: D
Feedback: The modifier 50 would not be used since the integumentary system is considered a
single organ.
5. The correct CPT and ICD-9-CM codes for a complicated I&D of purulent material from
the upper arm are:
Ans: B
Feedback: 10061 is specific to incision and drainage of an abscess, and the term purulent
material should have led the coder to abscess.
7. The __________ acts as a seal between the nail plate and the skin.
Ans: C
Feedback: The cuticle acts as a seal between the nail plate and the skin.
9. The patient has an ischial ulcer that is excised, including an ostectomy with a skin flap
closure. Select the appropriate code(s).
Ans: B
Feedback: 15945 includes the excision, the skin flap closure, and the ostectomy.
11. When coding flaps and tissue transfer, which of the following questions should a coder
ask before choosing the appropriate code?
Ans: D
Feedback: Before selecting the appropriate codes for adjacent tissue transfers and flaps, coders
need to find answers in the medical record to these questions:
 Did the tissue remain in its original location?
 What is the anatomical site of the defect?
 What is the total size of the defect? (primary + secondary defect = total)
13. The patient presents with a burn that extends beyond the epidermis and deeper into
the dermis. The patient is experiencing pain and blistering. If coders see this type of
description in a report, they would code the condition as what degree of burn?
Ans: B
Feedback: Second degree burn – the pain, blistering and the depth described would help them
identify the degree of burn.
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50
Applying Your Knowledge
Case Study
Preoperative diagnosis: Lacerations of right palm and forearm and left leg
Postoperative diagnosis: Same
An 8-year-old male was brought to the emergency room. While playing basketball with friends,
he ran through a sliding glass door. He suffered lacerations on his right hand and arm and on his
left leg just above and at the knee.
Procedure: The patient was placed on the table in supine position. Satisfactory local anesthesia
was obtained. All wounds were cleaned and examined and no sign of glass or other foreign
bodies were found. The laceration of the left thigh, right above the patella, was repaired first by
layered closure and the 4.8cm laceration was carefully sutured.
The lacerations on the hand and arm were attended to next. A 3-cm laceration on the right-hand
palm and a 4-cm laceration on the right forearm proximal to the elbow were carefully sutured in
a single layer with 4-0 Vicryl, as well.
Process 1: CPT
1. What is the procedure?
Ans: Repair, skin
Feedback: The procedure is Repair, skin.
3. Upon review of all the code choices identified in the index, what additional questions can
be determined?
Ans: Anatomic site, size of wound
Feedback: The additional questions are Anatomic site and size of wound.
Process 2: ICD
ICD-9-CM
1. Based on the operative report header, what is the preoperative diagnosis?
Ans: Lacerations of right palm and forearm and left leg
Feedback: Per the operative report header, the preoperative diagnosis is lacerations of right palm
and forearm and left leg.
3. Is the postoperative diagnosis supported?
Ans: Yes
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Feedback: Yes, the postoperative diagnosis is supported.
5. Based on the subterm choices, what question(s) can be developed for this condition?
Ans: Anatomic site, and if the wounds are complex or deep (with tendon involvement)
Feedback: Based upon the subterm choices, the questions developed for this condition are:
Anatomic site, and if the wounds are complex or deep (with tendon involvement).
7. Is the additional condition, sign, or symptom an integral part of the primary (or other)
condition coded?
Ans: Not applicable
Feedback: Not applicable, since there was no additional condition, sign, or symptom.
9. Based upon the documentation what are the correct ICD-9-CM codes for this case?
Ans: A. 890.0, 881.00, 882.0
Feedback: The ICD-9-CM codes for this case are 890.0, 881.00, and 882.0.
ICD-10-CM
1. Based on the operative report header, what is the preoperative diagnosis?
Ans: Lacerations of right palm and forearm and left leg
Feedback: Per the operative report header, the preoperative diagnosis is lacerations of right palm
and forearm and left leg.
3. Is the postoperative diagnosis supported?
Ans: Yes
Feedback: The postoperative diagnosis is supported.
5. Based on the subterm choices what question(s) can be developed for this condition?
Ans: Anatomic location, type of wound, with amputation
Feedback: Based on the subterm choices, the questions developed by this condition are:
Anatomic location, type of wound, with amputation.
7. Is any sign, symptom, or additional condition documented?
Ans: Not applicable
Feedback: There is no sign, symptom, or additional condition documented.
9. Does the additional condition require or affect patient care, treatment, or management?
Ans: Not applicable
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52
Feedback: Not applicable, since there is no additional condition.
Process 3: Modifiers
1. Was the procedure performed different from that described by the nomenclature of the
code?
Ans: No
Feedback: The procedure performed was not different from that described by the nomenclature
of the code.
3. Was the procedure performed in the global period of another procedure?
Ans: No
Feedback: The procedure was not performed in the global period of another procedure.
5. Did the surgeon have help from another surgeon or another appropriate person?
Ans: No
Feedback: The surgeon did not have help from another surgeon or other appropriate person.
7. What modifier should be appended to the CPT code for this case?
Ans: B. 51
Feedback: The modifier 51 is appended to the CPT code for this case.
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53
Chapter 10 – Surgery Section: Musculoskeletal System
Exercise 10.1
1. Explain the difference between a tendon and a ligament.
Ans: Tendon is a narrow band of nonelastic, dense, fibrous connective tissue which attaches muscle to a
bone.
Ligaments are bands of fibrous tissue that connect two or more bones or cartilage.
Feedback: Tendons attach muscle to a bone, while ligaments connect two or more bones or cartilage.
3. Where is the deep fascia?
Ans: The deep fascia lies beneath the second layer of subcutaneous tissue.
Feedback: The deep fascia is found beneath the second layer of subcutaneous tissue.
5. Describe the bones that make up the appendicular skeleton.
Ans: Bones of the shoulder: clavicle, scapula, acromion
Bones of the arms: humerus, radius, ulna, olecranon process
Bones of the wrists, hands, fingers: carpals, metacarpals, phalanges
Bones of the pelvis and hips: ilium, ischium, pubis
Bones of the legs: femur, knees, tibia, femur
Bones of the ankles and toes: tarsals, metatarsals, phalanges
Feedback: The appendicular skeleton is made up of the following: Bones of the shoulder (clavicle,
scapula, acromion); bones of the arms (humerus, radius, ulna, olecranon process); bones of the wrists,
hands, fingers (carpals, metacarpals, phalanges); bones of the pelvis and hips (ilium, ischium, pubis);
bones of the legs (femur, knees, tibia); and bones of the ankles and toes (tarsals, metatarsals, phalanges).
Exercise 10.2
1. List some of the more common conditions associated with the musculoskeletal system that would
be reported using codes from this chapter of ICD
Ans: Some of the more common conditions of the musculoskeletal system include diseases of the
connective tissue such as systemic lupus erythematosus; poliomyelitis; arthropathy; Osteoarthosis;
derangement joint disorders; spondylosis; and disorders of muscles, ligaments and fascia.
Feedback: Some of the more common conditions of the musculoskeletal system that would be reported
using codes from this chapter of ICD include diseases of the connective tissue such as systemic lupus
erythematosus; poliomyelitis; arthropathy; osteoarthosis; derangement joint disorders; spondylosis; and
disorders of muscles, ligaments and fascia.
3. In reporting osteoarthritis (OA), what elements of the condition are defined by the fourth and
fifth digits?
Ans: The fourth digit in this category of codes defines if the condition is generalized or localized and
whether it is primary or secondary.
The fifth digit in this category of codes defines the anatomic site.
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Feedback: In reporting osteoarthritis, the fourth digit defines whether the condition is generalized or
localized and whether it is primary or secondary. The fifth digit in this category of codes defines the
anatomical site.
Exercise 10.3
1. List terms found in provider documentation that would lead the coder to assign the ICD code in
which “complicated” appears in the code description.
Ans: Infection or treatment delay
Feedback: Infection or treatment delay are examples of terms that could appear in the documentation
which would lead the coder to assign the code in which “complicated” appears in the code description.
3. CPT codes for procedures of the upper arm are located in which range of codes?
Ans: 23930-24999 – Humerus and Elbow
Feedback: CPT codes for procedures of the upper arm would be located in the range 23930-24999 –
Humerus and Elbow.
Exercise 10.4
1. How would a coder report a replantation of an incomplete amputation of an extremity or digit?
Ans: Coders are instructed when reporting a replantation of an incomplete amputation to see specific
codes for repair of bone, ligaments, tendons, nerves, or blood vessels with the use of modifier -52
(reduced service).
Feedback: When reporting a replantation of an incomplete amputation, coders are instructed to see
specific codes for repair of bone, ligaments, tendons, nerves, or blood vessels with the use of modifier 52
(reduced service).
3. Explain the guidelines for coding excision of subcutaneous and fascial or subfascial soft tissue
tumors.
Ans: Excision of subcutaneous soft tissue tumors involves tumors located below the skin but above the
deep fascia.
Excision of fascial or subfascial soft tissue involves tumors confined to the tissue within or below the
deep fascia.
Radical resection of soft tissue or bone tumors requires excision of surrounding soft tissue. Excision of
this tissue is included in the tumor excision and is not coded separately.
Feedback: N/A
5. Explain why an arthrodesis or fusion procedure would be performed.
Ans: This procedure may be performed to strengthen an area, such as the spine, after other surgical
procedures or to eliminate pain upon flexion and extension at the site of a joint.
Feedback: This procedure may be performed to strengthen an area after other surgical procedures or to
eliminate pain upon flexion and extension at the site of a joint.
Exercise 10.5
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1. For what type of procedures within the Musculoskeletal subsection would it not be appropriate
to append modifier 62.
Ans: It is not appropriate to append modifier 62 to spinal instrumentation codes or bone grafts.
Feedback: Do not append modifier 62 to spinal instrumentation codes or bone grafts.
Exercise 10.6
1. Explain the difference between a sprain and a strain.
Ans: Sprain: Injury to joint, such as ankle, wrist, or knee. Usually involves a stretched or torn ligament.
Strain: Injury to body of the muscle or the attachment of a tendon. Usually associated with overuse
injuries that involve a stretched or torn muscle or tendon.
Feedback: N/A
3. If the word cautery, cryo, or laser is part of the description of the procedure performed, what
main term could be used to describe all of these words?
Ans: Destruction
Feedback: Destruction would be the main term used to describe cautery, cryo, or laser for the procedure
performed.
Chapter Ten Review
Using Terminology
1.
I
Axial skeleton
11.
D
Manipulation
3.
G
Closed fracture
13.
F
Open fracture
5.
C
Dislocation
15.
Q
Osteoporosis
7.
O
External fixation
17.
B
Tendon
9.
J
Ligament
Feedback: N/A
Checking Your Understanding
Complete each of the following statements with the most appropriate answer or code.
1. The correct procedure code for subcutaneous foreign body removal from the elbow is
_______________.
Ans: 24200
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Feedback: When coding for removal of foreign bodies, check the site; in this case the foreign body was
described as subcutaneous. Code 24201 would be used if the foreign body was documented as deep
(subfascial or intramuscular).
3. Some examples of irregular bones are _______________, ________________, and ____________.
Ans: zygomatic, maxillary, vertebrae
Feedback: Some examples of irregular bones are zygomatic, maxillary, and vertebrae.
5. Some trigger words to look for in an operative report to support using the wound exploration
codes are ______________, _____________, and ___________.
Ans: Trauma, penetrating wounds, gunshot wound
Feedback: Some trigger words to look for in an operative report to support using the wound exploration
codes are trauma, penetrating wounds, and gunshot wound.
Choose the most appropriate answer for the following questions.
1. This lies beneath the layer of subcutaneous tissue of the integumentary system, lines extremities,
and holds together groups of muscles.
Ans: C
Feedback: The deep fascia lies beneath the layer of subcutaneous tissue of the integumentary system,
lines extremities, and holds together groups of muscles.
3. What is the correct code for an open repair of an acute ruptured rotator cuff?
Ans: A
Feedback: Code 23410 is the correct code for an open repair of an acute rotator cuff tear. The other codes
are for reconstruction and/or chronic rotator cuff tear.
5. This type of joint is movable and also called a ball-and-socket joint:
Ans: D
Feedback: Synovial and hinge joint is the type of joint which is movable and is also called a ball-andsocket joint.
7. What is the appropriate code for arthrocentesis of the shoulder?
Ans: B
Feedback: Code 20610 is the appropriate code for arthrocentesis of the shoulder, since the shoulder is
considered a large or major joint.
9. When an arthroscopy is performed at the same time as an arthrotomy, which modifier would be
appended?
Ans: C
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Feedback: When an arthroscopy is performed at the same time as an arthrotomy, modifier 51 would be
appended.
Applying Your Knowledge
Case Study
Preoperative diagnosis: Cervical spondylosis, central stenosis C5-C6.
Postoperative diagnosis: Cervical spondylosis, central stenosis C5-C6.
Procedure: Anterior cervical arthrodesis anterior body C5-C6 using PEEK cages and DynaTran 18mm
Stryker plate, autologous local bone and putty.
Anesthesia: General anesthesia
The patient was placed in a supine position on the operating table with an interscapular roll. The anterior
aspect of the neck was prepped and draped in a sterile fashion. Interoperative fluoroscopy was used to
center our incision over the C5 through C6 interspace. A transverse incision was made across the
sternocleidomastoid on the right side, and the incision was carried down through the subcutaneous
tissues, controlling bleeding with unipolar cautery. Initially, retraction was done using a small Weitlaner,
and the anterior border of the sternocleidomastoid was identified. I followed a plane medial to this and
medial to the carotid artery but lateral to the esophagus and trachea. I followed this plane until the
prevertebral space was identified and the longus colli muscles were divided in the midline. The selfretaining blades of the Trimline retractor were placed underneath this muscle, and then we placed a
marker at the C4–C5 level, which was the most inferior, still visible identifiable disc space.
From here I counted down to the C4–C5 level and proceeded with a minimal anterior cervical discectomy
and decompression at C5–C6. The ventral osteophytes were removed using a Leksell rongeur, and then
the disc was incised using a 15-blade knife in the interspace distracted using the Caspar distraction
system. The discectomy was performed; the disc was quite collapsed using a combination of curettes and
Midas Rex drill. The discectomy and bony removal was followed posteriorly until the posterior
longitudinal ligament was identified. This was opened and removed, and then working carefully over the
dura, bilateral foraminotomies were performed.
After verifying that the spinal cord was well decompressed in the midline, the roots out laterally, the area
was irrigated with an antibiotic saline solution. I then selected a 6-mm in height PEEK cage, which was
filled with some local bone that had been harvested as part of our bony removal combined with
autologous bone putty. The cage was then tapped into position and distraction was released.
I then selected an 18 mm in length DynaTran translational plate, and this was secured with two variableangle screws into C5 and two into C6. Once the screws were partially in position, the translational stops
were removed and the screws were secured beyond the backup stops for all screws. The muscles were
reapproximated with 2-0 Vicryl, a 2-0 Vicryl subcutaneous closure including the platysma, and a running
4-0 Vicryl subcuticular stitch in the skin.
Process 1: CPT
1. What is the procedure?
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Ans: Arthodesis and instrumentation, anterior and intervertebral
Feedback: Arthodesis and instrumentation, anterior and intervertebral is the procedure.
3. Upon review of all the code choices identified in the index what additional questions can be
determined?
Ans: Arthrodesis: Approach and vertebral bodies fused? Instrumentation: Number of vertebral segments
and number of interspaces?
Feedback: Upon review of all the code choices identified in the index, the additional questions are as
follows: Arthrodesis: Approach and vertebral bodies fused? Instrumentation: Number of vertebral
segments and number of interspaces?
Process 2: ICD
ICD-9-CM
1. Based on the operative report header, what is the preoperative diagnosis?
Ans: Cervical spondylosis, central stenosis C5-C6
Feedback: Per the operative report header, the pre-operative diagnosis is Cervical spondylosis, central
stenosis C5-C6.
3. Is the postoperative diagnosis supported?
Ans: Yes
Feedback: The postoperative diagnosis is supported.
5. Based upon the subterm choices, what question(s) can be developed for this condition
Ans: For spondylosis: Anatomic site, with myelopathy. For stenosis: anatomic location
Feedback: Based upon the subterm choices, the questions can be developed for this condition are as
follows: For spondylosis - Anatomic site, with myelopathy; for stenosis - anatomic location.
7. Is the additional condition, sign, or symptom an integral part of the primary (or other) condition
coded?
Ans: No
Feedback: No, the additional condition, sign, or symptom is not an integral part of the primary (or other)
condition coded.
9. Based upon the documentation, what are the correct ICD-9-CM codes for this case?
Ans: A
Feedback: Based upon the documentation, the correct ICD-9-CM codes for this case are 721.1 and 723.0.
ICD-10-CM
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1. Based on the operative report header, what is the preoperative diagnosis?
Ans: Cervical spondylosis, central stenosis C5-C6
Feedback: Per the operative report header, the preoperative diagnosis is Cervical spondylosis, central
stenosis C5-C6.
3. Is the postoperative diagnosis supported?
Ans: Yes
Feedback: The postoperative diagnosis is supported.
5. Based upon the subterm choices what question(s) can be developed for this condition?
Ans: For spondylosis: Anatomic site or level of the spine and with or without other associated conditions
such as myelopathy or radiculopathy. For stenosis: Anatomic site (foramina or spinal) and cause, such as
bone or soft tissue.
Feedback: Based upon the subterm choices, the questions can be developed for this condition are as
follows: For spondylosis - Anatomic site or level of the spine and with or without other associated
conditions such as myelopathy or radiculopathy. For stenosis - Anatomic site (foramina or spinal) and
cause, such as bone or soft tissue.
7. Is any sign, symptom, or additional condition documented?
Ans: Yes
Feedback: Yes, a sign, symptom, or additional condition is documented.
9. Does the additional condition require or affect patient care, treatment, or management?
Ans: Yes, stenosis was also treated by removal of bony structures.
Feedback: Yes, the additional condition does require and affects patient care, treatment, or management.
Stenosis was also treated by removal of bony structures.
Process 3: Modifiers
1. Was the procedure performed different from that described by the nomenclature of the code?
Ans: No
Feedback: The procedure performed was not different than that described by the nomenclature of the
code.
3. Was the procedure performed in the global period of another procedure?
Ans: No
Feedback: The procedure was not performed in the global period of another procedure.
5. Did the surgeon have help from another surgeon or other appropriate person?
Ans: No
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60
Feedback: The surgeon did not have help from another surgeon or other appropriate person.
7. What modifier should be appended to the CPT for this case?
Ans: D
Feedback: No modifier should be appended to the CPT for this case.
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61
Chapter 11 – Surgery Section: Respiratory System
Exercise 11.1
1. a. The upper respiratory tract includes which part of the digestive system anatomy?
Ans: nose, sinuses, pharynx, larynx
Feedback: The upper respiratory tract includes the nose, sinuses, pharynx, and larynx.
1. b. The lower respiratory tract includes which parts of the respiratory system anatomy?
Ans: trachea, bronchial tubes, lungs
Feedback: The lower respiratory tract includes the trachea, bronchial tubes, and lungs
3. What is the name of the partition of cartilage that divides the left and right nasal cavities?
Ans: Nasal Septum
Feedback: The partition of cartilage which divides the left and right nasal cavities is called the nasal
septum.
5. Describe the function of the bronchioles.
Ans: Bronchioles end in small air sacs called alveoli where oxygen and carbon dioxide pass. Oxygen
goes into the bloodstream and the rest of the body and carbon dioxide goes into the alveoli to be expelled
during exhalation.
Feedback: N/A
Exercise 11.2
1. a. Identify what the abbreviation VAP stands for, and assign the appropriate ICD-9-CM code.
Ans: Ventilator Associated Pneumonia. ICD-9-CM code 997.31.
Feedback: VAP stands for Ventilator Associated Pneumonia and is assigned ICD-9-CM code 997.31.
1. b. What instruction is given to the coder by the instructional note included with the ICD-9-CM
code?
Ans: Use additional code to identify organism.
Feedback: The instructional note states to use additional code to identify organism.
3. Explain the difference between the definition of pneumonia and that of pneumonitis.
Ans: Pneumonia is defined as infectious inflammation of lung tissue and pneumonitis is defined as
noninfectious inflammation of lung tissue
Feedback: Pneumonia is defined as infectious inflammation of lung tissue and pneumonitis is defined as
noninfectious inflammation of lung tissue. Both involve inflammation of lung tissue, but one is infectious
and the other noninfectious.
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5. Define acute exacerbation.
Ans: An acute exacerbation is a worsening or a decompensation of a chronic condition.
Feedback: An acute exacerbation is a worsening or a decompensation of a chronic condition. An acute
exacerbation is not equivalent to an infection superimposed on a chronic condition, though an
exacerbation may be triggered by an infection.
Exercise 11.3
1. What does a plus (+) sign in front of a CPT code mean about the code?
Ans: A plus (+) sign indicates that the code is an add-on code.
Feedback: A plus sign in front of a CPT code means the code is an add-on code and must be used with the
code for the primary procedure.
3. Assign the appropriate CPT code(s) for insertion of indwelling tunneled pleural catheter with
cuff with imaging guidance.
Ans: 32550 and 75989
Feedback: The CPT codes for insertion of an indwelling tunneled pleural catheter with cuff with imaging
guidance are 32550 and 75989.
5. Assign the appropriate CPT code for catheter aspiration; tracheobronchial with fiberscope,
bedside.
Ans: 31725
Feedback: N/A
Exercise 11.4
1. Explain modifier 50, and give an example of its use in the Respiratory System subsection of CPT.
Ans: Bilateral procedure. Answers for the example will vary; one example is 30115 excision of nasal
polyps (there will be many other examples that can be used).
Feedback: Modifier 50 indicates bilateral procedure: one example of where this modifier can be used is
30115 excision of nasal polyps (there will be many other examples that can be used).
3. Explain modifier 52, and give an example of its use in the Respiratory System subsection of CPT.
Ans: Reduced services. Answers for the example will vary; one example is 30465.
Feedback: Modifier 52 indicates reduced services: one example of where this modifier can be used is
30465 (there will be many other examples that can be used).
5. Explain modifier 59, and determine whether it is a modifier that would be used with codes from
the Respiratory subsection of CPT.
Ans: Distinct procedural service
Feedback: Modifier 59 indicates a distinct procedural service.
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63
Exercise 11.5
1. What does the abbreviation ABG stand for?
Ans: Arterial Blood Gas: arterial blood is examined for levels of oxygen, carbon dioxide, or other gases.
Feedback: ABG stands for Arterial Blood Gas; arterial blood is examined for levels of oxygen, carbon
dioxide, or other gases.
3. What is the meaning of the abbreviation ARDS, and what is another term for this condition that
could be used in the documentation?
Ans: Adult Respiratory Distress Syndrome; capillary leak syndrome
Feedback: ARDS stands for Adult Respiratory Distress Syndrome; capillary leak syndrome is another
way this condition could be referred to in the documentation.
5. What is a V/Q scan?
Ans: Ventilation/Perfusion scan is a nuclear medicine study which evaluates the circulation of air and
blood within a patient's lungs to determine the ventilation/perfusion ratio.
Feedback: A V/Q scan is a Ventilation/Perfusion scan. This is a nuclear medicine study which evaluates
the circulation of air and blood within a patient's lungs to determine the ventilation/perfusion ratio. The
ventilation is the ability of air to reach all parts of the lungs, while the perfusion evaluates how well the
blood circulates within the lungs.
Chapter Eleven Review
Using Terminology
1.
F
Alveoli
9.
L
Internal approach
3.
G
Bronchi
11.
B
Nasal hemorrhage
5.
H
Ethmoid sinus
13.
E
Posterior nasal hemorrhage control
7.
J
External approach
15.
O
Trachea
Feedback: N/A
Checking Your Understanding
1. A pneumonectomy involves surgical removal of the:
Ans: C
Feedback: pneum/o = lungs; -ectomy = excision
3. The use of a lighted endoscope to view the pleural spaces and thoracic cavity or to perform a
surgical procedure is called:
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64
Ans: B
Feedback: Bronchoscopy is the use of a lighted endoscope to view the pleural spaces and thoracic cavity
or to perform a surgical procedure.
5. The term that identifies the measurement of oxygen saturation of the blood is:
Ans: A
Feedback: The term that identifies the measurement of oxygen saturation of the blood is oximetry.
7. In coding pharyngitis using the ICD-10-CM manual, the identification of the ________________
causing the pharyngitis must be documented and reported.
Ans: A
Feedback: In coding pharyngitis using the ICD-10-CM manual, the identification of the organism causing
the pharyngitis must be documented and reported.
9. Assign the appropriate code for drainage of a nasal abscess by an internal approach.
Ans: A
Feedback: 30020 is for nasal septum and 10060 and 10140 are for external approaches.
Applying Your Knowledge
Case 1
PREOPERATIVE DIAGNOSIS: Tracheal stenosis, subglottic.
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: Fiberoptic bronchoscopy.
SURGEON: Stine, Frank MD
INDICATIONS: Tracheal stenosis.
Details of procedure, and potential risks and alternatives were explained and patient consent was
obtained.
MEDICATIONS: Xylocaine spray was applied to the throat and Xylocaine gel placed in the nostrils. The
patient received 50 mcg of fentanyl and 8 mg of Versed intravenous.
PROCEDURE: The bronchoscope was placed orally once sufficient sedation was obtained. The vocal
cords were visualized and the patient appeared to have some right true vocal cord weakness. Just below
the vocal cords, in the subglottic area, scar tissue was noted and moderate narrowing of the upper trachea
with almost complete closure of the airway on exhalation. Airways were immediately examined. The
trachea, carina, right upper, middle and lower lobe bronchi, left main stem bronchus and upper and lower
lobe bronchi were examined and found to be normal and without significant mucosal abnormalities. The
patient tolerated the procedure well. No specimens were collected.
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Process 1: CPT
1. What is the procedure?
Ans: Fiberoptic bronchoscopy
Feedback: The procedure is fiberoptic bronchoscopy.
3. Upon review of all the code choices identified in the index what additional questions can be
determined?
Ans: Brushing, lavage
Feedback: Upon review of all the code choices identified in the index, the additional questions involve
brushing and lavage.
Process 2: ICD
ICD-9-CM
1. Based on the operative report header, what is the preoperative diagnosis?
Ans: Tracheal stenosis, subglottic
Feedback: Per the operative report header, the preoperative diagnosis is tracheal stenosis, subglottic.
3. Is the postoperative diagnosis supported?
Ans: Yes
Feedback: The postoperative diagnosis is supported.
5. Based upon the subterm choices, what question(s) can be developed for this condition?
Ans: Is the stenosis congenital, syphilitic, or tuberculous?
Feedback: Based upon the subterm choices, the following question(s) can be developed for this condition:
Is the stenosis congenital, syphilitic, or tuberculous?
7. Is the additional condition, sign, or symptom an integral part of the primary (or other) condition
coded?
Ans: No
Feedback: No additional condition, sign, or symptom is an integral part of the primary (or other)
condition coded.
9. Based upon the documentation what is (are) the correct ICD-9-CM code(s) for this case?
Ans: 519.19
Feedback: Based upon the documentation, the ICD-9-CM code for this case is 519.19.
ICD-10-CM
1. Based on the operative report header, what is the preoperative diagnosis?
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66
Ans: Tracheal stenosis, subglottic.
Feedback: Per the operative report header, the preoperative diagnosis is tracheal stenosis, subglottic.
3. Is the postoperative diagnosis supported?
Ans: Yes
Feedback: Yes, the postoperative diagnosis is supported.
5. Based upon the subterm choices, what question(s) can be developed for this condition?
Ans: Is the stenosis congenital, syphilitic, or tuberculous?
Feedback: Based upon the subterm choices, the question that can be developed for this condition is: Is the
stenosis congenital, syphilitic, or tuberculous?
7. Is any sign, symptom, or additional condition documented?
Ans: No
Feedback: No signs, symptoms, or additional conditions are documented.
9. Does the additional condition require or affect patient care, treatment, or management?
Ans: N/A
Feedback: N/A
Process 3: Modifiers
1. Was the procedure performed different from that described by the nomenclature of the code?
Ans: No
Feedback: The procedure performed was not different from that described by the nomenclature of the
code.
3. Was the procedure performed in the global period of another procedure?
Ans: No
Feedback: The procedure performed was not in the global period of another procedure.
5. Did the surgeon have help from another surgeon or other appropriate person?
Ans: No
Feedback: The surgeon did not have help from another surgeon or other appropriate person.
7. What modifier(s) should be appended to the CPT for this case?
Ans: None
Feedback: No modifiers should be appended to the CPT for this case.
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67
Case 2
PREOPERATIVE DIAGNOSIS: Pulmonary infiltrates, bilateral.
POSTOPERATIVE DIAGNOSES: Bilateral pneumonia and tracheobronchitis, diffuse.
PROCEDURE PERFORMED: Bronchoscopy with biopsy.
SURGEON: Harold Potter, MD
ANESTHESIA: Conscious sedation was provided and monitored by Dr. H. Granger, anesthesiologist
Specimens gathered and sent to pathology include: Bronchoalveolar lavage and bronchial brushings sent
for cytology
Bronchial washings sent to pathology for culture, gram stain, C&S and DFA for Legionella.
Transbronchial biopsies for pathology.
FINDINGS: Trachea of this 61-year- old man was within normal limits. There appeared to be mild
diffuse tracheobronchitis from the level of the carina and extending throughout the right and left bronchial
trees. No endobronchial lesions or mucosal irregularities were found. During lavage of left lower lobe,
yellow purulent mucous plugs were aspirated. All mucous plugs were cleared upon completion of lavage
procedure.
PROCEDURE: The patient was brought to the endoscopy suite and local anesthesia of the left naris and
posterior pharynx was administered followed by conscious sedation. After adequate conscious sedation
was achieved the Olympus bronchofiberscope was inserted into the left naris and advanced to the
posterior pharynx through the vocal cords and into the trachea. The entire tracheobronchial tree was then
systematically inspected. The bronchoscope was advanced to the left upper lobe and the bronchoscope
was wedged into the apical segment. Bronchoalveolar lavage was then performed at this segment
utilizing 80 mL of saline. Bronchoscope was then pulled back at the level of the carina and advanced into
the left lower lobe. Bronchial brushings were obtained from the medial and lateral segments of the left
lower lobe under fluoroscopic guidance. Under fluoroscopic guidance, transbronchial biopsies x 3 were
obtained from various subsegments of both the left lower lobe and left upper lobe. The areas were then
inspected for any acute hemorrhage, none seen. The bronchoscope was withdrawn. The patient tolerated
the procedure well, without complications.
Process 1: CPT
1. What is the procedure?
Ans: Transbronchial biopsy, bronchial alveolar lavage and bronchial brushings
Feedback: The procedure is transbronchial biopsy, bronchial alveolar lavage and bronchial brushings.
3. Upon review of all the code choices identified in the index, what additional questions can be
determined?
Ans: How were the transbronchial biopsy(s) performed and in how many different lobes?
Feedback: Upon review of all the code choices identified in the index, the following additional questions
can be determined: How were the transbronchial biopsy(s) performed and in how many different lobes?
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Process 2: ICD
ICD-9-CM
1. Based on the operative report header, what is the preoperative diagnosis?
Ans: Pulmonary infiltrates, bilateral
Feedback: Per the operative report header, the preoperative diagnosis is pulmonary infiltrates, bilateral.
3. Is the postoperative diagnosis supported?
Ans: Yes: “yellow purulent mucous plugs were aspirated”
Feedback: Yes, the postoperative diagnosis is supported: “yellow purulent mucous plugs were aspirated”.
5. Based upon the subterm choices, what question(s) can be developed for this condition?
Ans: Anatomic site, type, underlying condition or cause, and additional related conditions
Feedback: Based upon the subterm choices, the following question topics can be developed for this
condition: Anatomic site, type, underlying condition or cause, and additional related conditions.
7. Is the additional condition, sign or symptom an integral part of the primary (or other) condition
coded?
Ans: No
Feedback: The additional condition, sign or symptom is not an integral part of the primary (or other)
condition coded.
9. Based upon the documentation, what are the correct ICD-9-CM codes for this case?
Ans: B
Feedback: Based upon the documentation, the correct ICD-9-CM codes for this case are 486 and 490.
ICD-10-CM
1. Based on the operative report header, what is the preoperative diagnosis?
Ans: Pulmonary infiltrates, bilateral
Feedback: Per the operative report header, the preoperative diagnosis is pulmonary infiltrates, bilateral.
3. Is the postoperative diagnosis supported?
Ans: Yes: “yellow purulent mucous plugs were aspirated”
Feedback: The postoperative diagnosis is supported as follows: “yellow purulent mucous plugs were
aspirated”.
5. Based upon the subterm choices, what question(s) can be developed for this condition?
Ans: Anatomic site, type, underlying condition or cause, and additional related conditions.
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69
Feedback: Based upon the subterm choices, the following question topics can be developed for this
condition: Anatomic site, type, underlying condition or cause, and additional related conditions.
7. Is any sign, symptom, or additional condition documented?
Ans: Yes, tracheobronchitis
Feedback: Tracheobronchitis is a sign, symptom, or additional condition documented.
9. Does the additional condition require or affect patient care, treatment, or management?
Ans: Yes, inspection
Feedback: The additional condition does require or affect patient care, treatment, or management as it
requires inspection.
Process 3: Modifiers
1. Was the procedure performed different then as described by the nomenclature of the code?
Ans: No
Feedback: The procedure performed was not different then as described by the nomenclature of the code.
3. Was the procedure performed in the global period of another procedure?
Ans: No
Feedback: The procedure performed was not in the global period of another procedure.
5. Did the surgeon have help from another surgeon or another appropriate person?
Ans: No
Feedback: The surgeon did not have help from another surgeon or other appropriate person.
7. What modifier(s) should be appended to the CPT for this case?
Ans: B
Feedback: Modifier 51 should be appended to the CPT code for this case.
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70
Chapter 12 – Surgery Section: Cardiovascular and Lymphatic
Systems
Exercise 12.1
1. Between which two chambers of the heart is the tricuspid valve located?
Ans: Right atrium and right ventricle
Feedback: The tricuspid valve is located between right atrium and right ventricle.
3. What is the name of the heart’s natural pacemaker?
Ans: S-A (sinoatrial) node
Feedback: The heart’s natural pacemaker is called the sinoatrial (SA) node.
Exercise 12.2
1. Which structure of the lymphatic system produces T cells?
Ans: Thymus
Feedback: The thymus is the structure of the lymphatic system that produces T cells.
3. What is (are) the function(s) of the lymph nodes?
Ans: They act as filters and produce antibodies and lymphocytes.
Feedback: The lymph nodes act as filters and produce antibodies and lymphocytes.
Exercise 12.3
1. The patient presents with a diagnosis of congestive heart failure (CHF) due to hypertension
(HTN). What is (are) the correct ICD-9-CM code(s)?
Ans: 402.91 and 428.0
Feedback: The statement of “due to hypertension” defines the causal relationship. The hypertension is not
specific as to benign or malignant so the 4th digit for category 402 would be 9 in this case. The CHF is
unspecified so 428.0 would be the correct code.
3. The patient is diagnosed with acute rheumatic fever with severe inflammation of the heart
muscle. What is the appropriate ICD-9-CM code?
Ans: 391.2
Feedback: The appropriate ICD-9-CM code for this situation is 391.2, acute rheumatic myocarditis.
5. List the types of heart failure that affect code assignment.
Ans: Congestive heart failure, left heart failure, systolic heart failure, diastolic heart failure
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71
Feedback: The types of heart failure that affect code assignment are: Congestive heart failure, left heart
failure, systolic heart failure, and diastolic heart failure.
Exercise 12.4
1. What are the three types of coronary artery bypass grafting?
Ans: Arterial only, venous only, combination arterial and venous
Feedback: The three types of coronary artery bypass grafting are: Arterial only, venous only, and
combination arterial and venous.
3. To qualify as a central venous access device, where must the tip of the catheter terminate?
Ans: In the subclavian, brachiocephalic (innominate), or iliac veins, the superior or inferior vena cava, or
the right atrium.
Feedback: The guidelines at the beginning of this range of codes instruct the coder that to qualify as a
central venous access device, the tip of the catheter must terminate in the subclavian, brachiocephalic
(innominate), or iliac veins; the superior or inferior vena cava; or the right atrium.
Exercise 12.5
1. What is the appropriate code for the injection procedure for identification of a sentinel node?
Ans: 38792
Feedback: N/A
Exercise 12.6
1. The patient presents in the office today with atrial fibrillation, and the physician decides to
insert a dual-chamber pacemaker the next day. Assign the appropriate CPT code along with any
needed modifier.
Ans: 33208 -57
Feedback: This requires modifier 57, decision for surgery.
3. The physician starts a valvuloplasty procedure, and the patient becomes tachycardic and the
vavluloplasty is stopped. Which modifier would be used to tell the story of this patient encounter?
Ans: Modifier 53
Feedback: Modifier 53, discontinued service, is needed.
Exercise 12.7
1. An opening or hole between the right and left atriums is a_____.
Ans: ASD, or atrial septal defect
Feedback: An opening or hole between the right and left atrium is described as ASD, or atrial septal
defect.
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72
3. An abnormal blowing sound heard on ausculation could be indicated in the documentation as a
____________.
Ans: bruit
Feedback: An abnormal blowing sound heard upon auscultation could be indicated in the documentation
as a bruit.
5. What is the difference between a shunt and a stent?
Ans: A stent is used to keep a vessel open. A shunt is used to bypass fluids.
Feedback: The difference between a shunt and a stent is that a stent is used to keep a vessel open, while a
shunt is used to bypass fluids.
Chapter Twelve Review
Using Terminology
1.
F
Ablation
9.
K
Defibrillator
3.
G
Angina pectoris
11.
E
Infarction
5.
H
Aorta
13.
J
Lymph node
7.
A
Coronary artery bypass graft (CABG)
15.
O
Pacemaker
Feedback: N/A
Checking Your Understanding
1. A mass of undissolved matter that is transported in the blood is called a(n):
Ans: D. embolus
Feedback: An embolus is a mass of undissolved matter that is transported in the blood. A clot is a type of
embolus, an abscess is a collection of pus, and a neoplasm is a new growth.
3. The patient is diagnosed with acute coronary insufficiency and is admitted for CABG using four
veins harvested endoscopically from the left saphenous vein. Select the appropriate ICD-9-CM and
CPT codes.
Ans: A. 33513, 33508, 411.89.
Feedback: Since the saphenous vein was harvested endoscopically, code 33508 should be reported along
with 33513, which describes the bypass using four vein grafts.
5. A patient is admitted to the cardiac unit with an acute MI of the inferolateral wall and a thirddegree AV block. The patient has no history of prior MI. Select the appropriate ICD-9-CM codes.
Ans: B. 410.21, 426.0
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73
Feedback: No history of previous MI should direct the coder to initial episode.
7. Choose the appropriate ICD-9-CM code for diagnosis of ataxia due to CVA.
Ans: A. 438.84
Feedback: The late effect of a CVA requires only one code, 438.84.
9. The heart wall is composed of three layers. They are the epicardium, myocardium, and:
Ans: C. Endocardium
Feedback: The endocardium is the third layer of the heart wall. Echocardium is not a term. Epithelium
pertains to the covering of internal and external surfaces of the body. Valves are a membranous fold in a
canal or passage, which prevent the reflux of the contents passing through.
Applying Your Knowledge
Case Study: Cardio Note
PROCEDURE PERFORMED: Placement of permanent pacemaker, dual chamber.
INDICATIONS: A definite diagnosis of atrial fibrillation was made, and I determined during the office
visit yesterday that a permanent dual-chamber pacemaker device would be inserted today.
POST-OPERATIVE DIAGNOSIS: Atrial fibrillation
PROCEDURE: The patient was prepped and draped in the usual sterile fashion. A needle was passed into
the left subclavian vein, and good blood was noted. The guide wire was passed through the needle, and
the needle was removed. The dilator and introducer were then passed over the wire. Once in position, the
dilator and guide wire were removed and leads were placed.
Leads were placed in the right ventricle and atrium sequentially.
I then turned to placement of the pulse generator. A subcutaneous pacemaker pocket was created in the
right anterior chest wall, and the pulse generator was placed in the pocket. A subcutaneous tunnel was
made, and the leads were threaded thru and attached to the generator. The pocket was sutured in the usual
sterile fashion, and the patient tolerated the procedure well. A chest x-ray was ordered to verify placement
of leads and generator upon completion of the procedure.
Process 1: CPT
1. What is the procedure?
Ans: Insertion of permanent pacemaker, dual chamber
Feedback: The procedure is insertion of permanent pacemaker, dual chamber.
3. What additional questions or set of question can be determined?
Ans: Pacemaker, Heart. Pacing, Cardio-defibrillator.
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74
Feedback: Additional questions can be related to the following topics: Pacemaker, Heart; Pacing, Cardiodefibrillator.
5. Based on the documentation, what is (are) the correct code(s) for this case?
Ans: C
Feedback: Based upon the documentation, the correct code for this case is 33208. The documentation tells
the coder the device was a pacemaker. The documentation tells the coder this was an insertion of the
generator and the leads. The documentation tells the coder this was dual chamber placement of leads
(“leads were place in the right ventricle and atrium sequentially”). The documentation tells the coder the
approach was transvenous.
Process 2: ICD
ICD-9-CM
1. Based on the operative report header, what is the preoperative diagnosis?
Ans: Atrial fibrillation
Feedback: Per the operative report header, the preoperative diagnosis is atrial fibrillation (which is located
in the indication section of the report).
3. What is the main term for this condition?
Ans: Fibrillation
Feedback: The main term for this condition is fibrillation.
5. Is any sign, symptom, or additional condition documented?
Ans: Yes: “Patient has been experiencing palpitations and an awareness of an irregular heartbeat with
some dizziness and weakness”
Feedback: Yes, signs, symptoms, or additional conditions are documented: “Patient has been
experiencing palpitations and an awareness of an irregular heartbeat with some dizziness and weakness.”
7. Based on the documentation, what is the correct ICD-9-CM code for this case?
Ans: A
Feedback: Based upon the documentation, the correct ICD-9-CM code for this case is 427.31.
Process 3: Modifiers
1. Was the procedure performed different from that described by the nomenclature of the code?
Ans: No
Feedback: The procedure performed was not different from that described by the nomenclature of the
code.
3. Was the procedure performed in the global period of another procedure?
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75
Ans: No
Feedback: The procedure performed was not in the global period of another procedure.
5. Did the surgeon have help from another surgeon or another appropriate person?
Ans: No
Feedback: The surgeon did not have help from another surgeon or other appropriate person.
7. What modifier should be appended to the CPT for this case?
Ans: C
Feedback: No modifier(s) should be appended to the CPT for this case. Note: The report does mention
that the decision for surgery was determined during the office visit the day before the pacemaker
insertion; therefore, the office visit would be reported with a 57 modifier.
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76
Chapter 13 – Surgery Section: Digestive System
Exercise 13.1
1. What structure located in the mouth triggers a gag reflex and assists in speech and sound?
Ans: Uvula
Feedback: The uvula is the structure located in the mouth that triggers the gag reflex and assists in
producing sounds and speech.
3. Name the accessory organs of the digestive system, and explain their functions.
Ans: Salivary glands: Produce saliva which when mixed with food starts the digestive process.
Liver: Produces bile which is necessary for digestion of fats
Gallbladder: Main function is storage of bile.
Pancreas: Functions as both a digestive and endocrine organ.
Feedback: The accessory organs of the digestive system and their functions are as follows: Salivary
glands produce saliva, which when mixed with food starts digestive process. Liver produces bile, which is
necessary for digestion of fats. Gallbladder stores bile. Pancreas functions as both a digestive and
endocrine organ.
5. Which structure connects the small and large intestines?
Ans: The cecum
Feedback: The cecum connects the small and large intestines.
Exercise 13.2
1. What questions should be asked before selecting the appropriate ICD code for a hernia
diagnosis?
Ans: Where is the hernia located?
Is gangrene present?
Is there an obstruction?
Was it bilateral or unilateral?
Was it recurrent?
Feedback: The questions that should be asked before selecting the appropriate ICD code for a hernia
diagnosis are: Where is the hernia located? Is gangrene present? Is there an obstruction? Was it bilateral
or unilateral? Was it recurrent?
3. Which type of hernia is defined as a protrusion through a tear in the lower abdominal wall and
can be direct or indirect?
Ans: inguinal
Feedback: An inguinal hernia is defined as a protrusion through a tear in the lower abdominal wall and
can be direct or indirect.
5. Codes for digestive system ulcers in both ICD-9-CM and ICD-10-CM have a high degree of
specificity assigned to them such as whether they are _______________.
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Ans: acute, chronic, obstructed, perforated, or hemorrhaging.
Feedback: Codes for digestive system ulcers in both ICD-9-CM and ICD-10-CM have a high degree of
specificity assigned to them such as whether they are acute, chronic, obstructed, perforated, or
hemorrhaging.
Select the appropriate ICD-9 code for the following:
7. The patient presents with severe abdominal pain, fever, and vomiting. This has been occurring
for the past 2 days. The final diagnosis was acute cholecystitis.
ICD-9-CM code _____:
Ans: 575.0
Feedback: There was no mention of stone, calculus, or lithiasis with this diagnosis.
Exercise 13.3
1. For conversion of a gastrostomy tube (G tube) to a gastrojejunostomy tube (G-J tube), CPT
code _________is the appropriate code to use.
Ans: 49446
Feedback: 49446 is the appropriate CPT code to use for conversion of a gastrostomy tube (G tube) to a
gastrojejunostomy tube (G-J tube).
3. During an open abdominal procedure, exploration of the surgical field is routinely performed.
In this case, should an exploratory laparoscopy, CPT code 49000, be reported separately with the
open procedure?
Ans: No; this code would be bundled into the open procedure.
Feedback: N/A
Exercise 13.4
1. The patient is returned to the operating room by the same physician following the initial
procedure for an unplanned procedure and this happens during the postoperative period for a
procedure that has a 90-day global period. The coder should append modifier _______ to the
appropriate CPT code from the Digestive System section.
Ans: Modifier 78
Feedback: If the patient is returned to the operating room by the same physician following the initial
procedure for an unplanned procedure and this happens during the postoperative period for a procedure
which has a 90-day global period, modifier 78 is appended.
3. An esophagogastroduodenoscopy (EGD) performed for a separate condition should be reported
with modifier __________ to let the payer know that it was a distinct procedure.
Ans: Modifier 59.
Feedback: Modifier 59 indicates a distinct procedural service.
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Exercise 13.5
1. The patient presents with abdominal pain and a swollen belly. The physician is concerned about
bleeding into the abdomen and orders a procedure in which the abdomen will be punctured and
fluid will be drained. This procedure is called a(n) ____________.
Ans: Abdominocentesis
Feedback: Abdominocentesis is the surgical puncture of the abdomen.
3. The patient presents with difficult and painful swallowing. The diagnosis on the chart could be
_____________.
Ans: dysphagia
Feedback: Dysphagia is a term for difficulty swallowing.
Chapter 13 Review
Understanding Terminology
1. F
Bolus
9. L
Gastroesophageal reflux disease (GERD)
3. G
Choledocholithiasis
11. B
Intusssception
5. H
Diverticulitis
13. E
Laprascopy
7. J
Duodenum
Feedback: N/A
Checking Your Understanding
1. The patient was brought to the operating room for a diaphragmatic hernia. A transthoracic
repair was performed. Select the appropriate CPT and ICD-9-CM code:
Ans: A
Feedback: A diaphragmatic hernia codes to 553.3. CPT code 43334 indicates the transthoracic repair.
CPT code 43336 would indicate a thoracoabdominal incision, which is not indicated in the statement.
3. Which one of the following statements best describes a hiatal hernia?
Ans: A
Feedback: One way to find this answer in the ICD-9-CM index in many of the editions is under “hernia,
hiatal,” then cross reference to this code set and review the codes for definitions.
5. A patient was brought back to the operating room 60 days after an initial surgical repair on a
strangulated inguinal hernia; this procedure was performed by the physician who previously
performed the initial surgery. The surgical decision was made due to the patient’s presenting to the
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79
ER for lower abdominal pain and radiological testing that confirmed a restrangulation of the
hernia. Select the appropriate ICD-9-CM and CPT codes:
Ans: A
Feedback: 49521 identifies a recurrent inguinal hernia that is strangulated. The modifier 78 reports an
unplanned return back to the OR during a postoperative global period and the patient returned 60 days
after the initial procedure. 550.11 reports an inguinal hernia, recurrent, strangulated.
7. Emily had been complaining of abdominal pain for the past 4 months. It seemed to be worse after
she ate fatty foods or ice cream. She was diagnosed with gallbladder disease and underwent a
laparoscopic cholecystectomy that revealed chronic cholecystitis and cholelithiasis. Select the
appropriate ICD-9-CM and CPT codes to report Emily’s encounter:
Ans: C
Feedback: Index cholelithiasis with cholecystitis, chronic. The fifth digit of “0” indicates there was no
mention of obstruction. The abdominal pain would not be coded, as it is a symptom and there is a more
definitive diagnosis.
9. Which of the following is not a part of the stomach?
Ans: D
Feedback: The ileum is the last section of the small intestine.
Applying Your Knowledge
Case 1
Preoperative Diagnosis: Chronic tonsillitis and enlarged adenoids
Postoperative Diagnosis: Chronic tonsillitis and enlarged adenoids
Procedure: Tonsillectomy with adenoidectomy
The patient, a 6-year-old male, was placed under general anesthesia for bilateral removal of tonsils
with adenoids. The tonsils were grasped with an Allis forceps, and the incision made around the
anterior tonsillar pillar. The tonsillar capsule was identified, and the tonsils bluntly dissected free.
Next we turned our attention to the nasopharynx, which was viewed indirectly. There was a
considerable amount of hypertrophic adenoids present; they were removed by curette, and all
nubbins of adenoid tissue were removed. All bleeding was controlled with pressure sponges, and
several small bleeding areas were touched with electrocoagulation. At the close of both procedures,
there was no bleeding present. Blood loss was minimal, and the postoperative condition of the
patient was good.
Process 1: CPT
1. What is the procedure?
Ans: Tonsillectomy
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Feedback: Tonsillectomy is the procedure.
3. What additional questions or set of question can be determined?
Ans: None
Feedback: There are no additional questions or set of questions.
5. Based on the documentation, what is the correct code for this case?
Ans: C
Feedback: Based upon the documentation, the correct code for this case is 42820.
Process 2: ICD
ICD-9-CM
1. Based on the operative report header, what is the preoperative diagnosis?
Ans: Chronic tonsillitis and enlarged adenoids
Feedback: Per the operative report header, the preoperative diagnosis is chronic tonsillitis and enlarged
adenoids.
3. Is the postoperative diagnosis supported?
Ans: Yes
Feedback: Yes, the postoperative diagnosis is supported.
5. Based on the subterm choices, what question(s) can be developed for this condition?
Ans: Are other conditions present? Chronic or acute? Due to hypertrophic (enlarged), infection, or
another condition?
Feedback: Based upon the subterm choices, the following questions can be developed for this condition:
Are other conditions present? Chronic or acute? Due to hypertrophic (enlarged), infection, or another
condition?
7. Is the additional condition, sign, or symptom an integral part of the primary (or other) condition
coded?
Ans: No
Feedback: No, the additional condition, sign, or symptom is not an integral part of the primary (or other)
condition coded.
9. Based on the documentation what is (are) the correct ICD-9-CM code(s) for this case?
Ans: D
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Feedback: Based upon the documentation, the correct ICD-9-CM codes for this case are 474.00 and
474.12.
ICD-10-CM
1. Based on the operative report header, what is the preoperative diagnosis?
Ans: Chronic tonsillitis and enlarged adenoids
Feedback: Per the operative report header, the preoperative diagnosis is chronic tonsillitis and enlarged
adenoids.
3. Is the postoperative diagnosis supported?
Ans: Yes
Feedback: Yes, the postoperative diagnosis is supported.
5. Based on the subterm choices, what question(s) can be developed for this condition?
Ans: Are other conditions present? Chronic or acute? Due to hypertrophic (enlarged), infection, or
another condition?
Feedback: Based upon the subterm choices, the following questions can be developed for this condition:
Are other conditions present? Chronic or acute? Due to hypertrophic (enlarged), infection, or another
condition?
7. Is any sign, symptom, or additional condition documented?
Ans: Yes, hypertrophied adenoids
Feedback: Yes, a sign, symptom, or additional condition—hypertrophied adenoids—was documented.
9. Does the additional condition require or affect patient care, treatment, or management?
Ans: Yes, excision of adenoids
Feedback: Yes, the additional condition does require or affect patient care, treatment, or management:
excision of adenoids.
Process 3: Modifiers
1. Was the procedure performed different then as described by the nomenclature of the code?
Ans: No
Feedback: The procedure performed was not different then as described by the nomenclature of the code.
3. Was the procedure performed in the global period of another procedure?
Ans: No
Feedback: The procedure performed was not in the global period of another procedure.
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5. Did the surgeon have help from another surgeon or another appropriate person?
Ans: No
Feedback: The surgeon did not have help from another surgeon or other appropriate person
7. What modifier(s) should be appended to the CPT for this case?
Ans: D
Feedback: No modifiers should be appended to the CPT code for this case.
Case 2
Procedure: Small bowel enteroscopy
Anesthesia: Premedication: Versed slow IV push, Blucagon 0.2mg in increments during the
procedure
Indications: The patient is a 77-year-old woman admitted for recurrent anemia and angina pectoris
related to her anemia.
The patient has profound microcytic, hypochromic anemia, initially presenting with a hemoglobin
of 6.5. A few weeks ago, she was transfused, discharged, and then returned with a hemoglobin of
6.4 with recurrent anginal symptoms and marked fatigue. Most recent stool Hemoccults have been
negative. She did, however, report having black tarry stool immediately prior to admission.
Operative Procedure: The instrument was passed through the oropharynx into the stomach. The
esophagus was well seen and was normal. On retroversion, the cardia and fundus were well seen
and were unremarkable. There was a small hiatal hernia but no evidence of erosions in the gastric
mucosa and nothing to suggest a lesion. The body of the stomach distended well and had normal
rugal pattern. The antrum was well seen and was normal, as was the duodenal bulb. The
instrument was withdrawn into the stomach at this point, and the overtube, which had been
premounted on the scope, was then passed into the antrum. The enteroscope was then passed into
the duodenal bulb, the descending duodenum, distal duodenum to the ligament of Treitx and the
jejunum to what was felt to be the mid jejunum, which at least was well seen. The patient was
given Glucagons to facilitate visualization of the small bowel. No abnormalities were noted
specifically with nothing to suggest inflammatory change, AVMs, or neoplasia.
Impression: Unremarkable enteroscopy and upper gastrointestinal tract.
Plans: Will discuss the situation with Dr. Smith. An option will be to follow the patient and
consider reassessing her distal bowel in the event of recurrent bleeding. The patient did, however,
have a significant drop in hemoglobin and hematocrit just this past week from reasons that are still
entirely unclear.
Process 1: CPT
1. What is the procedure?
Ans: Endoscopy
Feedback: Endoscopy is the procedure.
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3. What additional questions or set of question can be determined?
Ans: Anatomic site and definitive procedure
Feedback: The additional questions or set of questions should be regarding anatomic site and definitive
procedure.
5. Based on the documentation, what is the correct code for this case?
Ans: C
Feedback: Based upon the documentation, the correct code for this case is 44360.
Process 2: ICD
ICD-9-CM
1. Based on the operative report header, what is the preoperative diagnosis?
Ans: microcytic, hypochromic anemia; anginal symptoms; fatigue; tarry stools
Feedback: Per the operative report header, the preoperative diagnosis is microcytic, hypochromic anemia;
anginal symptoms; fatigue; and tarry stools.
3. Is the postoperative diagnosis supported?
Ans: Yes
Feedback: Yes, the postoperative diagnosis is supported.
5. Based on the subterm choices, what question(s) can be developed for this condition?
Ans: Type of anemia, causes (due to), and associated disorders or conditions
Feedback: Based upon the subterm choices, the following question topics can be developed for this
condition: Type of anemia, causes (due to), and associated disorders or conditions.
7. Is the additional condition, sign, or symptom an integral part of the primary (or other) condition
coded?
Ans: Yes: fatigue [others (tarry stools and angina) are not]
Feedback: Yes, fatigue is an integral part of the primary (or other) condition coded; however, the others
(tarry stools [melena] and angina) are not.
9. Based on the documentation what is (are) the correct ICD-9-CM code(s) for this case?
Ans: B
Feedback: Based upon the documentation, the correct ICD-9-CM codes for this case are 280.9, 578.1, and
413.9.
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ICD-10-CM
1. Based on the operative report header, what is the preoperative diagnosis?
Ans: microcytic, hypochromic anemia; anginal symptoms; fatigue; tarry stools
Feedback: Per the operative report header, the preoperative diagnosis is microcytic, hypochromic anemia;
anginal symptoms; fatigue; and tarry stools.
3. Is the postoperative diagnosis supported?
Ans: Yes
Feedback: Yes, the postoperative diagnosis is supported.
5. Based on the subterm choices, what question(s) can be developed for this condition?
Ans: Type of anemia, causes (due to), and associated disorders or conditions
Feedback: Based upon the subterm choices, the following question topics can be developed for this
condition: Type of anemia, causes (due to), and associated disorders or conditions.
7. Is any sign, symptom, or additional condition documented?
Ans: Yes
Feedback: Yes, there are signs, symptoms, or additional conditions documented.
9. Does the additional condition require or affect patient care, treatment, or management?
Ans: Yes, melena supports the need for endoscopy
Feedback: Yes, the additional condition melena supports the need for endoscopy.
Learning Outcome: 13.1
Process 3: Modifiers
1. Was the procedure performed different then as described by the nomenclature of the code?
Ans: No
Feedback: The procedure performed was not different then as described by the nomenclature of the code.
3. Was the procedure performed in the global period of another procedure?
Ans: No
Feedback: The procedure performed was not in the global period of another procedure.
5. Did the surgeon have help from another surgeon or another appropriate person?
Ans: No
Feedback: The surgeon did not have help from another surgeon or another appropriate person
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7. What modifier(s) should be appended to the CPT for this case?
Ans: D
Feedback: No modifiers should be appended to the CPT code for this case.
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86
Chapter 14 – Surgery Section: Urinary System and Male
Reproductive System
Exercise 14.1
1. What hormone released by the kidneys stimulates the production of red blood cells?
Ans: erythropoietin
Feedback: Erythropoietin is the hormone released by the kidneys which stimulates the production of red
blood cells.
3. List the functions of the kidneys.
Ans: Filter blood; form urine; regulate blood volume, blood pressure, and pH level; produce red blood
cells; excrete waste products (urea)
Feedback: The functions of the kidneys are to: filter blood; form urine; regulate blood volume, blood
pressure, and pH; produce red blood cells; and excrete waste products (urea).
5. If the ureters and urinary bladder are not able to prevent the backflow of urine, what condition
can develop?
Ans: Cystitis, which can develop into a kidney infection
Feedback: If the ureters and urinary bladder are not able to prevent the backflow of urine, cystitis can
develop, which can then turn into a kidney infection.
Exercise 14.2
1. Which structure of the male reproductive system has the functions of transportation, storage,
and maturation of the sperm cell?
Ans: Epididymis
Feedback: The epididymis is the structure of the male reproductive system which has the functions of
transportation, storage, and maturation of sperm cells.
3. Which structure of the male reproductive system protects and controls the climate for the testes?
Ans: The scrotum
Feedback: The scrotum protects and controls the climate for the testes.
Exercise 14.3
1. Both CKD and ESRD are documented in the report. Assign the appropriate code.
Ans: 585.6
Feedback: Only ESRD is coded, with ICD-9-CM code 585.6.
3. Assign the appropriate code for a diagnosis of staghorn calculus
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Ans: 592.0
Feedback: N/A
5. The diagnosis is an abscess of the epididymis with streptococcus identified as the organism.
Assign the appropriate code(s).
Ans: 604.0 and O41.00
Feedback: N/A
Exercise 14.4
1. What is the difference between an indwelling ureteral stent and an externally accessible ureteral
stent?
Ans: An internal placement has no part of the stent protruding from the body, whereas an externally
accessible stent protrudes outside of the body and is attached to a drainage tube.
Feedback: An indwelling, or internal placement, stent has no part of the stent protruding from the body,
while an externally accessible stent protrudes outside of the body and is attached to a drainage tube.
3. Define urodynamic procedure.
Ans: Urodynamic studies are performed to evaluate the bladder’s function and efficiency. Urodynamic
testing provides volume and pressure information.
Feedback: Urodynamic studies are performed to evaluate the bladder’s function and efficiency.
Urodynamic testing provides volume and pressure information.
Exercise 14.5
1. How are orchiectomy codes further defined?
Ans: Simple, partial, radical, laparoscopic
Feedback: Orchiectomy procedures are further defined as simple, partial, or radical. A surgical
laparoscopic orchiectomy is reported with CPT codes 54690 to 54699.
Exercise 14.6
1. A bilateral procedure was performed, but the CPT code description does not define the code as
unilateral or bilateral. Which modifier would be assigned?
Ans: 50
Feedback: Modifier 50 indicates a bilateral procedure.
3. When multiple procedures are performed in the same investigative session of urodynamic
procedures, which modifier would be reported?
Ans: 51
Feedback: Modifier 51 indicates multiple procedures.
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Exercises 14.7
1. List three types of renal failure and define each.
Ans: Acute renal failure (ARF) is the sudden onset of kidney failure. Some of the causes include
accidents that injure the kidneys, loss of a lot of blood, or some drugs or poisons.
Chronic kidney disease (CKD) is the gradual reduction of kidney function which may lead may lead to
permanent kidney failure or end stage renal disease (ESRD).
Feedback: Three types of renal failure are:
Acute renal failure (ARF): the sudden onset of kidney failure. Some of the causes include accident that
injures the kidneys, loss of a lot of blood, or some drugs or poisons
Chronic kidney disease (CKD): the gradual reduction of kidney function which may lead may lead to
permanent kidney failure
End stage renal disease (ESRD): permanent kidney
3. What is the term used to describe a congenital defect in which the urethra opens on the underside
of the penis?
Ans: Hypospadias
Feedback: Hypospadias is the term used to describe a congenital defect in which the urethra opens on the
underside of the penis.
5. What is the procedure in which an undescended testicle is lowered into the scrotum and fixed in
place?
Ans: Orchiodopexy
Feedback: Orchiodopexy is the procedure in which an undescended testicle is lowered into the scrotum
and fixed in place.
Chapter 14 Review
Understanding Terminology
1. G
BPH
9. L
Prepuce
3. H
Epididymis
11. J
Ureters
5. F
Glomerulus
13. A
Urinary system
7. D
Micturition
Feedback: N/A
Checking Your Understanding
1. A 1-year-old boy has a midshaft hypospadias with a very mild degree of chordee. He also has a
persistent right hydrocele. The surgeon brought the boy to the operating room to perform a right
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hydrocele repair and one-stage repair of the hypospadias with a preputial onlay flap. Select the
appropriate CPT and ICD-9-CM codes:
Ans: C
Feedback: CPT code 54324 includes the preputial flap.
3. A 31-year-old male presents with chronic glomerulonephritis due to type 2 diabetes. Select the
appropriate ICD-9-CM codes:
Ans: C
Feedback: Alphabetic index under “glomerulonephritis chronic due to or associated with diabetes” directs
the coder to 250.4x /582.81. The slanted bracket designates this code would not be the primary code.
5. An elderly gentleman has worsening bilateral hydronephrosis. He did not have much of a
postvoid residual on a bladder scan. The physician performed a bilateral cystoscopy and retrograde
pyelogram. The results came back as gross prostatic hyperplasia. Select the appropriate CPT and
ICD-9-CM codes:
Ans: C
Feedback: The scenario states that the patient had a bilateral procedure performed, so the modifier 50
should be appended. The ICD-9-CM code 600.9 requires a fifth digit.
7. A capillary tuft that performs the first step in filtering blood to form urine is called the:
Ans: D
Feedback: Medulla is the term used for the innermost part of an organ; cortex refers to an external layer; a
ureter is the tube which conveys the urine from the kidney to the bladder.
9. The patient was diagnosed with cystitis due to Escherichia coli. Choose the appropriate ICD-9CM codes:
Ans: C
Feedback: There is an instructional note under category 595 instructing the use of an additional code to
identify the organism.
Applying your Knowledge
Case 1
PREOPERATIVE DIAGNOSIS: Spontaneous rupture of bladder
POSTOPERATIVE DIAGNOSIS: Same
PROCEDUR: Repair of bladder tear.
INDICATIONS FOR PROCEDURE: 2.7-cm tear of the bladder dome. During surgical inspection
no other injuries were found.
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The patient was prepped and draped in the usual fashion. A Pfannenstiel incision was made at
previous cesarean section scar. Inspection of the bladder shows no other injury. The tear was a 2.7cm transverse tear in the dome of the bladder.
A two-layer closure was done of the mucosa using 4-0 continuous Vicryl. The muscularis was
closed using interrupted 2-0 Vicryl. Postrepair inspection revealed good hemostasis. No other tears
were noted. Minimal blood loss was noted.
Process 1: CPT
1. What is the procedure?
Ans: Repair of bladder tear
Feedback: Repair of bladder tear is the procedure.
3. What additional questions or set of question can be determined.
Ans: Was the wound simple or complicated?
Feedback: Additional question: Was the wound simple or complicated?
5. Based upon the documentation, what is the correct code(s) for this case?
Ans: A
Feedback: Based upon the documentation, the correct code for this case is 51860, cystorraphy, suture of
bladder wound, injury or rupture, simple.
Process 2: ICD
ICD-9-CM
1. Based on the operative report header, what is the preoperative diagnosis?
Ans: Spontaneous rupture of bladder
Feedback: Per the operative report header, the preoperative diagnosis is spontaneous rupture of bladder.
3. Is the postoperative diagnosis supported?
Ans: Yes
Feedback: The postoperative diagnosis is supported.
5. Based on the subterm choices, what question(s) can be developed for this condition?
Ans: Was the rupture due to obstetrical condition, trauma, or spontaneous?
Feedback: Based upon the subterm choices, the question developed for this condition is: Was the rupture
due to obstetrical condition, trauma, or spontaneous?
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7. Is the additional condition, sign, or symptom an integral part of the primary (or other) condition
coded?
Ans: N/A
Feedback: N/A
9. Based on the documentation, what is the correct ICD-9-CM code(s) for this case?
Ans: B
Feedback: Based upon the documentation, the correct ICD-9-CM code for this case is 596.6.
ICD-10-CM
1. Based on the operative report header, what is the preoperative diagnosis?
Ans: Spontaneous rupture of bladder
Feedback: Per the operative report header, the preoperative diagnosis is spontaneous rupture of bladder.
3. Is the postoperative diagnosis supported?
Ans: Yes
Feedback: The postoperative diagnosis is supported.
5. Based on the subterm choices, what question(s) can be developed for this condition?
Ans: Was the rupture due to obstetrical condition, trauma, or spontaneous?
Feedback: Based upon the subterm choices, the question developed for this condition is: Was the rupture
due to obstetrical condition, trauma, or spontaneous?
7. Is any sign, symptom, or additional condition documented?
Ans: No
Feedback: No signs, symptoms, or additional conditions were documented.
9. Does the additional condition require or affect patient care, treatment, or management?
Ans: N/A
Feedback: N/A
Process 3: Modifiers
1. Was the procedure performed different from that described by the nomenclature of the code?
Ans: No
Feedback: The procedure performed was not different from that described by the nomenclature of the
code.
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3. Was the procedure performed in the global period of another procedure?
Ans: No
Feedback: The procedure performed was not in the global period of another procedure.
5. Did the surgeon have help from another surgeon or another appropriate person?
Ans: No
Feedback: The surgeon did not have help from another surgeon or other appropriate person.
7. What modifier(s) should be appended to the CPT code for this case?
Ans: D
Feedback: No modifiers should be appended to the CPT code for this case.
Case 2
PROCEDURE: Bilateral segmental vasectomy, transscrotal
PREOPERATIVE DIAGNOSIS: Elective vasectomy
POSTOPERATIVE DIAGNOSIS: Same
INDICATIONS: This 32-year-old father of 3 request sterilization via vasectomy.
ANESTHESIA: Local with 1% Xylocaine infiltration.
PROCEDURE: The patient was placed in the supine position, prepped, and draped in routine
fashion for a scrotal procedure. The right vas deferens was identified and isolated adjacent to the
scrotal skin. Local anesthesia was obtained using infiltration of 1% Xylocaine without epinephrine.
An incision was made overlying the vas deferens. The vas deferens was identified and delivered to
the operative field. A 2.1-cm segment of the vas deferens was then excised between hemostats. The
ends of the vasa were then cauterized with Bovie electrocautery. The distal end was suture-ligated
and folded back upon itself with 3-0 chromic. The proximal end was suture-ligated. Hemostasis was
obtained using suture of 3-0 chromic. The distal end was then buried in surrounding adventitia
with a figure-of-eight suture of 3-0 chromic. Next, attention was directed to the left side and the
procedure was repeated.
After confirming adequate hemostasis, the vasa deferentia were returned to the normal locations
within the scrotum. The skin was closed using interrupted sutures of 3-0 chromic. After confirming
adequate hemostasis, the patient was returned to the recovery room in good condition.
No complications were noted, with minimal blood loss.
Process 1: CPT
1. What is the procedure?
Ans: Bilateral segmental vasectomy, transscrotal
Feedback: The procedure is bilateral segmental vasectomy, transscrotal.
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3. What additional questions or set of question can be determined?
Ans: The approach and method are needed.
Feedback: Additional questions are related to the approach and method.
5. Based on the documentation, what is the correct code(s) for this case?
Ans: D
Feedback: Based upon the documentation, the correct code for this case is 55250.
Process 2: ICD
ICD-9-CM
1. Based on the operative report header, what is the preoperative diagnosis?
Ans: Sterilization
Feedback: Per the operative report header, the preoperative diagnosis is sterilization.
3. Is the postoperative diagnosis supported?
Ans: Yes
Feedback: The postoperative diagnosis is supported.
5. Based on the subterm choices, what question(s) can be developed for this condition?
Ans: Status, such as tubal ligation or vasectomy
Feedback: Based upon the subterm choices, the question topics developed for this condition are related to
status, such as tubal ligation or vasectomy.
7. Is the additional condition, sign, or symptom an integral part of the primary (or other) condition
coded?
Ans: N/A
Feedback: N/A
9. Based on the documentation, what is the correct ICD-9-CM code for this case?
Ans: C
Feedback: Based upon the documentation, the correct ICD-9-CM code for this case is V26.52.
ICD-10-CM
1. Based on the operative report header, what is the preoperative diagnosis?
Ans: Sterilization
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Feedback: Per the operative report header, the preoperative diagnosis is sterilization.
3. Is the postoperative diagnosis supported?
Ans: Yes
Feedback: The postoperative diagnosis is supported.
5. Based upon the subterm choices, what question(s) can be developed for this condition?
Ans: Status, such as tubal ligation or vasectomy
Feedback: Based upon the subterm choices, the question topic developed for this condition is status, such
as tubal ligation or vasectomy.
7. Is any sign, symptom, or additional condition documented?
Ans: No
Feedback: There were no signs, symptoms, or additional conditions documented.
9. Does the additional condition require or affect patient care, treatment, or management?
Ans: N/A
Feedback: N/A
Process 3: Modifiers
1. Was the procedure performed different from that described by the nomenclature of the code?
Ans: No
Feedback: The procedure performed was not different from that described by the nomenclature of the
code.
3. Was the procedure performed in the global period of another procedure?
Ans: No
Feedback: The procedure performed was not in the global period of another procedure.
5. Did the surgeon have help from another surgeon or another appropriate person?
Ans: No
Feedback: The surgeon did not have help from another surgeon or other appropriate person.
7. What modifier should be appended to the CPT code for this case?
Ans: D
Feedback: There are no modifiers appended to the CPT code for this case.
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95
Chapter 15 – Surgery Section: Female Reproductive System and
Maternity Care and Delivery
Exercise 15.1
1. What are the primary functions of the ovaries?
Ans: Production of oocytes and ovum, and production of estrogen and progesterone
Feedback: N/A
3. What is the myometrium?
Ans: Smooth muscle which forms the wall of the uterus
Feedback: N/A
5. The lowest, narrow part of the uterus where it joins with the vagina is known as the__________.
Ans: cervix uteri
Feedback: The cervix uteri is the lowest, narrow part of the uterus where it joins with the vagina.
Exercise 15.2
1. List and define the three stages of labor.
Ans: Stage 1: From onset of labor to complete dilation and effacement of cervix
Stage 2: From complete dilation to birth
Stage 3: Directly following birth until placenta is expelled
Feedback: N/A
3. Conditions coded in categories 614 to 616 (ICD-9-CM) and N70 to N77 (ICD-10-CM), which
encompass inflammatory diseases of female pelvic organs, are further divided based on _______and
________.
Ans: anatomic site and status (such as chronic or acute)
Feedback: N/A
5. Delivery occurred prior to admission, and the mother is admitted for postpartum care without
any complications. Assign the appropriate ICD-9-CM codes.
Ans: V24.0
Feedback: N/A
Exercise 15.3
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1. Describe a total hysterectomy.
Ans: A total hysterectomy is the complete removal of the uterus and cervix with or without the tubes and
ovaries.
Feedback: N/A
3. CPT codes in the ectopic pregnancy code range (59120–59151) are determined based on what
criteria?
Ans: approach, location of the ectopic pregnancy, and excision/resection of tubes and uterus
Feedback: N/A
5. CPT defines codes of a destruction of vaginal lesions as simple (57061) and extensive (57065).
Explain the difference between simple destruction and extensive destruction.
Ans: Simple destruction is defined as a few small lesions that are simple to destroy. Extensive destruction
involves numerous large lesions that are difficult to destroy.
Feedback: N/A
Exercise 15.4
1. When a procedure such as a vulvectomy is performed bilaterally and the code is not inherently
bilateral or there is no specific code for the bilateral procedure, which modifier should be appended
to the report?
Ans: Modifier 50
Feedback: Modifier 50 indicates bilateral procedure. This case refers to code 56640 Vulvectomy, radical,
complete with inguinofemoral, iliac, and pelvic lymphadenectomy.
3. How would you indicate to the payer that the diagnostic procedure led to an open procedure and
should be reported separately?
Ans: Append modifier 58 to the code.
Feedback: Modifier 58 indicates distinct procedural service.
Exercise 15.5
1. Premature separation of the placenta could be documented in a medical record as ________.
Ans: abruptio placentae
Feedback: N/A
3. A procedure that is performed during labor to prevent perineal laceration or tearing and is
considered part of the normal-delivery ICD code is called a(n) _________ .
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Ans: episiotomy
Feedback: N/A
5. When indexing the condition uterine fibroid the Alphabetic Index of ICD directs the coder to see
also _________.
Ans: leiomyoma
Feedback: The alphabetic index of ICD directs the coder to see also leiomyoma when indexing the
condition uterine fibroid.
Chapter 15 Review
Using Terminology
Ans:
1. O
Antepartum
9. M
Labia minora
3. J
Colposcopy
11. G
Ovary
5. C
Corpus uteri
13. B
Puerperium
7. D
Fimbriae
15. L
Vulva
Feedback: N/A
Checking Your Understanding
1. Preoperative diagnosis: Ovarian cyst, right
Postoperative diagnosis: Ovarian cyst, right
Anesthesia: General
Procedure: Open, drainage of cyst
The patient was taken to the operating room, prepped, and draped in the usual manner, and
adequate anesthesia was induced. An infraumbilical incision was made, and an abdominal entrance
was made.
The abdomen was visualized. The cyst was noted on the right, a 4-cm ovarian cyst. This was
needled, and a hole was cut in it with scissors and the cyst was drained. Instruments were removed.
The patient was awakened and taken to the recovery room in good condition.
Select the appropriate CPT codes for this scenario:
Ans: B
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Feedback: CPT code 58805 correctly identifies drainage of an ovarian cyst using an abdominal approach;
this was indicated in the report by an incision being made into the abdomen. Diagnosis code 620.2
correctly identifies an ovarian cyst.
3. The patient is 25 weeks’ pregnant with her first child. She undergoes a routine prenatal
examination without complications. Select the appropriate ICD-9-CM code:
Ans: A
Feedback: V22.0 is the code for supervision of normal first pregnancy. The statement indicates this is her
first child and there are no complications.
5. Total obstetrical care does not include:
Ans: C
Feedback: Total obstetrical care does not include diagnostic procedures such as ultrasounds. Antepartum
care is the care prior to the baby’s birth, and postpartum care is the care after the birth of the baby. Total
obstetrical care includes antepartum, delivery, and postpartum care.
7. The patient had a cesarean section delivery 2 years ago and presented today for an attempted
vaginal delivery, which resulted in a repeat cesarean section delivery. Select the appropriate CPT
code for the delivery only:
Ans: C
Feedback: This code represents the cesarean delivery only following attempted vaginal delivery. 59612
and 59614 represent vaginal deliveries after cesarean delivery, and 59618 is for routine obstetric care
including antepartum, cesarean delivery, and postpartum.
9. Menopause consists of four stages. Which one of the following stages is actually the stage of
menopause?
Ans: D
Feedback: Menopause is the third stage; it begins with a woman’s final period and lack of menstrual
period for one year. The other stages are premenopause, perimenopause, and postmenopause.
Applying Your Knowledge
Case 1
Maternal labor and delivery note: Patient is a 38-year-old female with estimated date of conception 10/09
and estimated gestational age of +41 weeks. Her prolonged labor began with uterine contractions for the
past 2 days, mild this a.m. and increasingly more severe this evening, with contractions now every 2 to 4
minutes. Cervix is 1 cm/20 percent/_1 station, EFW3, 500 g, 7/21. Patient did progress to 7 cm; however,
she was exhausted due to labor and loss of sleep for the past 2 nights due to her labor pain.
Delivery of a single viable female infant was performed vaginally with vacuum assistance. Episiotomy
with fourth-degree laceration was repaired with 2-0 and 3-0 Vicryl.
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Process 1: CPT
1. What is the procedure?
Ans: Vaginal delivery, vacuum assistance
Feedback: Vaginal delivery, vacuum assistance is the procedure.
3. What additional questions or set of questions can be determined?
Ans: Was it delivery only? Was there a previous cesarean delivery?
Feedback: Other questions to ask from the index include: Was it delivery only? Was there a previous
cesarean delivery?
5. Based on the documentation, what is the correct code for this case?
Ans: A
Feedback: Based upon the documentation, the correct code for this case is 59409, vaginal delivery only
(with or without episiotomy and/or forceps).
Process 2: ICD
ICD-9-CM
1. Based on the operative report header, what is the preoperative diagnosis?
Ans: Delivery, prolonged labor
Feedback: Per the operative report header, the preoperative diagnosis is Delivery, prolonged labor.
3. Is the postoperative diagnosis supported?
Ans: Yes
Feedback: Yes, the post-operative diagnosis is supported.
5. Based on the subterm choices, what question(s) can be developed for this condition?
Ans: Vacuum extractor; did this affect fetus or newborn?
Feedback: Based upon the subterm choices, the following question(s) can be developed for this condition:
Vacuum extractor; did this affect fetus or newborn?
7. Is the additional condition, sign, or symptom an integral part of the primary (or other) condition
coded?
Ans: Yes; the exhaustion is part of the prolonged labor (dystocia code).
Feedback: Yes, the additional condition, sign, or symptom is an integral part of the primary (or other)
condition coded: The exhaustion is part of the prolonged labor (dystocia code).
9. Based on the documentation, what are the correct ICD-9-CM codes for this case?
Ans: D
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Feedback: Based upon the documentation, the correct ICD-9-CM codes for this case are 669.51, 661.01,
664.34, and V27.0.
ICD-10-CM
1. Based on the operative report header, what is the preoperative diagnosis?
Ans: Delivery, prolonged labor
Feedback: Per the operative report header, the preoperative diagnosis is delivery, prolonged labor.
3. Is the postoperative diagnosis supported?
Ans: Yes
Feedback: Yes, the postoperative diagnosis is supported.
5. Based on the subterm choices, what question(s) can be developed for this condition?
Ans: Vacuum extractor; did this affect fetus or newborn?
Feedback: Based upon the subterm choices, the following question(s) can be developed for this condition:
Vacuum extractor; did this affect fetus or newborn?
7. Is any sign, symptom, or additional condition documented?
Ans: Yes; exhaustion due to prolonged labor
Feedback: Yes, there were signs, symptoms, or additional conditions documented: exhaustion due to
prolonged labor.
9. Does the additional condition require or affect patient care, treatment, or management?
Ans: Yes
Feedback: Yes, the additional condition does require or affect patient care, treatment, or management.
Process 3: Modifiers
1. Was the procedure performed different from that described by the nomenclature of the code?
Ans: No
Feedback: The procedure performed was not different from that described by the nomenclature of the
code.
3. Was the procedure performed in the global period of another procedure?
Ans: No
Feedback: The procedure performed was not in the global period of another procedure.
5. Did the surgeon have help from another surgeon or another appropriate person?
Ans: No
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Feedback: The surgeon did not have help from another surgeon or other appropriate person.
7. What modifier(s) should be appended to the CPT code for this case?
Ans: B
Feedback: No modifier should be appended to the CPT code for this case.
Case 2
Preoperative diagnosis: Uterine fibroids and menometrorrhagia
Postoperative diagnosis: Same
Operation: Total abdominal hysterectomy
Pathology specimen: Uterus, approximately 240 grams; tubes and ovaries
Approach and surgical procedure: The patient was placed in the dorsal supine position, prepped, and
draped in the routine fashion. A lower abdominal midline incision was made through the skin,
subcutaneous tissue, and anterior rectus fascia.
The retractor was placed, and the bowel retracted laterally. Kelly clamps were placed on the round the
anterior peritoneum was entered. The contents of the abdomen were explored; the liver, gallbladder,
kidneys, and aorta were noted as grossly normal in appearance. The appendix was in place. The bladder
was retracted anteriorly. Clamps were placed across the adnexa, and the pedicles were sutured with
figure-of-eight #1 chromic and a free tie of #1 chromic. The infundibulopelvic ligament, broad ligament,
and cardinal ligament were clamped, transected, and ligated bilaterally.
The posterior peritoneum was entered, and the uterine vessels were grasped with an Allis clamp and
sutured with #1 chromic. Clamps were placed on either side of the ligature; the vessels were divided and
again suture-ligated with #1 chromic. The vagina was entered anteriorly, and the cervix was removed.
Figure-of-eight #1 chromic sutures were placed to the lateral vaginal cuff. The cuff was then reefed using
continuous interlocking #1 chromic. Hemostasis was noted as good, and the posterior peritoneum was
closed with continuous catgut. The retractor and packs were removed. Sponge and instrument counts
were correct. The abdominal peritoneum was closed with continuous 0 chromic gut.
The fascia was closed with continuous interlocking 0 Vicryl. The fat was closed with continuous #2-0
plain and the skin closed with staples. The patient tolerated the procedure well and left the operating suite
in satisfactory condition.
Process 1: CPT
1. What is the procedure?
Ans: Total abdominal hysterectomy
Feedback: Total abdominal hysterectomy is the procedure.
3. What additional questions or set of question can be determined?
Ans: What is the approach?
Feedback: The additional question determined is: What is the approach? (Answer is: open abdominal)
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5. Based on the documentation, what is the correct code for this case?
Ans: A
Feedback: Based upon the documentation, the correct code for this case is 58150.
Process 2: ICD
ICD-9-CM
1. Based on the operative report header, what is the preoperative diagnosis?
Ans: Uterine fibroid
Feedback: Per the operative report header, the preoperative diagnosis is uterine fibroid.
3. Is the postoperative diagnosis supported?
Ans: Yes
Feedback: The postoperative diagnosis is supported.
5. Based on the subterm choices, what question(s) can be developed for this condition?
Ans: What is the anatomic site?
Feedback: Based upon the subterm choices, the following question(s) can be developed for this condition:
What is the anatomic site? (Answer: uterus)
7. Is the additional condition, sign, or symptom an integral part of the primary (or other) condition
coded?
Ans: No
Feedback: The additional condition, sign, or symptom is not an integral part of the primary (or other)
condition coded.
9. Based on the documentation, what are the correct ICD-9-CM codes for this case?
Ans: C
Feedback: Based upon the documentation, the correct ICD-9-CM codes for this case are 218.9 (uterine
fibroid, unspecified) and 626.2 (menometrorrhagia).
ICD-10-CM
1. Based on the operative report header, what is the preoperative diagnosis?
Ans: Uterine fibroid
Feedback: Per the operative report header, the preoperative diagnosis is uterine fibroid.
3. Is the postoperative diagnosis supported?
Ans: Yes
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103
Feedback: The postoperative diagnosis is supported.
5. Based upon the subterm choices, what question(s) can be developed for this condition?
Ans: What is the anatomic site?
Feedback: Based upon the subterm choices, the following question(s) can be developed for this condition:
What is the anatomic site? (Answer: uterus)
7. Is any sign, symptom, or additional condition documented?
Ans: Yes, menometrorrhagia
Feedback: Yes, menometrorrhagia was documented as a sign, symptom, or additional condition.
9. Does the additional condition require or affect patient care, treatment, or management?
Ans: No
Feedback: The additional condition does not require or affect patient care, treatment, or management.
Process 3: Modifiers
1. Was the procedure performed different from that described by the nomenclature of the code?
Ans: No
Feedback: The procedure performed was not different from that described by the nomenclature of the
code.
3. Was the procedure performed in the global period of another procedure?
Ans: No
Feedback: The procedure performed was not in the global period of another procedure.
5. Did the surgeon have help from another surgeon or another appropriate person?
Ans: No
Feedback: The surgeon did not have help from another surgeon or other appropriate person.
7. What modifier should be appended to the CPT code for this case?
Ans: B
Feedback: No modifier should be appended to the CPT code for this case.
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Chapter 16 – Surgery Section: Nervous System
Exercise 16.1
1. The CNS consists of what anatomical parts?
Ans: Brain and spinal cord
Feedback: The CNS is comprised of the brain and spinal cord.
3. Name the four lobes of the brain, and explain the function of one.
Ans: Frontal lobe, Parietal lobe, Temporal lobe, Occipital lobe. Answers may vary as far as which lobe is
chosen for function description.
Feedback: The four lobes of the brain are:
Frontal lobe: involved in planning, organizing, problem solving, memory, impulse control, decision
making, selective attention, and control of behavior and emotions.
Parietal lobe: integrate sensory information from various parts of the body, and map objects perceived
visually into body coordinate positions, telling us which way is up and helping to keep us from bumping
into things when we walk. They also allow for knowledge of numbers and their relations.
Temporal lobe: involved in auditory perception and contain the primary auditory cortex. They allow for
processing of semantics in both speech and vision, recognizing and processing sound, and understanding
and producing speech, as well as various aspects of memory, comprehension, naming, verbal memory,
and other language functions.
Occipital lobe: located at the lower back of the head; contain the primary visual cortex, which receives
and processes visual information such as color and motion, and contain areas that help in perceiving and
interpreting shapes and colors.
5. What is the function of the spinal cord?
Ans: The spinal cord carries sensory information from the peripheral nerves to the brain and from the
brain to the peripheral nerves.
Feedback: The spinal cord is divided into four regions: cervical, thoracic, lumbar and sacral and carries
information from the peripheral nerves to the brain and back to the peripheral nerves.
Exercise 16.2
1. Define bruxism.
Ans: Bruxism is a movement disorder which results in clenching of the jaw or grinding of teeth.
Feedback: N/A
3. Define mononeuritis and mononeuritis multiplex, and explain how these conditions are further
defined in ICD.
Ans: Mononeuritis is the inflammation of a single nerve and may affect the body along the entire nerve
path. Mononeuritis multiplex is the inflammation of at least two unrelated nerves and is coded to 354.5
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(G56-G57 ICD-10-CM). Coding of mononeuritis is categorized anatomically by upper limb 354 (G56
ICD-10-CM) and lower limb 355 (G57 ICD-10-CM). Each of these categories is subdivided based upon
the nerve affected. A very common condition included in these categories is carpal tunnel syndrome
354.0 (G56.0- ICD-10-CM).
Feedback: N/A
Exercise 16.3
1. Burr holes are commonly used to begin a craniotomy or craniectomy. Is this procedure coded in
addition to the more extensive approach when it is performed for this purpose?
Ans: No
Feedback: Burr holes are commonly used to begin a craniotomy or craniectomy and are not coded in
addition to the more extensive approach when performed for this purpose.
3. What is the commonly used code for carpal tunnel surgery?
Ans: 64721
Feedback: N/A
5. Laminotomy is also known as_________.
Ans: hemilaminectomy
Feedback: Laminotomy is the removal of the superior or inferior half of the lamina (multiple levels are
counted by interspace). It is also called hemilaminectomy.
Exercise 16.4
1. Which modifier is used to identify that a procedure normally bundled into another procedure is
actually a separate procedure and is medically necessary?
Ans: Modifier 59
Feedback: Modifier 59 indicates a distinct procedural service.
3. Which modifier identifies that a procedure was performed bilaterally?
Ans: 50 or RT. LT depending on the payer.
Feedback: N/A
Exercise 16.5
1. The patient record documents diagnosis of vertigo. Would the ICD code for syncope be the
appropriate code to report? If not, why?
Ans: No. Syncope is for fainting or loss of consciousness and vertigo is lightheadedness.
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Feedback: N/A
3. What test is performed to record electrical activity of the brain?
Ans: Electroencephalography
Feedback: Electroencephalography is a test performed to record electrical activity of the brain.
Chapter 14 Review
Using Terminology
1. E
Alzheimer’s disease
9. H
Meningitis
3. G
Encephalitis
11. B
Peripheral nervous system (PNS)
5. L
Hemiparesis
13. N
Vertebral interspace
7. F
Hydrocephalus
Feedback: N/A
Checking Your Understanding
1. The name of the entire motor nervous system is:
Ans: A
Feedback: The name of the entire motor nervous system is the autonomic nervous system. The peripheral
nervous system connects the brain and the spinal cord to the body. The parasympathetic nervous system
brings all systems back to normal. The sympathetic nervous system is responsible for the fight or flight
response
3. Callie has been a medical transcriptionist for 25 years and has been complaining of a tingling
sensation in her right arm. She was diagnosed with carpal tunnel syndrome and underwent an open
procedure that included neuroplasty and transposition of the median nerve at the carpal tunnel.
Select the appropriate ICD and CPT codes from the following:
Ans: A
Feedback: CPT code 64721 is the correct code to identify carpal tunnel surgery. ICD-9-CM code 354.0
describes median nerve entrapment while 354.1 describes median nerve neuritis.
5. A patient presents to the operating room for enlargement of the foramen, or hole, through which
the nerve root exits the spinal canal. This type of procedure would be identified on an operative
report as a:
Ans: B
Feedback: Corpectomy is the removal or resection of the anterior portion of the vertebra (spinal column).
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Facetectomy is the removal of the facet or bone overgrowth from the facet which leads to compression of
the nerve root. Laminectomy is the removal of the lamina of a vertebral segment.
7. A patient presents for reprogramming of a programmable CSF shunt. Select the appropriate
CPT code:
Ans: C
Feedback: The description of code 62252 is reprogramming of programmable cerebrospinal shunt, and
there is an instructional note which informs the coder to use code 62252 for reprogramming of
programmable CSF shunt. CPT code 62256 is for removal of complete cerebrospinal fluid shunt system
without replacement. CPT code 62230 is for replacement or revision of cerebrospinal fluid shunt,
obstructed valve, or distal catheter in shunt system. CPT code 61070 is for percutaneous irrigation or
aspiration of shunt reservoir
9. In an anterior C2–3 discectomy for decompression of the spinal cord, the approach to the spinal
column was performed by a thoracic surgeon and decompression was completed by a
neurosurgeon. Select the appropriate CPT code with the appropriate modifier, if needed, for both
surgeons:
Ans: C
Feedback: 63077 is for the thoracic spine. The guidelines with this section in the CPT manual instruct the
coder on the use modifier 62 with code 63076.
Applying Your Knowledge
Case 1
Preoperative diagnosis: Herniated disk left L4–5 interspace, with sequestered fragment, left L5
radiculopathy
Postoperative diagnosis: Herniated disk left L4–5 interspace, with sequestered fragment, left L5
radiculopathy
Procedure: Left L4–5 partial hemilaminectomy, medial facetectomy, removal of herniated disk and
sequestered far lateral disk
Anesthesia: General anesthesia
Estimated blood loss: 30 ml
Endotracheal anesthesia was administered, and the back was prepped and draped in the usual
fashion. We used intraoperative x-ray to approximate the location of the L4–5 interspace such that
we could center the incision over this area. An incisionwas made over the L4–5 interspace, and the
incision carried down through the subcutaneous tissues, which in this lady were quite considerable.
The lumbosacral fascia was opened on the left side only, and the paraspinal muscles were stripped
subperiosteally to expose the spinous processes and laminae of L4 and L5. We obtained an x-ray
with our marker at the L5 lamina. Once this was done, the L4–5 interspace was identified and a left
L4–5 partial hemilaminectomy and medial facetectomy were performed. Verifying that was inferior
enough sufficiently to be able to reach the L5 nerve root and sequestered fragment. Partially, the
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bony removal was accomplished also, in addition to the Midas Rex drill. It was performed using
curettes and Kerrisons. The yellow ligament was removed, exposing the common dural sac, and I
was able toidentify the L4–5 interspace, which appeared to be indurated and consistent with a
previous disc herniation.The L5 nerve root was identified and was gently mobilized medially, and I
was able to identify the sequestered disc, which was actually in three large fragments. These were
mobilized with a blunt hook and then delivered with a small pituitary punch. Perhaps the largest of
the fragments actually appeared to extend out the foramina along with the L5 nerve root. After the
fragments were released, the dura and nerve root appeared to be much more relaxed and I probed
out the foramina using both a blunt hook and then a Woodson. No additional fragments were
uncovered. I inspected the L4–5 disk with an Epstein curette. There were no additional rents that
appeared to be scarred, and rather than risk a second disc herniation through an area that
appeared to be already healed, this was left alone. The common dural sac was well decompressed en
route. The area was irrigated with an antibiotic saline solution. A small autologous fat graft was
harvested and placed over the root and dura and then covered with a Gelfoam thrombin slurry.
The wound was infiltrated with25 percent Marcaine with epinephrine, and the wound was closed
by reapproximating the muscles and fascia with O Vicryl: a 2-0 Vicryl subcutaneous closure and a
running 4-0 subcuticular stitch in the skin. The wound was reinforced with Steri-Strips. A sterile
dressing was applied. Throughout the case the patient remained hemodynamically stable.
Process 1: CPT
1. What is the procedure?
Ans: Hemilaminectomy
Feedback: Hemilaminectomy is the procedure.
3. What additional questions or set of questions can be determined?
Ans: None
Feedback: No additional questions or set of question can be determined.
5. Based on the documentation, what is (are) the correct code(s) for this case?
Ans: D
Feedback: Based upon the documentation, the correct code for this case is 63042. Laminotomy
(hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy
and/or excision of herniated intervertebral disc, reexploration, single interspace; lumbar. The
documentation states “the L4-5 interspaces which appeared to be indurated and consistent with a
previous disk herniation” indicating the procedure is a reexploration at the same level of a previous
hemilaminectomy.
Process 2: ICD
ICD-9-CM
1. Based on the operative report header, what is the preoperative diagnosis?
Ans: Herniated disk left L4-5 interspace, with sequestered fragment, left L5 radiculopathy.
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Feedback: Per the operative report header, the preoperative diagnosis is herniated disk left L4-5
interspace, with sequestered fragment, left L5 radiculopathy.
3. Is the postoperative diagnosis supported?
Ans: Yes
Feedback: Yes, the postoperative diagnosis is supported. The surgeon was able to identify the herniated
disc fragments: “and I was able to identify the sequestered disk which was actually in 3 large fragments”.
5. Based on the subterm choices, what question(s) can be developed for this condition?
Ans: What is the anatomic site (intervertebral) and spinal level of the displacement? Due to trauma? Is
another condition (myelopathy) present with the condition?
Feedback: Based upon the subterm choices, the following questions can be developed for this condition:
What is the anatomic site (intervertebral) and spinal level of the displacement? Due to trauma? Is another
condition (myelopathy) present with the condition?
7. Is the additional condition, sign, or symptom an integral part of the primary (or other) condition
coded?
Ans: No; however, radiculopathy is included in the diagnosis code for disc displacement and would not
be coded separately.
Feedback: No, the additional condition, sign or symptom is not an integral part of the primary (or other)
condition coded. However, radiculopathy is included in the diagnosis code for disc displacement and
would not be coded separately.
9. Based on the documentation, what is (are) the correct ICD-9-CM code(s) for this case?
Ans: B
Feedback: Based upon the documentation, the correct ICD-9 code for this case is 722.10, displacement of
lumbar intervertebral disc without myelopathy is the correct answer. 722.52 is incorrect as the
documentation does not indicate degeneration of the lumbar disc. 722.10, 724.4 is also incorrect as an
inclusion note listed below code 722.10 indicates that radiculitis due to displacement or rupture of the
intervertebral disc is integral to the code. 722.11 indicates displacement of a thoracic intervertebral disc
without myelopathy, the spinal level indicated in the documentation is lumbar.
ICD-10-CM
1. Based on the operative report header, what is the preoperative diagnosis?
Ans: Herniated disk left L4-5 interspace, with sequestered fragment, left L5 radiculopathy.
Feedback: Per the operative report header, the preoperative diagnosis is herniated disk left L4-5
interspace, with sequestered fragment, left L5 radiculopathy.
3. Is the postoperative diagnosis supported?
Ans: Yes
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Feedback: The postoperative diagnosis is supported. The surgeon was able to identify the herniated disc
fragments: “…and I was able to identify the sequestered disk which was actually in 3 large fragments”.
5. Based on the subterm choices, what question(s) can be developed for this condition?
Ans: What is the anatomic site (intervertebral) and spinal level of the displacement? Due to trauma? Is
another condition (myelopathy) present with the condition?
Feedback: Based upon the subterm choices, the following questions can be developed for this condition:
What is the anatomic site (intervertebral) and spinal level of the displacement? Due to trauma? Is another
condition (myelopathy) present with the condition?
7. Is any sign, symptom, or additional condition documented?
Ans: Yes, radiculopathy
Feedback: Yes, radiculopathy is documented as a sign, symptom, or additional condition.
9. Does the additional condition require or affect patient care, treatment, or management?
Ans: No
Feedback: The additional condition does not require or affect patient care, treatment, or management.
Process 3: Modifiers
1. Was the procedure performed different from that described by the nomenclature of the code?
Ans: No
Feedback: The procedure performed was not different from that described by the nomenclature of the
code.
3. Was the procedure performed in the global period of another procedure?
Ans: No
Feedback: The procedure performed was not in the global period of another procedure.
5. Did the surgeon have help from another surgeon or another appropriate person?
Ans: No
Feedback: The surgeon did not have help from another surgeon or other appropriate person.
7. What modifier should be appended to the CPT code for this case?
Ans: C
Feedback: The modifier LT should be appended to the CPT for this case. As this procedure can be
perform bilaterally or unilaterally, an anatomic site modifier should be appended to the procedure code.
Modifier 78 is incorrect; although this is a re-exploration of a previous laminectomy, there is no
indication that the procedure is being performed in the global (postop) period of the previous
laminectomy. This is confirmed by the surgeon’s statement “and rather than risk a second disk
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111
herniation through an area that appeared to be already healed this was left alone. Modifier58 is also
incorrect as a procedure of this nature would not be planned or considered during the previous procedure.
Case 2
Preoperative diagnosis: Acute/chronic subduralhematoma, headaches, and right-sided weakness
Postoperative diagnosis: Acute/chronic subduralhematoma, headaches, and right-sided weakness
Procedure: Left-sided burr hole evacuation of subdural hematoma
Anesthesia: General anesthesia
Estimated blood loss: Less than 10 ml
Description of procedure: Following a thorough discussion of the risk, benefits, and alternative
treatments with the patient and verifying that she has sufficient information to make an informed
decision, we proceeded. The patient received preoperative antibiotics and had sequential
compression devices that were operating prior to the induction of the general anesthetic. Under
general endotracheal anesthesia, the patient was placed supine on the operating table and prepped
and draped in the usual fashion. The CT scan of the head was verified. Following our last time-out,
two incisions were made over the left convexity, one anteriorly and one posteriorly. These were
approximated at 2.5 to 3 cm in length. The incision was carried down through the scalp, using
unipolar cautery for homeostasis. The wound was retracted using a small Weitlaner, and the soft
tissue was cleared from the periosteum. Using the perforator, 2 burr holes were made, again one
anteriorly and one posteriorly. The bony edges were waxed for homeostasis. The discoloration
through the dura was visible, consistent with the subdural hematoma. We first opened the anterior
burr hole, opening the dura. The dura was coagulated using bipolar cautery and a 15-blade knife.
From here there was aflow of straw-colored fluid consistent with a chronic subdural hematoma. We
irrigated from one burr hole to the other until the fluid cleared. Once the fluid was cleared, we then
left a 1-French drain in the subdural space. The drain was brought out through a separate trocar
incision. The burr holes were covered with Gelfoam, and then the wound was closed by
reapproximating the galea with 2-0 Vicryl and staples in the skin. Postoperatively a full head
dressing was applied. The patient tolerated the procedure well and remained hemodynamically
stable throughout the case.
Process 1: CPT
1. What is the procedure?
Ans: Burr hole
Feedback: Burr hole is the procedure.
3. What additional questions or set of questions can be determined?
Ans: What is the procedure or condition?
Feedback: After locating the main term in the index, the additional question determined is: What is the
procedure or condition?
5. Based on the documentation, what is the correct code for this case?
Ans: D
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Feedback: Based upon the documentation, the correct code for this case is 61154, which correctly reports
the evacuation of a subdural hematoma through a burr hole. 61312 reports the evacuation of a hematoma
through a craniectomy or craniotomy, not a burr hole. 61150 reports the correct approach, burr hole, but
for the drainage of an abscess or cyst, not a hematoma. 61314 reports the evacuation of a hematoma;
however, the approach is craniectomy or craniotomy, not burr hole, and the site is infratentorial (below
the tentorium) and we know the site is supratentorial by the location of the burr holes, “left convexity”
(skull vault or dome).
Process 2: ICD
ICD-9-CM
1. Based on the operative report header, what is the preoperative diagnosis?
Ans: Subdural hematoma acute over chronic
Feedback: Per the operative report header, the preoperative diagnosis is subdural hematoma acute over
chronic.
3. Is the postoperative diagnosis supported?
Ans: Yes
Feedback: Yes, the postoperative diagnosis is supported.
5. Based on the subterm choices, what question(s) can be developed for this condition?
Ans: Was the condition traumatic or nontraumatic? What is the anatomic site of the hematoma? What is
the age of the patient?
Feedback: Based upon the subterm choices, the following questions can be developed for this condition:
Was the condition traumatic or nontraumatic? What is the anatomic site of the hematoma? What is the
age of the patient?
Instructors note: the coders should be led to a nontraumatic hematoma as the condition is acute on
chronic and no injury is documented to lead to a traumatic hematoma. Additional questions will then be,
cause, age of patient, and anatomic site.
7. Is the additional condition, sign, or symptom an integral part of the primary (or other) condition
coded?
Ans: Yes, it is an integral part of the condition
Feedback: The additional condition, sign, or symptom is an integral part of the primary (or other)
condition coded.
9. Based on the documentation, what is the correct ICD-9-CM code for this case?
Ans: A
Feedback: Based upon the documentation, the correct ICD-9-CM code for this case is 432.1, which
identifies a nontraumatic subdural hemorrhage. 432.10 is incorrect as this is not a current ICD-9-CM
code. 852.20 identifies a traumatic subdural hematoma; however, as this patient had a chronic hematoma
which has become acute, this diagnosis would be incorrect. 432.0 reports a nontraumatic hemorrhage, but
extradural not subdural.
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ICD-10-CM
1. Based on the operative report header, what is the preoperative diagnosis?
Ans: Subdural hematoma acute over chronic
Feedback: Per the operative report header, the preoperative diagnosis is subdural hematoma acute over
chronic.
3. Is the postoperative diagnosis supported?
Ans: Yes
Feedback: Yes, the postoperative diagnosis is supported.
5. Based on the subterm choices, what question(s) can be developed for this condition?
Ans: What is the anatomic site? Is the condition traumatic or nontraumatic?
Feedback: Based upon the subterm choices, questions developed for this condition are: What is the
anatomic site? Is the condition traumatic or nontraumatic? Note: Under the terms non-traumatic
hematoma the coder is instructed to see hemorrhage, intracranial.
7. Is any sign, symptom, or additional condition documented?
Ans: Yes, headaches and right-sided weakness
Feedback: Yes, the signs, symptoms or additional conditions—headaches and right-sided weakness—are
documented.
9. Does the additional condition require or affect patient care, treatment, or management?
Ans: No
Feedback: The additional condition does not require or affect patient care, treatment, or management.
Process 3: Modifiers
1. Was the procedure performed different from that described by the nomenclature of the code?
Ans: No
Feedback: No, the procedure performed was not different than that described by the nomenclature of the
code.
3. Was the procedure performed in the global period of another procedure?
Ans: No
Feedback: The procedure performed was not in the global period of another procedure.
5. Did the surgeon have help from another surgeon or another appropriate person?
Ans: No
Feedback: The surgeon did not have help from another surgeon or other appropriate person.
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7. What modifier should be appended to the CPT code for this case?
Ans: D
Feedback: No modifier should be appended to the CPT code for this case. LT would be used to report a
site with laterality and although the skull has a right and left side it is considered one structure. As the
skull is not considered a site with laterality, modifier 50 would be inappropriate. There is no indication in
the documentation to support a substantial increase in the work, time, intensity or technical of the
procedure or severity of patient’s condition warranting appending modifier 22.
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115
Chapter 17 – Surgery Section: Eyes, Ears, and Endocrine System
Exercise 17.1
1. Explain the pathway of light.
Ans: Cornea, aqueous humor of anterior chamber, pupil, vitreous humor of posterior chamber, retina,
electrical signal, optic nerve and brain and then the image.
Feedback: Pathway of light: cornea  aqueous humor of anterior chamber  pupil  vitreous humor of
posterior chamber  retina  electrical signal or impulse  optic nerve  brain
3. List the structures of the endocrine system.
Ans: Pituitary gland, pineal gland, thyroid gland, parathyroid gland, and thymus
Feedback: The structures of the endocrine system include the pituitary gland, pineal gland, thyroid gland,
parathyroid gland, and thymus.
5. Which endocrine gland produces the hormone melatonin?
Ans: The pineal gland
Feedback: The pineal gland produces the hormone melatonin.
Exercise 17.2
1. List the types of cataracts.
Ans: Congenital: Occurs at or prior to birth and may or may not affect vision significantly enough to
require surgery.
Age-related or senile: Typically occurs in patients over 70 years of age, but may develop as early as 40
or 50 years of age.
Secondary: May develop after surgical procedures on the eye, or due to an underlying condition such as
diabetes or the prolonged use of medications such as steroids.
Traumatic: Develops due to a direct injury to the eye, typically from blunt trauma or exposure to certain
chemicals
Feedback: N/A
3. What is the subclassification for acute/subacute iridocyclitis based upon?
Ans: Acute/subacute iridocyclitis is subclassified based upon the type of iridocyclitis: primary, recurrent,
secondary due to infection or not due to infection.
Feedback: N/A
Exercise 17.3
1. Identify the further differentiations of nonsuppurative and suppurative conditions of otitis
media.
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Ans: Nonsuppurative conditions are further classified based upon the type as serous, mucoid, or
sanguinous. Suppurative conditions are classified as acute and chronic. Acute suppurative codes are
further defined based on a rupture of the eardrum. Chronic suppurative codes are further defined based
upon the structures affected or the location of the condition in relation to the tympanic membrane.
Feedback: Otitis media is coded to categories 381 and 382 (H65–H66, ICD-10-CM). ICD categorizes
otitis media as nonsuppurative, 381 (H65, ICD-10-CM), and suppurative, 382 (H66, ICD-10-CM). Each
of these categories is further divided based on acuity of the condition as acute or chronic. Nonsuppurative
conditions are further classified based on the type: serous, mucoid, or sanguinous. Suppurative conditions
are classified as acute or chronic. Acute suppurative codes are further defined based on a rupture of the
eardrum, and chronic suppurative codes are further defined based on the structures affected or the location
of the condition in relation to the tympanic membrane.
3. Further define the subcategories used to assign codes for otitis externa.
Ans: These subcategories are primarily broken down into infective and noninfectious forms of otitis
externa. Conditions included in each of these subcategories are classified by the underlying cause or
nature of the condition.
Feedback: Otitis externa is an infection or inflammation that extends into the cartilage of the ear, and ICD
subcategories are primarily divided into infectious and noninfectious forms of otitis externa. Conditions
included in each of these subcategories are classified by the underlying cause or nature of the condition.
Exercise 17.4
1. Removal of the eyeball is coded based upon how much of the eyeball and orbital structures are
removed with the eye. Define the terms evisceration, enucleation, and exenteration.
Ans: Evisceration: Removal of the contents within the eye leaving the scleral shell intact.
Enucleation: Removal of the eyeball in total by cutting it free of the extraocular muscles and the optic
nerve.
Exenteration: Removal of the eyeball and orbital support structure, with or without orbital bone.
Feedback: N/A
3. To accurately code a keratoplasty, what must the coder be able to determine from the medical
record.
Ans: Keratoplasty, also known as corneal transplants, is divided in CPT based upon the thickness of the
donor graft or the portion of the cornea grafted to the donor’s eye such as the endothelial disc (65756).
Penetrating keratoplasties are further specified by CPT by the presence of a natural lens.
Feedback: Keratoplasty, also known as a corneal transplant, is divided by CPT based on the thickness of
the donor graft or the portion of the cornea grafted to the donor’s eye, such as the endothelial disc
(65756). Penetrating keratoplasties are further specified by CPT by the presence of a natural lens
(65730), the absence of a lens (65750), and an artificial lens (65755).
Exercise 17.5
1. Would it be appropriate to append modifier 50 to CPT code 69210 when impacted cerumen is
removed from both ears?
Ans: No, the code description for CPT code 69210 indicates 1 or both ears.
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Feedback: N/A
3. Explain the difference between a modified radical mastoidectomy and a radical mastoidectomy.
Ans: In a modified radical mastoidectomy, some middle ear bones are left in place and the eardrum is
rebuilt. In a radical mastoidectomy, most of the bone is removed.
Feedback: The mastoidectomy codes, 69502-69511, are further defined as complete, modified radical
(some middle ear bones are left in place and the eardrum is rebuilt) or radical (most of the bone is
removed).
Exercise 17.6
1. Debridement, mastoidectomy cavity, complex is performed bilaterally. Assign the appropriate
CPT code with the appropriate modifier appended.
Ans: 69222-50
Feedback: N/A
3. Which modifier is not to be used with CPT code 65820?
Ans: Modifier 63
Feedback: Modifier 63 may not be appended to code 65820 Goniotomy, also known as a DeVincintus or
Barken’s operation.
Exercise 17.7
1. What is the difference between a Rinne test and a Weber test?
Ans: A Weber test is used to determine hearing deficit as conductive or sensor neural. A Rinne test is
used for bone air conduction of sound wave.
Feedback: N/A
3. How might an excessive secretion of thyroid hormone be described in a medical record?
Ans: Graves’ disease, hyperthyroidism, toxic diffuse goiter
Feedback: N/A
Chapter 17 Review
Using Terminology
1. L
AU
9. K
Otitis Externa
3. N
Cushing’s syndrome
11. C
Sclera
5. G
Hyperopia
13. O
Thyroid storm
7. J
Impacted cerumen
15. F
Tympanic membrane
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118
Feedback: N/A
Checking Your Understanding
1. A 25-year-old patient has been diagnosed with noise-induced hearing loss due to the exposure of
continuous music. Select the appropriate ICD-9-CM code:
Ans: A. 388.12
Feedback: 389.14 is for central hearing loss, 388.11 is for acoustic trauma such as explosion to the ear,
and 389.8 is for unspecified hearing loss. The documentation does specify the hearing loss as noiseinduced.
3. The clear part of the eye that covers the pupil and iris and controls and focuses light entering the
eye is the:
Ans: A. Cornea
Feedback: The sclera forms the visible white of the eye and surrounds the optic nerve. The conjunctiva is
the mucous membrane lining the supporting structures of the eye and inner eyelids. The lens is located
directly behind the cornea and focuses light rays onto the retina.
5. A patient who had previous eye surgery that did not involve the extraocular muscle presented
for strabismus surgery on two horizontal muscles. Select the appropriate CPT code(s):
Ans: B. 67311, 67331
Feedback: 67331 is an add-on code for the previous eye surgery and would not be the primary procedure
code. 67316 is for 2 vertical muscles.
7. A procedure was performed on the ocular sinister. Which of the following modifiers should be
appended to the code?
Ans: B. OS
Feedback: OS is oculus sinister - left eye. OD is oculus dexter - right eye. OU is oculus uterque - each
eye. AS is auris sinistra - left ear.
9. A 52-year-old male presents with tachycardia, weight loss, and nervousness. The physician is
concerned the patient’s heart rate is high. Stat labs are run, and the physician determines that the
patient is experiencing hyperthyroidism with thyroid storm. The patient is admitted. Select the
appropriate ICD-9-CM code:
Ans: B. 242.91
Feedback: 242.91 correctly describes hyperthyroidism with mention of thyrotoxic crisis or storm. 244.9 is
unspecified hypothyroidism; 242.90 is without mention of thyrotoxic storm.
Appling Your Knowledge
Case 1
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Procedure performed: Bilateral tympanostomy
Preoperative diagnosis: Bilateral recurrent otitis media with effusion
Postoperative diagnosis: Left recurrent otitis media with effusion
Procedure: The patient was placed in the supine position and under the adequate general
anesthesia; the patient was prepped and draped in the usual manner. Using the operating
microscope, the left tympanic membrane was visualized. The canal was cleaned of cerumen and a
radial incision was made in the anteroinferior quadrant of the membrane. A 0.40 tube was placed
in the previously created myringotomy. Suspension drops were instilled, and a cotton ball was
placed at the meatus.
Process 1: CPT
1. What is the procedure?
Ans: Tympanostomy
Feedback: Tympanostomy is the procedure.
3. What additional questions or set of question can be determined?
Ans: None
Feedback: There are no additional questions or set of questions.
5. Based on the documentation, what is the correct code for this case?
Ans: B
Feedback: Based upon the documentation, the correct code for this case is 69436, which correctly reports
tympanostomy with tube insertion under general anesthesia. 69421 reports an incision of the tympanic
membrane for aspiration of the middle ear and/or Eustachian tube. 69433 does report a tympanostomy
with tube insertion, but performed with local anesthesia, and the procedure was documented as completed
under general anesthesia. 69424 reports the removal of ventilating tubes; the procedure performed is
insertion of tubes.
Process 2: ICD
ICD-9-CM
1. Based on the operative report header, what is the preoperative diagnosis?
Ans: Otitis media with effusion, recurrent
Feedback: Per the operative report header, the preoperative diagnosis is otitis media with effusion,
recurrent.
3. Is the postoperative diagnosis supported?
Ans: Yes
Feedback: Yes, the postoperative diagnosis is supported.
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5. Based on the subterm choices, what question(s) can be developed for this condition?
Ans: Is the condition chronic or acute? Is effusion present or what other conditions are present?
Feedback: Based upon the subterm choices, the following questions can be developed for this condition:
Is the condition chronic or acute? Is effusion present or what other conditions are present?
7. Is the additional condition, sign, or symptom an integral part of the primary (or other) condition
coded?
Ans: N/A
Feedback: N/A
9. Based on the documentation, what is the correct ICD-9-CM code(s) for this case?
Ans: D
Feedback: Based upon the documentation, the correct ICD-9-CM code for this case is 381.4, which
reports a nonsuppurative otitis media (with effusion). Both 381.00 and 381.3 report nonsuppurative otitis
media (with effusion); however, as the documentation does not indicate whether the condition is acute or
chronic and ICD-9-CM does not provide direction for coding this recurrent condition as acute or chronic,
this element of the condition cannot be indicated in the reported ICD code. Therefore, neither of those
codes would be correct. 382.00 reports an acute suppurative otitis media; however, although otitis media
with effusion does involve fluid behind the tympanic membrane, it is not the suppurative otitis media
which involves pus behind the tympanic membrane.
ICD-10-CM
1. Based on the operative report header, what is the preoperative diagnosis?
Ans: Otitis media with effusion, recurrent
Feedback: Per the operative report header, the preoperative diagnosis is otitis media with effusion,
recurrent.
3. Is the postoperative diagnosis supported?
Ans: Yes
Feedback: Yes, the postoperative diagnosis is supported.
5. Based on the subterm choices, what question(s) can be developed for this condition?
Ans: Is the condition chronic, acute, or recurrent? Is effusion present or what other conditions are
present?
Feedback: Based upon the subterm choices, the following questions can be developed for this condition:
Is the condition chronic, acute, or recurrent? Is effusion present or what other conditions are present?
7. Is any sign, symptom, or additional condition documented?
Ans: No
Feedback: There were no signs, symptoms, or additional conditions documented.
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9. Does the additional condition require or affect patient care, treatment, or management?
Ans: N/A
Feedback: N/A
Process 3: Modifiers
1. Was the procedure performed different from that described by the nomenclature of the code?
Ans: No
Feedback: The procedure performed was not different from that described by the nomenclature of the
code.
3. Was the procedure performed in the global period of another procedure?
Ans: No
Feedback: The procedure performed was not in the global period of another procedure.
5. Did the surgeon have help from another surgeon or another appropriate person?
Ans: No
Feedback: The surgeon did not have help from another surgeon or other appropriate person.
7. What modifier should be appended to the CPT code for this case?
Ans: A
Feedback: The modifier 50 should be appended to the CPT for this case to identify that the procedure was
performed bilaterally. 51 is incorrect because although the procedure was performed multiple times, it
was the same procedure performed on a bilateral site, so 50 more accurately describes the procedure. 59 is
reported in cases where a separate distinct procedure is performed in addition to another procedure.
However, the 59 modifier is the modifier of last resort and should not be reported if another more
appropriate modifier is available.
Case 2
Procedure performed: Extracapsular cataract extraction with intraocular lens insertion, right eye.
Ophthalmic microscope was used.
Preoperative diagnosis: Senile subcapsular polar cataract, posterior
Postoperative diagnosis: Senile sub capsular polar cataract, posterior
Local anesthesia was administered with lidocaine 2 percent with epinephrine for a lid block.
Retrobulbar anesthesia was administered using marcaine 0.75 percent with epinephrine and
lidocaine 4 percent. Patient was prepped and draped in the usual sterile ophthalmic fashion.
The eye was stabilized with a 4-0 black silk superior rectus traction suture and was subsequently
deflected downward. A scleral incision was made 2 mm superior to the superior limbus and
approximately 12 mm in length. The dissection was then carried posteriorly from the base of the
incision into clear cornea. A stab wound was made into clear cornea at 1 o’clock to provide an
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access, and a keratome was utilized to enter the anterior chamber through the base of the
corneoscleral wound at 10 o’clock.
Healon was injected into the anterior chamber through a cystitome needle. The needle was
subsequently used to create an anterior capsulotomy, and capsule forceps were utilized to affect a
circular tear capsulorrhexis capsulotomy. Balanced salt solution was injected underneath the
capsule to dissect the nucleus free from the capsule.
Using a lens loop and Colibri forceps, the nucleus was expressed through the wound. Two
interrupted 10-0 nylon sutures were then inserted through the corneoscleral wound, dividing the
wound into equal thirds.
Lens cortical material was irrigated and aspirated from the wound. Following this, the posterior
capsule was noted to be intact, and Healon was injected into the anterior chamber.
The previously selected intraocular lens was soaked in balanced salt solution. The lens was flushed
with fresh balanced salt solution and coated with Healon. Angled forceps were then used to insert
the lens through the scleral incision, with the inferior foot of the haptic passing beneath the anterior
capsule at 6 o’clock. Long-angled tying forceps were then used to place the superior foot of the
haptic through the pupil behind the anterior capsule at 12 o’clock. The lens was rotated to ensure
stability. 10-0 nylon interrupted sutures were placed to close the corneoscleral wound.
Process 1: CPT
1. What is the procedure?
Ans: Cataract extraction with intraocular lens insertion, extracapsular
Feedback: Cataract extraction with intraocular lens insertion, extracapsular is the procedure.
3. What additional questions or set of question can be determined?
Ans: What is the method of removal?
Feedback: The additional question that can be determined is: What is the method of removal?
5. Based on the documentation, what is the correct code for this case?
Ans: B
Feedback: Based upon the documentation, the correct code for this case is 66984, which describes the
extracapsular extraction of a cataractous lens with concurrent insertion of an IOL. 66982 describes a
complex cataract extraction which requires additional work or devices to open the iris, such as expansion
devices or sutures to enlarge and maintain the pupil’s opening during the procedure, which was not
documented in this case. 66983 describes an intracapsular cataract extraction, and the documentation
indicates an extracapsular extraction was performed. 66985 describes a secondary implant of an IOL, not
an extraction and concurrent implant of the IOL as is documented.
Process 2: ICD
ICD-9-CM
1. Based on the operative report header, what is the preoperative diagnosis?
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Ans: Senile subcapsular polar cataract, posterior
Feedback: Per the operative report header, the preoperative diagnosis is senile subcapsular polar cataract,
posterior.
3. Is the postoperative diagnosis supported?
Ans: Yes
Feedback: The postoperative diagnosis is supported.
5. Based on the subterm choices, what question(s) can be developed for this condition?
Ans: What is the location or type of cataract? Is the cataract due to an injury or underlying condition?
Feedback: Based upon the subterm choices, the following questions can be developed for this condition:
What is the location or type of cataract? Is the cataract due to an injury or underlying condition?
7. Is the additional condition, sign, or symptom an integral part of the primary (or other) condition
coded?
Ans: N/A
Feedback: N/A
9. Based on the documentation, what is the correct ICD-9-CM code(s) for this case?
Ans: D
Feedback: Based upon the documentation, the correct ICD-9-CM code for this case is 366.14, which
reports a senile posterior subcapsular polar cataract as is supported by the documentation. 743.31 reports
a congenital cataract, and the condition documented is a senile cataract. 366.17 reports a total or mature
cataract. 366.13 reports a senile anterior subcapsular polar cataract and the location documented is
posterior.
ICD-10-CM
1. Based on the operative report header, what is the preoperative diagnosis?
Ans: Senile subcapsular polar cataract, posterior
Feedback: Per the operative report header, the preoperative diagnosis is senile subcapsular polar cataract,
posterior.
3. Is the postoperative diagnosis supported?
Ans: Yes
Feedback: Yes, the postoperative diagnosis is supported.
5. Based on the subterm choices, what question(s) can be developed for this condition?
Ans: What is the underlying cause or type of the cataract? Where is the cataract located within the lens?
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Feedback: Based upon the subterm choices, the following questions can be developed for this condition:
What is the underlying cause or type of the cataract? Where is the cataract located within the lens?
7. Is any sign, symptom, or additional condition documented?
Ans: No
Feedback: No signs, symptoms, or additional conditions were documented.
9. Does the additional condition require or affect patient care, treatment, or management?
Ans: N/A
Feedback: N/A
Process 3: Modifiers
1. Was the procedure performed different from that described by the nomenclature of the code?
Ans: No
Feedback: The procedure performed was not different from that described by the nomenclature of the
code.
3. Was the procedure performed in the global period of another procedure?
Ans: No
Feedback: The procedure performed was not in the global period of another procedure.
5. Did the surgeon have help from another surgeon or another appropriate person?
Ans: No
Feedback: The surgeon did not have help from another surgeon or other appropriate person.
7. What modifier should be appended to the CPT code for this case?
Ans: Both RT and OD correctly identify the right eye. Reporting would depend upon payer discretion.
Feedback: Either of the modifiers RT or OD should be appended to the CPT for this case. Both RT and
OD correctly identify the right eye. Reporting would depend upon payer discretion. 50 reports a bilateral
procedure; although the anatomic site has laterality, the procedure was performed only on the right side.
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Chapter 18 – Radiology Section
Exercise 18.1
1. The documentation states that the patient ingested the contrast material before the CT study
was performed. Would this CT study be reported as with or without contrast?
Ans: Without contrast, since the guidelines state oral contrast is not considered with contrast.
Feedback: The guidelines state that oral and/or rectal contact is not with contrast, so this would be
reported as without contrast.
3. Why is it important that the medical documentation state the number of views?
Ans: Many of the codes are very specific as to the minimum number of views needed to be performed and
documented in order to assign the code.
Feedback: Many of the code descriptions within the Radiology subsection specify a minimum number of
views. For example: 71020 Chest x-ray, two views.
5. When the findings on a chest x-ray are normal, what should the coder look for in the report to
use as the diagnosis for ICD coding?
Ans: Any signs or symptoms that are indications for the ordering of the chest x-ray.
Feedback: When a diagnosis has not been confirmed or the radiology report is documented as normal,
signs and symptoms should be reported.
Exercise 18.2
1. What is the difference between a CT scan and a CTA?
Ans: CT scans are used to visualize and study the structure of an organ, whereas a CTA is used to
visualize and study the vessels (arteries or veins).
Feedback: CT scans are used to visualize and study the structure of an organ, whereas a CTA is used to
visualize and study the vessels (arteries or veins).
3. What range of codes would be appropriate for cardiac computed tomography of the heart?
Ans: 75571-75574
Feedback: Computed tomography, thorax, 71250–71260 (An instructional note below this code range
directs the coder to code range 75571–75574 for cardiac CT of the heart.)
Exercise 18.3
1. What is the definition of a real-time scan?
Ans: A real-time scan is a two-dimensional ultrasonic scanning procedure with display of both twodimensional structure and motion with time.
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126
Feedback: Ultrasound procedures are defined as A-mode, M-mode, B-scan, and real-time scan. The
definitions are located in the guidelines before the code ranges for this subsection, Diagnostic Ultrasound
(76506–76999).
3. How does the CPT manual define a complete ultrasound of an extremity?
Ans: Real time scan of a specific joint that includes examination of the muscles, tendons, joint, other soft
tissue structures and any identifiable abnormality.
Feedback: The guidelines before this code range define a complete ultrasound of an extremity and a
limited ultrasound of an extremity.
5. What would be the appropriate code for an MRI of both breasts with contrast?
Ans: 77059
Feedback: N/A
Exercise 18.4
1. A dual energy x-ray absorptiometry (DXA) is documented as being performed on the hips and
spine. Which skeleton is being examined, and what is the appropriate code?
Ans: Axial; CPT Code 77080
Feedback: N/A
3. What is the appropriate CPT code for intraoperative radiation treatment management?
Ans: 77469
Feedback: N/A
Exercise 18.5
1. How can radioactive materials be administered to a patient?
Ans: ingestion, injection, or inhalation
Feedback: Nuclear medicine studies involve the diagnostic and therapeutic use of radioactive materials.
Examples of radioactive materials used to perform these studies are Xenon, DTP, technetium, iodine,
cardiolite, and thallium. These materials are administered by ingestion, injection, or inhalation.
3. Explain the difference between diagnostic and therapeutic nuclear medicine studies.
Ans: Diagnostic nuclear medicine studies establish or confirm a diagnosis. Therapeutic nuclear medicine
studies provide relief by the use of a radioactive material.
Feedback: Diagnostic nuclear medicine studies establish or confirm a diagnosis. Some examples of
diagnostic nuclear medicine studies are bone scans, lung scans, thyroid scans and uptakes, renal imaging,
SPECT, and PET studies. Therapeutic nuclear medicine studies provide relief by the use of a radioactive
material. Two examples are radioactive iodine for patients with hyperthyroidism (Graves’ disease) and
strontium (Metastron) for cancer patients.
Exercise 18.6
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1. What is the appropriate modifier to use when less than the minimum number of views is taken
and there is not a specific code for the lower number of views?
Ans: 52
Feedback: Modifier 52 indicates reduced services; less than the minimum number of views was
performed.
3. If a one view chest x-ray, CPT code 71010, is performed twice on the same day by the same
physician, which modifier would be attached to the second x-ray?
Ans: 76
Feedback: Modifier 76 indicates repeat procedure or service by the same physician or other qualified
health care professional. Example: A two-view chest x-ray (71020) is interpreted by physician A at 8
a.m., and another two-view chest x-ray (71020) is interpreted by the same physician later the same day.
Exercise 18.7
1. The radiology report finding states that there is an excess of fluid in the peritoneal cavity. What
term would the coder look for in the alphabetic index of ICD?
Ans: Ascites
Feedback: An accumulation of excess fluid in the peritoneal cavity is signified by the term ascites.
3. Describe a SPECT study?
Ans: SPECT = single photon emission computed tomography. It is a nuclear medicine study in which
images are produced in multiple dimensions in order to diagnose an abnormality within an area.
Feedback: A SPECT (single photon emission computed tomography) study is a nuclear medicine study in
which images are produced in multiple dimensions in order to diagnose an abnormality within the area.
Chapter 18 Review
Using Terminology
1.
A
Computed tomography
9.
E
Nuclear medicine
3.
G
Diagnostic study
11.
I
Radiopharmaceutical
5.
K
Extension
13.
J
Supination
7.
B
Fluoroscopy
Feedback: N/A
Checking your Understanding
1. George Smith was admitted for 3 days for interstitial application of six radioelement solution
ribbons into his prostate for treatment of his prostate cancer by the therapeutic radiologist, who
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128
also was saw the patient each day of his admission. Select the appropriate CPT and ICD-9-CM
codes:
Ans: D. 77777, 185
Feedback: 77777 is interstitial radiation source application, intermediate. The CPT manual defines
intermediate as five to ten sources/ribbons. This is brachytherapy and the guidelines inform the coder that
the hospital admission and daily visits are included in the code and not reported separately. ICD-9-CM
code 185 is the correct code for prostate cancer.
3. Betty presented for needle placement via ultrasound guidance for biopsy of two breast masses.
Select the appropriate supervision and interpretation codes:
Ans: A. 76942, 611.72
Feedback: 76942 is the code for ultrasonic guidance for needle placement (e.g., biopsy, aspiration,
injection, and localization device), imaging, supervision and interpretation. The diagnosis has not been
clarified at this time; therefore, billing for the breast mass is the more appropriate diagnosis.
5. A morbidly obese male, age 46, is seen for increasing pain in his knees, which is affecting his
mobility. The physician orders a bilateral x-ray of the knees, with the patient standing as part of the
workup. The x-ray report indicates bilateral osteoarthritis. Select the appropriate CPT and ICD-9CM codes:
Ans: D. 73565, 715.36
Feedback: Code 73565 description is radiologic, examination, knee; both knees standing, anteroposterior.
ICD-9-CM code 715.36 is the correct code since the report indicated osteoarthritis of the knees. The knee
pain would not be reported since it is an integral part of the osteoarthritis.
7. An ultrasound of a pregnant uterus, real time with image documentation, fetal and maternal
evaluation, second trimester, in a female carrying twins was performed. Select the appropriate
code(s) for this procedure:
Ans: C. 76805, 76810
Feedback: Both codes are needed: 76805 for the first gestation and 76810 for the second; as this is the
second trimester, the pairing is correct.
9. A 30-year-old male presents with flank pain and gross hematuria. The physician orders a CT of
the abdomen and pelvis without contrast followed by contrast in the pelvis. Select the appropriate
CPT code for the radiologist’s supervision and interpretation.
Ans: C. 74178-26
Feedback: Codes 72194 and 72193 are incorrect since the question said to code for the supervision and
interpretation, which means the code would need a modifier 26 appended. The description for 74178 is
computed tomography, abdomen and pelvis, without contrast material in one of both body regions,
followed by contrast material(s) and further sections in one or both body regions.
Applying your Knowledge
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Case Study
Indication: Right upper-quadrant abdominal pain
Procedure: Gallbladder ultrasound
There is a cyst in the left hepatic lobe. The liver is otherwise unremarkable. There is no biliary
ductal dilation. There is no abdominal ascites. There are multiple gallstones noted within the
gallbladder. There are no abnormalities in the visualized portions of the abdominal aorta or
pancreas. The spleen does not appear enlarged. The right kidney contains a 4-cm cyst. The left
kidney appears normal.
Impression:
1. Hepatic cyst
2. 4-cm kidney cyst
3. Cholelithiasis
Process 1: CPT
1. What is the procedure?
Ans: gallbladder ultrasound
Feedback: Gallbladder ultrasound is the procedure.
3. What additional questions or set of question can be determined?
Ans: anatomic site?
Feedback: The additional question topic is: anatomic site (answer: abdomen).
5. Based on the documentation, what is the correct code for this case?
Ans: A
Feedback: Based upon the documentation, the correct code for this case is 76700-26, Complete abdominal
ultrasound. Everything that needed to be documented for a complete abdominal ultrasound is in the
report. 76770 and 76775 are codes for retroperitoneal ultrasounds.
Process 2: ICD
ICD-9-CM
1. Based on the operative report header, what is the preexamination diagnosis?
Ans: Right upper quadrant pain
Feedback: Per the operative report header, the preoperative diagnosis is Right upper quadrant pain.
3. Is the postexamination diagnosis supported?
Ans: Yes
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130
Feedback: Yes, the postoperative diagnosis is supported.
5. Based on the subterm choices, what question(s) can be developed for this condition?
Ans: Cysts: Are they congenital or acquired, multiple or single? Cholelithiasis: Is it with or without
cholecystis? acute or chronic?
Feedback: Based upon the subterm choices, the following questions can be developed for this condition:
Cysts: Are they congenital or acquired, multiple or single? Cholelithiasis: Is it with or without
cholecystis? acute or chronic?
7. Is the additional condition, sign, or symptom an integral part of the primary (or other) condition
coded?
Ans: Yes
Feedback: Yes, the additional condition, sign, or symptom is an integral part of the primary (or other)
condition coded.
9. Based on the documentation, what are the correct ICD-9-CM codes for this case?
Ans: C
Feedback: Based upon the documentation, the correct ICD-9-CM codes for this case are 573.8, 593.2, and
574.20.
ICD-10-CM
1. Based on the operative report header, what is the preexamination diagnosis?
Ans: Right upper quadrant pain
Feedback: Per the operative report header, the preoperative diagnosis is Right upper quadrant pain.
3. Is the postexamination diagnosis supported?
Ans: Yes
Feedback: Yes, the postoperative diagnosis is supported.
5. Based on the subterm choices, what question(s) can be developed for this condition?
Ans: Cysts: Are they congenital or acquired, multiple or single? Cholelithiasis: Is it with or without
cholecystis? acute or chronic?
Feedback: Based upon the subterm choices, the following questions can be developed for this condition:
Cysts: Are they congenital or acquired, multiple or single? Cholelithiasis: Is it with or without
cholecystis? acute or chronic?
7. Is any sign, symptom, or additional condition documented?
Ans: yes, abdominal pain
Feedback: Yes, the signs, symptoms, or additional conditions (abdominal pain) are documented.
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9. Does the additional condition require or affect patient care, treatment, or management?
Ans: no
Feedback: The additional condition does not require or affect patient care, treatment, or management.
Process 3: Modifiers
1. Was the procedure performed different then as described by the nomenclature of the code?
Ans: No
Feedback: The procedure performed was not different from that described by the nomenclature of the
code.
3. Was the procedure performed in the global period of another procedure?
Ans: No
Feedback: The procedure performed was not in the global period of another procedure.
5. Did the surgeon have help from another surgeon or other appropriate person?
Ans: No
Feedback: The surgeon did not have help from another surgeon or other appropriate person.
7. What modifier should be appended to the CPT for this case?
Ans: B
Feedback: The modifier 26 (professional component) should be appended to the CPT code for this case.
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132
Chapter 19 – Pathology/Laboratory
Exercise 19.1
1. What are the four sections of the neoplasm table?
Ans: Malignant (primary, secondary, carcinoma in situ), Benign, Uncertain Behavior, Unspecified
Behavior
Feedback: The neoplasm table in the ICD is divided into four sections: Malignant (primary, secondary,
carcinoma in situ), Benign, Uncertain Behavior, and Unspecified Behavior.
3. What is an indicator?
Ans: An indicator is a laboratory tests in which, if a positive result occurs, an additional test would be
then be done as a follow-up.
Feedback: With some laboratory tests, if a positive result occurs, an additional test is then done as a
follow-up. These tests are called indicators and allow for additional tests without the written order of a
physician. This additional testing is reported separately since the initial results need additional testing to
add to the clinical value of the results.
Exercise 19.2
1. Explain the difference between qualitative and quantitative analyses.
Ans: Qualitative analysis measures the presence of a drug. Quantitative analysis measures the amount of
the drug present.
Feedback: Qualitative analysis is the laboratory procedure that identifies the presence of a drug.
Quantitative analysis is the laboratory procedure that measures the amount of a drug present.
3. What is the difference between a limited clinical pathology consultation and a comprehensive
one?
Ans: Limited: without review patient’s history and medical record. Comprehensive: complex diagnostic
problem with review of history and medical record.
Feedback: The reporting of only the test results is not enough to justify the use of a clinical pathology
code. The codes are further defined as to the level:
Limited: without review of the patient’s history and medical record (80500)
Comprehensive: complex diagnostic problem with review of history and medical record (80502)
Exercise 19.3
1. Which code range and subheading include codes for reporting blood banking?
Ans: Codes used to report blood banking, CPT codes 86077-86079, are found in the Immunology
subheading.
Feedback: N/A
3. Which type of laboratory tests is reported with codes from the range 86000-86849?
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133
Ans: Immunology, which is the study of the immune system. Codes within this code range report tests
used to identify immune system conditions caused by antibodies and antigens.
Feedback: Codes in the range of 86000-86849 are used to report immunology tests. Immunology is the
study of the immune system. Codes within this code range report tests used to identify immune system
conditions caused by antibodies and antigens. An antigen is a foreign substance that produces antibodies
that fight infection and disease. The tests in this section are mostly qualitative or semiquantitative unless
otherwise indicated.
Exercise 19.4
1. Codes within the anatomic pathology range are used to report postmortem examinations, that is,
necropsies (autopsies). How are they further defined?
Ans: They are further defined based on the following:
- The extent and type of exam, gross versus gross and microscopic
- Whether the examination is without the CNS, with the brain, with brain and spinal cord
- Whether the exam is a forensic examination, which is used for legal evidence
Feedback: An instructional note with the range of Anatomic Pathology codes (88000-88099) states that
these codes represent physician services only. It also instructs the use of modifier 90 for outside
laboratory services. These codes are for reporting postmortem examinations, that is, necropsies
(autopsies). They are further divided as to: The extent and type of exam (gross versus gross and
microscopic); whether the examination is without the CNS, with the brain, or with the brain and spinal
cord; and whether the exam is a forensic examination (used for legal evidence).
3. Gross and microscopic evaluation of a pituitary tumor with first tissue block, frozen tissue is
documented. What would be the appropriate code(s)?
Ans: 88305, 88331
Feedback: N/A
Exercise 19.5
1. The patient has two tests performed on the same day that were ordered by the physician and not
performed because of equipment malfunction. Which modifier would be appropriate to use?
Ans: Modifier 91
Feedback: Modifier 91, which indicates repeat clinical diagnostic laboratory test.
Exercise 19.6
1. Define specimen, block, and section.
Ans: A specimen is the unit submitted for evaluation, the block is a piece cut from the specimen to be
frozen, and a section is a further division of the block.
Feedback: Specimen is a unit submitted for evaluation, such as chemical, pathologic, or hematological.
Block is portion of a tissue obtained from a specimen. Section is a further division of the block.
3. Pap smears are the most common test reported with codes under what subheading?
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134
Ans: Cytopathology
Feedback: Pap smears are the most common test reported with codes in the subheading Cytopathology.
Chapter 19 Review
Using Terminology
1.
B
Block
9.
L
Molecular pathology
3.
C
Coagulation
11.
D
Organ Panel
5.
F
Cytopathology
13.
A
Qualitative
7.
J
Immunology
Feedback: N/A
Checking your Understanding
1. A 14-year-old boy has been suspended from school for allegations that he is using marijuana and
performing poorly in school as a result. The physician orders a urine drug screen to determine
whether the boy has used marijuana on this occasion. Select the appropriate CPT code:
Ans: B. 80101
Feedback: CPT code 80101 is for single drug class.
3. Clinical information: Cysts, right neck and chest
Specimen submitted:
1. Cyst, right neck
2. Cyst, right chest
Gross description:
1. Received, labeled with the patient’s name and “right neck cyst” is a skin ellipse
measuring 2.8 x 1.0 x 1.4 cm. The epithelial surface appears relatively unremarkable. A
subepidermal soft white nodule is identified and sampled in one cassette.
2. Received, labeled with the patient’s name and “right chest cyst” is an ellipse of skin and
subcutaneous tissue measuring 2.8 x 1.8 x 1.5 cm. On cut section, there is subepidermal
white nodular cystic structure present.
Microscopic and final diagnosis:
1. Cyst, right neck, excision. Epidermoid cyst.
2. Cyst, right chest, excision. Epidermoid cyst.
Select the appropriate CPT codes:
Ans: B. 88304 x 2, 706.2
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135
Feedback: Two separate specimens were submitted; therefore, 88304 would be reported twice, and the
cysts are not coded as benign neoplasms.
5. Sally had her first prenatal visit yesterday and presents at the laboratory today with an order for
a CBC w/differential, blood typing, RH typing, antibody screen, syphilis, rubella antibody, hepatitis
B surface antigen, alphafetoprotein, and urinalysis. Select the appropriate CPT code(s):
Ans: C. 80055, 82105, 81000
Feedback: All tests with the exception of the alphafetoprotein and urinalysis are included in the obstetric
panel 80055 and would not be coded separately.
7. Mr. Green was DOA of unknown causes in the ED. A complete autopsy, including brain and
spinal cord, was performed, followed by the appropriate microscopic examinations of the tissue to
determine his cause of death. Select the appropriate CPT code:
Ans: B. 88027
Feedback: 88027 correctly describes necropsy (autopsy), gross and microscopic with brain and spinal
cord. 88007 is for gross examination only. 88045 is for necropsy, forensic examination, coroner’s call.
88025 is for brain only, and this autopsy included the brain and spinal cord.
9. The patient presented in the ED complaining of nausea, vomiting, and diarrhea and is now
demonstrating epigastria pain and dehydration. The ED physician ordered the following tests:
basic metabolic panel with ionized calcium, CBC with automated differential, and urinalysis. Select
the appropriate ICD-9-CM and CPT codes for this encounter:
Ans: A. 80047, 85025, 81000, 787.01, 787.91, 789.06, 276.51
Feedback: 80047 is the basic metabolic panel, which included ionized calcium in the description; 85025 is
for the complete automated CBC with automated differential; 787.01 is the ICD-9-CM code for nausea
with vomiting (the codes for nausea alone and vomiting alone would not be coded since there is a
combination code); and in 789.06, the fifth digit “6” shows the location as epigastric.
Applying your Knowledge
Case Study
Specimen: Cervix, uterus, bilateral tubes, and ovaries
Gross: The specimen received consists of a pear-shaped uterus, attached ovaries, and fallopian
tubes. The uterus weighs 130 g and measures 9 x 5 x 4.2 cm. The external surface is smooth.
There is a small nodule protruding through the serosal surface. On cut section, the ectocervix is
smooth. The endocervical canal is patent. The endometrial cavity is pyramidal in shape and lined
by 0.4-cm endometrium. Serial sectioning shows four additional nodules ranging in diameter from
0.2 to 0.3 cm.
Specimen:
A. Cervix
B. Endomyometrium and nodules
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136
C. Right ovary, measuring 5 x 1.7 x 1.3 cm. Several subcapsular cysts are present. Adjacent
fallopian tube measures 7 cm in length by 0.5 cm in diameter. Sections of the fallopian tube are
unremarkable.
D. Left ovary measuring 5.2 x 2.1 x 2 cm. There are also several small cysts present in the left
ovary. The adjacent fallopian tube measures 8.2 cm in length and 0.6 in diameter. The section is
unremarkable.
Microscopic: Chronic inflammation of the uterine cervix revealed in specimen A.
Endometrium of proliferative histology revealed in sections of specimen B.
Sections of specimens C and D show sections of ovaries with follicular cysts and serosal adhesions.
Sections of fallopian tubes are unremarkable
Diagnoses: Endometrium of proliferative histology.
Follicular cysts and serosal adhesions of ovaries.
Fallopian tubes, unremarkable.
Chronic cervicitis.
Process 1: CPT
1. What is the procedure?
Ans: Surgical pathology, gross and microscopic
Feedback: Surgical pathology, gross and microscopic is the procedure.
3. What additional questions or set of question can be determined?
Ans: Was the pathology surgical or clinical? What is the type of surgical pathology exam?
Feedback: The additional questions are as follows: Was the pathology surgical or clinical? What is the
type of surgical pathology exam?
5. Based on the documentation, what is (are) the correct code(s) for this case?
Ans: C
Feedback: Based upon the documentation, the correct code for this case is 88307, which correctly reports
gross and microscopic pathologic examination of the female reproductive system for nonneoplastic or
prolapse reasons. 88305 reports gross and microscopic pathologic exam of the female reproductive
system, but for prolapse, which is not indicated in the documentation. Reporting 88305 for gross and
microscopic pathologic exam of the cervix separately would be incorrect as the cervix removed with the
uterus is consider part of the female reproductive system. Also, 88305 reports pathology for a biopsy of
the cervix and not removal and examination of the entire cervix. 88307 reports gross and microscopic
pathologic exam of the female reproductive system for neoplastic conditions.
Process 2: ICD
ICD-9-CM
1. Based on the report header, what is the preexamination indication/diagnosis?
Ans: None listed
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137
Feedback: Per the report header, there is no pre-examination indication/diagnosis listed.
3. Is the postexamination diagnosis supported?
Ans: Yes
Feedback: Yes, the post-examination diagnosis is supported.
5. Based on the subterm choices, what question(s) can be developed for this condition?
Ans: Is the condition following or due to another condition? What is the location or type of cyst?
Feedback: Based upon the subterm choices, the following questions can be developed for this condition:
Is the condition following or due to another condition? What is the location or type of cyst?
7. Is the additional condition, sign, or symptom an integral part of the primary (or other) condition
coded?
Ans: No; however, as an incidental finding, the documentation does not support a specific diagnosis.
Feedback: No, the additional condition, sign, or symptom was not an integral part of the primary (or
other) condition coded. However, as an incidental finding, the documentation does not support a specific
diagnosis.
9. Based on the documentation, what are the correct ICD-9-CM codes for this case?
Ans: B
Feedback: Based upon the documentation, the correct ICD-9-CM codes for this case are 616.0 and 620.0.
This code combination reports both the cervicitis and the follicular cyst of the ovary. Although an
incidental finding, the statement of endometrial proliferative histology does not indicate endometriosis of
the uterus; therefore, the other answer choices (which include 617.0 endometriosis of uterus) are
incorrect.
ICD-10-CM
1. Based on the report header, what is the preexamination indication/diagnosis?
Ans: None listed
Feedback: Per the report header, there is no pre-examination indication/diagnosis.
3. Is the postexamination diagnosis supported?
Ans: Yes
Feedback: Yes, the post-examination diagnosis is supported.
5. Based on the subterm choices, what question(s) can be developed for this condition?
Ans: Is the condition with or due to another condition? What is the anatomic location or type of cyst?
Feedback: Based upon the subterm choices, the following questions can be developed for this condition:
Is the condition with or due to another condition? What is the anatomic location or type of the cyst?
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138
7. Is any sign, symptom, or additional condition documented?
Ans: Yes: Endometrium of proliferative histology
Feedback: Yes, the signs, symptoms, or additional conditions (Endometrium of proliferative histology)
were documented.
9. Does the additional condition require or affect patient care, treatment, or management?
Ans: No
Feedback: The additional condition does not require or affect patient care, treatment, or management.
Process 3: Modifiers
1. Was the procedure performed different from that described by the nomenclature of the code?
Ans: Yes: professional component only
Feedback: Yes, the procedure performed was different from that described by the nomenclature of the
code: professional component only.
3. Was the procedure performed in the global period of another procedure?
Ans: N/A
Feedback: N/A
5. Did the surgeon have help from another surgeon or another appropriate person?
Ans: N/A
Feedback: N/A
7. What modifier should be appended to the CPT code for this case?
Ans: A
Feedback: Modifier 26 should be appended to the CPT code for this case (the services being reported are
the professional component only). Modifier 58 reports a staged procedure or service, which is not
reflected in the documentation and is not appropriate for this examination. Modifier 51 is not appropriate
as multiple procedures were not performed during this examination.
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139
Chapter 20 – Medicine Section
Exercise 20.1
1. In the Vaccine, Toxoid subsection, what does the lightning bolt symbol before code indicate to the
coder?
Ans: The lightning bolt before a code means that the code for that particular vaccine was published prior
to FDA approval.
Feedback: The lightning bolt symbol means that the code has been published prior to the drug being
approved by the Federal Food and Drug Administration. The symbol will be removed once there is
approval.
3. To accurately code for end-stage renal disease services, what questions must coders find answers
to in the medical record?
Ans: What is the age of the patient?
What was the number of face-to-face visits per month?
Were the services provided in the home?
Were the services less than a full month of services?
Feedback: To accurately code from this subheading, coders must find answers in the medical record to the
following questions: 1) What is the age of the patient? 2) What is the number of face-to-face visits per
month? 3) Were the services provided in the home? 4) Were the services less than a full month of
services?
Exercise 20.2
1. During comprehensive or intermediate ophthalmologic exams, additional services may be
provided that are not a normal part of these exams. Identify some of these services.
Ans: These services include examination under anesthesia, gonioscopy (glaucoma), fitting of contact lens
for treatment of disease (keratoconus, ocular surface diseases), retinal and optic nerve scans, retinal
imaging and mapping, and angioscopy.
Feedback: Additional services may be provided during comprehensive or intermediate ophthalmologic
exams that are not a normal part of these exams. These services include examination under anesthesia,
gonioscopy (glaucoma), fitting of contact lens for treatment of disease (keratoconus, ocular surface
diseases), retinal and optic nerve scans, retinal imaging and mapping, and angioscopy.
3. What is included in the cardiac catheterization codes that should not be reported separately?
Ans: The coding guidelines at the beginning of the Cardiac Catheterization subsection informs the coder
that the introduction, positioning and repositioning of catheters within the vascular system, recording of
intracardiac and intravascular pressure, and evaluation and report are included in the code descriptions for
cardiac catheterization .
Feedback: According to the coding guidelines at the beginning of the Cardiac Catheterization subsection,
the introduction, positioning and repositioning of catheters within the vascular system, the recording of
intracardiac and intravascular pressure, and the evaluation and report are included in the code descriptions
for cardiac catheterization. These guidelines also specify what is included in a right heart catheterization
and a left heart catheterization.
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140
Exercise 20.3
1. Explain what nerve conduction studies measure.
Ans: Nerve conduction studies measure the time required for a signal to traverse the nerve pathway to and
from the muscle.
Feedback: Nerve conduction studies measure the time required for a signal to traverse the nerve pathway
to and from the muscle.
3. Define allergen immunotherapy.
Ans: Allergen immunotherapy involves injecting small doses of what the patient is allergic to and
increasing the amount of the dose over time to desensitize the patient to the substance over time.
Feedback: Allergen immunotherapy involves injecting small doses of what the patient is allergic to and
increasing the amount of the dose over time to gradually desensitize the patient to the substance.
Exercise 20.4
1. Define modality as used in physical medicine and rehabilitation.
Ans: Modalities are the application of an agent or device used to change tissues. Modalities include heat,
sound, light, and mechanical or electrical energy.
Feedback: Modalities are the application of an agent or device used to change tissues and include heat,
sound, light, and mechanical or electrical energy.
3. What services are included with infusion and injection procedures?
Ans: (1) Use of local anesthesia. (2) IV start. (3) Access to indwelling IV/subcutaneous catheter or port.
(4) Flush at conclusion of infusion. (5) Standard tubing, syringes, and supplies.
Feedback: The following services are included with infusion and injection procedures: (1) Use of local
anesthesia. (2) IV start. (3) Access to indwelling IV/subcutaneous catheter or port. (4) Flush at conclusion
of infusion. (5) Standard tubing, syringes, and supplies.
Exercise 20.5
1. A limited bilateral noninvasive physiologic study of both the upper- and lower-extremity arteries
during the same encounter was performed. Since both the upper and lower extremities were
studied, which modifier would need to be appended?
Ans: Modifier 59 would be appended.
Feedback: Modifier 59 would be appended to the second procedure. The instructional notes under CPT
code 93922 inform the coder that when both the upper and lower extremities are evaluated in the same
setting, 93922 may be reported twice by adding modifier 59 to the second procedure.
3. The patient was seen in the office for a vaccination and a separate evaluation and management
service. Which modifier should be appended to the evaluation and management code?
Ans: Modifier 25
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141
Feedback: Modifier 25 would be appended to the evaluation and management code when the patient was
seen in the office for a vaccination and a separate evaluation and management service.
Exercise 20.6
1. What type of ultrasound study is often performed to check for blockage of blood flow in an
extremity?
Ans: Duplex scan
Feedback: A duplex scan is a type of ultrasound study used to evaluate the flow of blood within arteries
and veins.
3. Explain photodynamic therapy
Ans: A photosensitizing agent is applied to a lesion such as an actinic keratosis, and the patient returns for
light treatment which activates the chemical agent in order to destroy the lesion.
Feedback: Photodynamic therapy is therapy in which a photosensitizing agent is applied to a lesion, such
as an actinic keratosis, and the patient returns for light treatment, which activates the chemical agent in
order to destroy the lesion.
Chapter 20 Review
Using Terminology
1.
E
Allergen immunotherapy
9.
D
Minimally invasive
3.
J
Hemodialysis
11.
C
Modalities
5.
K
Sensory Nerve Studies
13.
L
Peritoneal dialysis
7.
F
Intracutaneous
Feedback: N/A
Checking your Understanding
1. The patient undergoes an initial 2-D echocardiogram, including spectral Doppler and color flow,
to confirm a diagnosis of mitral valve stenosis with aortic insufficiency. Select the appropriate ICD9-CM and CPT codes:
Ans: A. 93306, 396.1
Feedback: 396.1 identifies the combined disorder of mitral valve stenosis with aortic valve insufficiency.
The initial ECHO is coded as 93306 since it includes the spectral Doppler and color flow.
3. A 35-year-old female patient presented for a psychiatric diagnostic evaluation which included a
history, mental stats exam, and recommendations. The evaluation and treatment plan were
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142
communicated to the family as the patient has requested their involvement in her case. Select the
appropriate CPT code:
Ans: B. 90791, 90785
Feedback: Be sure to read the guidelines with these codes (90791, 90785) as they are new to CPT 2013.
90785 is an add-on code, and the guidelines state this code may be used with 90791.
5. Barry has been diagnosed with intracranial stenosis within the arteries, and the physician has
ordered a complete bilateral transcranial Doppler study to determine the flow of blood of the right
and left circulation territories of the brain. Select the appropriate CPT code:
Ans: D. 93886
Feedback: Since arterial flow is managed on both sides of the skull, the correct code would be 93886 as
this is a complete study. 93880 is a duplex scan of extra cranial arteries, 93888 is a limited study, and
93890 is a vasoreactivity study.
7. A 60-year-old patient was in a car accident and arrived at the ED in a coma. Based on the
injuries, it was determined that his condition was terminal. An EEG was ordered for cerebral
death evaluation. Select the appropriate CPT code for this procedure:
Ans: C. 95824
Feedback: 95824 EEG for cerebral death evaluation only. 95822 is an EEG for recording in coma or sleep
only; 95829 is an electrocorticogram at surgery.
9. Beth, a 46-year-old female with breast cancer, presents today for her chemotherapy treatment.
An IV line was started, and an antiemetic was administered over 35 minutes; then the patient
received Cytoxan via IV infusion over 60 minutes, followed by a 1-hour infusion of Adriamycin.
Select the appropriate CPT codes for this encounter:
Ans: A. 96360, 96413, 96417
Feedback: 96360, 96413, 96417 includes the antiemetic, and according to the CPT manual, when two
sequential infusions up to one hour each are given, the correct sequencing is 96413 and 96417.
Applying your Knowledge
Case One
PREOPERATIVE DIAGNOSIS: Coronary artery disease
POSTOPERATIVE DIAGNOSIS: Two-vessel coronary disease with ejection fraction of 60 to 65
percent
PROCEDURES PREFORMED: Left heart catheterization, left ventriculogram, and coronary
angiography via the left femoral artery
INDICATIONS: This is an elderly male with palpitations with no significant chest discomfort and
no previous cardiac history. Echocardiogram showed cardiomyopathy, ejection fraction of 60
percent, with slow heart movement globally. A cardiac catheterization was recommended to
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143
determine the cause of his cardiomyopathy. Risks and benefits were explained, and informed
consent was obtained.
PROCEDURE: Patient was prepped and draped in a sterile manner, and the left groin was
anesthetized with 1 percent plain lidocaine. Entry into the right femoral artery was accomplished
by means of a single-wall puncture. A guidewire was inserted into the left femoral artery, and a
hemostatic sheath with its dilator was advanced over the guidewire into the left femoral artery.
The guidewire and dilator were removed, and the hemostatic sheath was flushed with normal
saline. A pigtail catheter was inserted with its guidewire and passed into the left ventricular
chamber. The pigtail catheter was connected to the injection system, and left ventricular pressures
were obtained.
Left ventriculogram was obtained. The catheter was removed, leaving the guidewire in place. The
left coronary catheter was advanced over the guidewire to the aortic root and left main coronary
artery; the guidewire was removed and the catheter connected to the injection system, and multiple
injections of the left coronary system were completed.
At this time the injection system was disengaged from the catheter, and the left coronary catheter
was removed, leaving the guidewire in place; a right coronary catheter was then advanced over the
guidewire up to the aortic root and attached to the injection system. The catheter was then placed
into the right coronary artery, and views were obtained.
The injection system was then disconnected from the catheter, and the catheters were removed.
FINDINGS:
The left heart systemic blood pressure was 128/72 and left ventricular end-diastolic pressure 20
mmHg.
Left ventriculogram demonstrated mild global hypokinesis with ejection fraction 60 to 65 percent.
There was no significant mitral regurgitation, and the aortic valve appeared normal.
The left anterior descending had 20 to 25 percent distal narrowing. The remainder of the left
anterior descending was free of focal stenosis. The left circumflex was found to have 30 percent
smooth, discrete narrowing in the proximal portion. The right coronary artery was found to be
free of narrowing or focal stenosis.
Process 1: CPT
1. What is the procedure?
Ans: Catheterization (Left heart catheterization with left ventriculogram and coronary angiography)
Feedback: The procedure is catheterization (Left heart catheterization with left ventriculogram and
coronary angiography).
3. What additional questions or set of question can be determined?
Ans: What is the anatomic site? Is the cardiac catheterization combined or of one side of the heart? What
side of the heart is being catheterized? Is the procedure diagnostic or therapeutic?
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144
Feedback: Additional questions that can be determined are: What is the anatomic site? Is the cardiac
catheterization combined or of one side of the heart? What side of the heart is being catheterized? Is the
procedure diagnostic or therapeutic?
5. Based on the documentation, what is (are) the correct code(s) for this case?
Ans: C
Feedback: 93452 and 93454 report left heart catheterization and ventriculography and at a separate
procedure coronary artery angiography. As CPT provides a combination code for these procedures when
performed during the same operative session, it would be incorrect to unbundle these procedures. 93458
reports a left heart catheterization with coronary angiography and is the correct code. 93563 reports
injection of contrast during a cardiac catheterization for congenital heart conditions and a congenital
condition is not documented in this case. (CAD) 93458 reports a left heart catheterization with coronary
angiography and is the correct code. 93462 reports access to the left heart through a transseptal puncture;
however, the patient’s heart was accessed via the femoral artery.
Process 2: ICD
ICD-9-CM
1. Based on the operative report header, what is the preoperative diagnosis?
Ans: Coronary artery disease (CAD)
Feedback: Per the operative report header, the preoperative diagnosis is Coronary artery disease (CAD).
3. Is the postoperative diagnosis supported?
Ans: Yes
Feedback: The postoperative diagnosis is supported.
5. Based on the subterm choices, what question(s) can be developed for this condition?
Ans: What is the anatomic location of the condition? Is it a native or grafted vessel? Is the condition due
to another condition?
Feedback: Based upon the subterm choices, the following questions can be developed for this condition:
What is the anatomic location of the condition? Is it a native or grafted vessel? Is the condition due to
another condition?
7. Is the additional condition, sign, or symptom an integral part of the primary (or other) condition
coded?
Ans: No; slow movement of the muscle of the heart is due to and a sign the ischemia is due to the CAD.
Feedback: Slow movement of the muscle of the heart is due to and a sign the ischemia due to the CAD.
9. Based on the documentation, what is (are) the correct ICD-9-CM code(s) for this case?
Ans: B
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145
Feedback: Based upon the documentation the correct ICD-9-CM code for this case is 414.01, which
reports coronary atherosclerosis of a native vessel. We know this is a native vessel (vessel patient is born
with) due to the surgeon’s statement “…no previous cardiac history…”. 414.00 reports coronary
atherosclerosis of an unknown vessel (native or graft), but the documentation supports CAD of a native
vessel. 414.00 correctly reports CAD of a native vessel. 414.8 reports myocardial ischemia which is
present; however, this code is only reported in chronic ischemic heart disease which is not documented.
414.01 and 414.8 do not report CAD of a native coronary vessel.
ICD-10-CM
1. Based on the operative report header, what is the preoperative diagnosis?
Ans: Coronary artery disease (CAD)
Feedback: Per the operative report header, the preoperative diagnosis is Coronary artery disease (CAD).
3. Is the postoperative diagnosis supported?
Ans: Yes
Feedback: The postoperative diagnosis is supported.
5. Based on the subterm choices, what question(s) can be developed for this condition?
Ans: What is the anatomic site? Is the condition in a graft, native or autologous vessel?
Feedback: Based upon the subterm choices, the following questions can be developed for this condition:
What is the anatomic site? Is the condition in a graft, native or autologous vessel?
7. Is any sign, symptom, or additional condition documented?
Ans: Yes, hypokinesis
Feedback: Hypokinesis was documented as a sign, symptom, or additional condition.
9. Does the additional condition require or affect patient care, treatment, or management?
Ans: No
Feedback: The additional condition does not require or affect patient care, treatment, or management.
Process 3: Modifiers
1. Was the procedure performed different from that described by the nomenclature of the code?
Ans: No
Feedback: The procedure performed was not different from that described by the nomenclature of the
code.
3. Was the procedure performed in the global period of another procedure?
Ans: No
Feedback: The procedure was not performed in the global period of another procedure.
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146
5. Did the surgeon have help from another surgeon or another appropriate person?
Ans: No
Feedback: The surgeon did not have help from another surgeon or other appropriate person.
7. What modifier(s) should be appended to the CPT code for this case?
Ans: D
Feedback: No modifier should be appended to the CPT code for this case. Modifiers 59 and 51 would
only be appropriate in cases where more than one CPT code is reported. LD, LC, and RC do identify the
correct vessels imaged; however, the vessel does not need to be identified by a modifier as no procedures
were performed on any of these vessels. Also, as the CPT code description includes any and all coronary
arteries the vessel(s) imaged do not need to be identified.
Case Two
The patient returns for follow-up ocular examination 1 year after cataract surgery of the left eye.
The exam shows best acuity of 20/400 secondary to macular degenerative changes. Her pupils are
normal; her pressures are 10. There is a small hemorrhage just inferior to the fovea in the left
macula. The remainder of the ocular exam is unremarkable.
Diagnosis: No new ocular changes or disease of note apart from a right lower-lid marginal
chalazion.
The patient was instructed to use a warm compress on the right lower lid chalazion. There are no
other ocular concerns at present. Unfortunately, no treatment is available that would restore her
acuity given her current retinal findings. She should continue to be examined periodically to make
sure no other ocular disease develops.
Process 1: CPT
1. What is the procedure?
Ans: Ocular examination, follow-up
Feedback: The procedure is ocular examination, follow-up.
3. What additional questions or set of question can be determined?
Ans: What is the reason for or type of examination? Where screenings provided? Is the patient new or
established? Was the exam done under anesthesia?
Feedback: The following additional questions can be determined: What is the reason for or type of
examination? Where screenings provided? Is the patient new or established? Was the exam done under
anesthesia?
5. Based on the documentation, what is the correct code for this case?
Ans: C
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147
Feedback: Based upon the documentation, the correct code for this case is 92012; it reports an
intermediate ophthalmological exam of an established patient. An intermediate exam is typically a more
limited exam focusing on a particular condition or problem such as an acute condition which does not
require a complete examination of the visual system.
92002 and 92004 report ophthalmic examinations for new patients, and the documentation identifies this
patient as a returning (established) patient. 92014 reports a comprehensive ophthalmic exam, which
requires a general exam of the complete visual system, which was not provided during this exam.
Process 2: ICD
ICD-9-CM
1. Based on the documentation, what is the diagnosis or reason(s) for the encounter?
Ans: Macular degeneration
Feedback: Per the documentation, the diagnosis or reason for the encounter is Macular degeneration (as
the focus of treatment becomes the macular degeneration, this becomes the main term).
3. Based on the subterm choices, what question(s) can be developed for this condition?
Ans: What is the anatomic site? What is the nature, cause or type of degeneration?
Feedback: Based upon the subterm choices, the following questions can be developed for this condition:
What is the anatomic site? What is the nature, cause or type of degeneration?
5. Is the additional condition, sign, or symptom an integral part of the primary (or other) condition
coded?
Ans: No
Feedback: The additional condition, sign, or symptom is not an integral part of the primary (or other)
condition coded.
7. Based on the documentation, what is (are) the correct ICD-9-CM code(s) for this case?
Ans: D
Feedback: Based upon the documentation, the correct ICD-9-CM codes for this case are 362.50, 373.2,
and V43.1. Although the patient was scheduled for a follow-up exam for a previous cataract surgery, the
focus of the encounter became the macular degeneration (362.50) and chalazion (373.2), and these should
be coded first before the reason for follow up, pseudophakos (V43.1). ICD Section IV guidelines (H)
clearly state to list first the code for the condition shown in the documentation to be chiefly responsible
for the services provided. V72.0 reports a routine examination of the eyes; however, the examination in
this encounter was documented as a follow up with another condition found during the examination, and,
therefore, not a routine or preventive exam of the eyes.
ICD-10-CM
1. Based on the documentation, what is the diagnosis or reason(s) for the encounter?
Ans: Macular degeneration
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148
Feedback: Per the documentation, the diagnosis or reason for the encounter is Macular degeneration (as
the focus of treatment becomes the macular degeneration, this becomes the main term).
3. Based on the subterm choices, what question(s) can be developed for this condition?
Ans: What is the anatomic site? What is the nature, cause or type of degeneration?
Feedback: Based upon the subterm choices, the following questions can be developed for this condition:
What is the anatomic site? What is the nature, cause or type of degeneration?
5. Is any sign, symptom, or additional condition documented?
Ans: Yes, chalazion and pseudophakos (prosthetic lens)
Feedback: Chalazion and pseudophakos (prosthetic lens) were also documented.
7. Does the additional condition require or affect patient care, treatment, or management?
Ans: Yes, warm compresses for chalazion.
Feedback: The additional condition does require or affect patient care, treatment, or management: warm
compresses are required for chalazion.
Process 3: Modifiers
1. Was the service performed different from that described by the nomenclature of the code?
Ans: No
Feedback: The service performed was not different from that described by the nomenclature of the code.
3. Was the service performed in the global period of another procedure?
Ans: No
Feedback: The service was not performed in the global period of another procedure.
5. Did the surgeon have help from another surgeon oran other appropriate person?
Ans: N/A
Feedback: N/A
7. What modifier should be appended to the CPT code for this case?
Ans: D
Feedback: No modifier should be appended to the CPT code for this case. Modifier 52 would be reported
for an eye exam when only one eye is examined (CPT code 92002 -92014 is inherently bilateral). The
documentation in this case clearly shows that both eyes were examined. Modifier E4 identifies the right
lower eyelid, and modifier LT in this case would identify the left eye. Use of these modifiers would be
incorrect as no procedure was performed on either eye which would require identification of the eye or
eyelid.
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149
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distribution in any manner. This document may not be copied, scanned, duplicated, forwarded, distributed, or posted on a
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150
Chapter 21 – HCPCS Level II: Category II and Category III Codes
Exercise 21.1
1. Define the acronym HCPCS and identify the specific code levels.
Ans: Healthcare Common Procedure Coding System; Level I is CPT codes and Level II is the national
codes.
Feedback: The Healthcare Common Procedure Coding System, which is more commonly termed
HCPCS, consists of two levels. Level I comprises the Current Procedural Terminology (CPT) codes, and
Level II comprises the national codes.
3. Explain the criteria for determining whether to use a Level I or Level II code.
Ans: If a Level I (CPT) and a Level II code description are identical, the CPT code should be used unless
otherwise indicated by Medicare or another payer. If the Level I and Level II codes are not identical and
the Level II code is more specific, the Level II code is to be reported.
Feedback: To determine whether it is appropriate to use a HCPCS Level I or Level II code, coders need to
determine certain factors or criteria and follow these rules: If a Level I (CPT) code description and a
Level II code description are identical, the CPT code should be used unless otherwise indicated by
Medicare or another payer. If the Level I and Level II codes are not identical and the Level II code is
more specific, the Level II code is to be reported.
Exercise 21.2
1. Assign the appropriate modifier to report a patient’s origin site as an SNF and destination site as
the hospital.
Ans: NH
Feedback: NH designates an origin site of a skilled nursing facility (SNF) and destination site of the
hospital.
3. Using your HCPCS Level II manual, assign the appropriate code(s) for trimming of five
dystrophic nails, and indicate where you would look in the index to locate the code(s).
Ans: G0127. The coder would look at “trim, nail”.
Feedback: This code is for any number of nails so the code would only be used once.
Exercise 21.3
1. Identify the appropriate HCPCS Level II modifiers for the following:
a. Right foot, great toe
b. Left hand, fourth digit
c. Upper left eyelid
Ans: a. T5; b. F3; c. E1
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151
Feedback: N/A
3. Identify the appropriate HCPCS Level II modifier for the following:
a. Performance and payment of a screening mammogram and diagnostic mammogram on the same
patient, same day.
Ans: GG
Feedback: Don’t confuse this with the GH modifier, which is a diagnostic mammogram converted from a
screening mammogram on same day.
Exercise 21.4
1. Give an example in which less than or equal to is a factor in a code in the A-code range.
Ans: Answers will vary – should be taken from the dialysis supply codes A4720-A4725.
Feedback: N/A
3. The abbreviation TPN is used for total parental nutrition. Give an example of a code that has
this abbreviation in the code description.
Ans: Answers will vary – should be taken from range S9364-S9368
Feedback: N/A
Exercise 21.5
1. Which category I codes do category III codes supersede?
Ans: Unlisted procedure codes
Feedback: Category III codes supersede unlisted procedure codes in category I.
3. How often are category III codes updated?
Ans: Updated semi-annually and published in the CPT manual annually
Feedback: N/A
Chapter 21 Review
Using Terminology
1.
K
Advanced Life Support (ALS)
7.
J
Intrathecal (IT)
3.
D
Durable Medical Equipment (DME)
9.
E
Orthotic
5.
A
Intra-arterial (IA)
11.
B
Parenteral
Feedback: N/A
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distribution in any manner. This document may not be copied, scanned, duplicated, forwarded, distributed, or posted on a
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152
Checking your Understanding
1. A 20-year-old female is seen in her OB/GYN clinic. She receives an injection of Depo-Provera,
150mg, for family planning. Select the appropriate HCPCS Level II code:
Ans: C. J1055
Feedback: J1055: Depo-Provera is considered a birth control shot.
3. HCPCS Level II modifiers may be added to:
Ans: D
Feedback: HCPCS Level II modifiers may be used with both CPT HCPCS Level I and HCPCS Level II
codes. They are not use with ICD-9-CM codes.
5. HCPCS Level II dental codes (D0000 to D9999) are maintained by the:
Ans: C. American Dental Association
Feedback: The HCPCS Dental codes are copyrighted, published, and maintained by the American Dental
Association (ADA) as the Current Dental Terminology (CDT). The D codes are no longer published in
the HCPCS Level II manual.
7. Which of the following HCPCS modifiers is appropriate to report when a diagnostic
mammogram is converted from a screening mammogram on the same day for the same patient?
Ans: D. GH modifier
Feedback: GH is the modifier to report when a diagnostic mammogram is converted from a screening
mammogram on the same day, same patient. GS modifier is used for ESRD patients. GW modifier is used
for hospice patients. GA modifier is used to indicate waiver of liability statement on file (this is the
modifier used with an ABN).
9. A patient received Level 2 advanced life support (ALS). Select the appropriate HCPCS Level II
code:
Ans: C. A0433
Feedback: N/A
Applying your Knowledge
1. Explain C Codes (Outpatient PPS, C1000 – C9999).
Ans: Outpatient Prospective Payment System (OPPS) is Medicare's system for payment to outpatient
departments of hospitals and other outpatient facilities. Codes within this code range are used to report
drugs, biologicals, and device codes that must be used by OPPS hospitals. These codes can only be
reported for facility or technical services. Some of the items/services reported using codes in this
subheading include: Brachytherapy sources; Cardioverter-defibrillator, single or dual
chamber/pacemaker; Catheters; Leads for pacemakers and cardioverter-defibrillators; Magnetic
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153
Resonance Imaging (MRI); Transesophageal echocardiography (TEE). For example: C1750 is assigned
for catheter, hemodialysis/peritoneal, long term.
Feedback: N/A
3. Discuss routes of administration, and give examples of some of the abbreviations and their
definitions.
Ans: Enteral and parenteral therapies are forms of routes of administration. Routes of administration are
the methods or paths used for the entrance of a drug or other substance into the body. Enteral therapy is
within the intestine; this is often accomplished through the gastrointestinal tract via a gastric feeding tube
or gastrostomy. In parenteral therapy, the patient receives the nutritional material other ways than
through the intestine such as subcutaneous, intravenously, or intramuscularly. Some abbreviations
include: Intra-arterial (IA); intravenous (IV); intramuscular (IM); intrathecal (IT); subcutaneous (SC);
inhalation (INH).
Feedback: N/A
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154
Chapter 22 – Practice Management
Exercise 22.1
1. What does adhering to the AAPC code of ethics mean to coders and the coding profession?
Ans: Adherence to these standards assures public confidence in the integrity and service of medical
coding, auditing, compliance and practice management professionals who are AAPC members.
Feedback: Commitment to ethical professional conduct is expected of every AAPC member. The
specification of a Code of Ethics enables AAPC to clarify to current and future members, and to those
served by members, the nature of the ethical responsibilities held in common by its members. This
document establishes principles that define the ethical behavior of AAPC members. All AAPC members
are required to adhere to the Code of Ethics, and the Code of Ethics will serve as the basis for processing
ethical complaints initiated against AAPC members.
Exercise 22.2
1. Define coinsurance, copayment, and deductible.
Ans: Coinsurance: The patient responsible portion based upon a percentage of the allowed charge.
Copayment: The patient responsible portion of a set amount based per service or encounter.
Deductible: A predetermined amount which is deemed patient responsibility before the payer benefits
begin.
Feedback: Co-insurance is the patient responsible portion based upon a percentage of the allowed charge.
Co-payment is the patient responsible portion of a set amount based per service or encounter. Deductible
is a predetermined amount which is deemed patient responsibility before the payer benefits begin.
3. Which type of provider agrees to accept assignment of the claim and Medicare’s allowed amount
as identified by the Medicare provider fee schedule for approved and medically necessary services?
Ans: Participating providers (PAR)
Feedback: Medicare contracted providers, also known as participating (PAR) providers, agree to accept
assignment of the claim and Medicare’s allowed amount as identified by the Medicare provider fee
schedule (MPFS) for approved and medically necessary services. PAR providers are allowed 100 percent
of the MPFS, with 80 percent paid by Medicare and 20 percent paid by the beneficiary. Another
incentive for participation is faster processing of claims, resulting in more timely and direct
reimbursement of services.
Exercise 22.3
1. Explain the American Recovery and Reinvestment Act (ARRA).
Ans: The ARRA was enacted to promote economic recovery and growth and provided the opportunity to
enhance the nation’s health care system through investment in health information technology (HIT) and
Electronic Health Records (EHR).
Feedback: The American Recovery and Reinvestment Act (ARRA) of 2009 was enacted to promote
economic recovery and growth and provide the opportunity to enhance the nation’s health care system
through investment in health information technology (HIT) and electronic health records (EHRs).
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distribution in any manner. This document may not be copied, scanned, duplicated, forwarded, distributed, or posted on a
website, in whole or part.
155
3. Describe an ABN.
Ans: An Advance Beneficiary Notice (ABN) of Noncoverage is needed for any service that does not meet
the coverage criteria established in an NCD or LCD. An ABN, also known as form CMS-R-131, is not
intended to be used when the service provided is never covered by Medicare but when a service usually
covered by Medicare may not be covered under a particular circumstance, such as diagnosis restrictions,
frequency of the service or procedure, or another payment limitation.
Feedback: An Advance Beneficiary Notice (ABN) of Noncoverage is needed for any service that does not
meet the coverage criteria established in an NCD or LCD. An ABN, also known as form CMS-R-131, is
not intended to be used when the service provided is never covered by Medicare but when a service
usually covered by Medicare may not be covered under a particular circumstance, such as diagnosis
restrictions, frequency of the service or procedure, or another payment limitation.
Chapter 22 Review
Using Terminology
1.
A
Advance Beneficiary Notice (ABN)
3.
I
Covered Entity
5.
C
Hierarchal Condition Category (HCC)
7.
B
Medicare Administrative Contractor (MAC)
9.
E
National Coverage Determinations (NCD)
11.
H
Protected Health Information (PHI)
Feedback: N/A
Checking your Understanding
1. Which of the following statements are not true for a non-PAR provider? Choose all that apply.
Ans: C. Payment is sent directly to the provider.
Feedback: Claims are filed by the provider and reimbursement is collected from the beneficiary.
3. The patient-responsible portion of a set amount per service or encounter is the definition of:
Ans: C. Copayment
Feedback: Coinsurance is the patient responsible portion based upon a percentage of the allowed charge.
Deductible is the predetermined amount which is deemed patient responsibility before the payer benefits
begin.
5. Which service is not considered a Medicare Part A benefit?
Ans: A. DME
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156
Feedback: DME is not considered a Medicare Part A benefit. Hospice, inpatient stays, and some home
healthcare services are considered Medicare Part A benefits.
7. Which of the following statements is not a benefit of an effective compliance plan?
Ans: A. Eliminates the risk of an audit
Feedback: An effective compliance plan does not eliminate the risk of an audit; it reduces the risk of an
audit.
9. Which of the following is responsible for enforcing the rules of HIPAA?
Ans: C. OCR
Feedback: The OCR is responsible for enforcing the rules of the Health Insurance Portability and
Accountability Act of 1996 (HIPAA). OIG (Office of Inspector General) investigates allegations of fraud,
waste, abuse, or misconduct and assists the executive branch in identifying and correcting operational
deficiencies. NCD (National Coverage Determinations) identify payment coverage for a specific service,
procedure, test, or technology based upon medical necessity or frequency. NCCI (National Correct
Coding Initiative) was created to encourage correct coding methodologies and control inappropriate
payments due to improper coding of Part B claims.
Applying your Knowledge
1. Discuss the HITECH Act and its implications to a practice.
Ans : The American Recovery and Reinvestment Act of 2009 (ARRA) was enacted to promote economic
recovery and growth and provided the opportunity to enhance the nation’s health care system through
investment in health information technology (HIT) and Electronic Health Records (EHR). As part of this
act and to promote the implementation of meaningful use of health information technology, the ARRA
enacted the Health Information Technology for Economic and Clinical Health Act (HITECH Act). The
HITECH Act addresses security and privacy issues related to the electronic transmission of health
information. In addition to the security and privacy rules set out by HIPAA, the HITECH Act outlines
rules and regulations as well as penalties for violation of these rules: (a) Provide authorized disclosures of
PHI in an electronic format at a cost equal to the cost incurred to process the request. (b) Mandatory
notification of a breach in PHI affecting 500 or more patients to both HHS and the media in addition to
the patient.
Feedback: American Recovery and Reinvestment Act (ARRA): Legislation enacted to promote economic
recovery and growth and provide the opportunity to enhance the nation’s health care system through
investment in health information technology.
Health Information Technology for Economic and Clinical Health (HITECH) Act: Legislation that
addresses security and privacy issues related to the electronic transmission of health information; outlines
rules and regulations as well as penalties for violations of the rules.
3. Discuss the AAPC code of ethics.
Ans: AAPC members shall:
a) Maintain and enhance the dignity, status, integrity, competence, and standards of our profession.
b) Respect the privacy of others and honor confidentiality.
c) Strive to achieve the highest quality, effectiveness and dignity in both the process and products of
professional work.
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157
d) Advance the profession through continued professional development and education by acquiring
and maintaining professional competence.
e) Know and respect existing federal, state and local laws, regulations, certifications and licensing
requirements applicable to professional work.
f) Use only legal and ethical principles that reflect the profession’s core values and report activity
that is perceived to violate this Code of Ethics to the AAPC Ethics Committee.
g) Accurately represent the credential(s) earned and the status of AAPC membership.
h) Avoid actions and circumstances that may appear to compromise good business judgment or
create a conflict between personal and professional interests.
Feedback: N/A
© 2014 by McGraw-Hill Education. This is proprietary material solely for authorized instructor use. Not authorized for sale or
distribution in any manner. This document may not be copied, scanned, duplicated, forwarded, distributed, or posted on a
website, in whole or part.