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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 © 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. 2 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. © 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. 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 © 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. 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 © 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. 5 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. © 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. 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: © 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. 7 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. © 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. 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 © 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. 9 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. © 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. 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. © 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. 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 © 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. 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 © 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. 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. © 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. 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 © 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. 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. © 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. 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 © 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. 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. © 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. 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 © 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. 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. © 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. 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. © 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. 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. © 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. 22 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. © 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. 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. © 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. 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. © 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. 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. © 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. 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? © 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. 27 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: © 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. 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 © 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. 29 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 © 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. 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 © 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. 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. © 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. 32 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 © 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. 33 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. © 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. 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? © 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. 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? © 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. 36 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 © 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. 37 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? © 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. 38 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 © 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. 39 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 © 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. 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. © 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. 41 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. © 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. 42 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. © 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. 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 © 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. 44 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? © 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. 45 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 © 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. 46 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. © 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. 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. © 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. 48 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 © 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. 49 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. © 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. 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 © 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. 51 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 © 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. 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. © 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. 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. © 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. 54 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 © 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. 55 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 © 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. 56 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 © 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. 57 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? © 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. 58 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 © 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. 59 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 © 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. 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. © 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. 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. © 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. 62 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. © 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. 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: © 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. 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. © 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. 65 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? © 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. 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. © 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. 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? © 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. 68 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. © 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. 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. © 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. 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 © 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. 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. © 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. 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 © 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. 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. © 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. 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? © 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. 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. © 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. 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 _______________. © 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. 77 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. © 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. 78 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 © 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. 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 © 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. 80 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 © 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. 81 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. © 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. 82 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. © 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. 83 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. © 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. 84 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 © 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. 85 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. © 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. 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 © 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. 87 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. © 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. 88 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 © 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. 89 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. © 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. 90 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? © 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. 91 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. © 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. 92 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. © 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. 93 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 © 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. 94 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. © 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. 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 © 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. 96 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) _________ . © 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. 97 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 © 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. 98 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. © 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. 99 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 © 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. 100 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 © 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. 101 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) © 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. 102 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 © 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. 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. © 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. 104 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 © 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. 105 (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. © 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. 106 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). © 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. 107 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 © 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. 108 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. © 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. 109 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 © 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. 110 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 © 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. 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 © 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. 112 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. © 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. 113 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. © 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. 114 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. © 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. 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. © 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. 116 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. © 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. 117 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 © 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. 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 © 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. 119 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. © 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. 120 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. © 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. 121 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 © 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. 122 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? © 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. 123 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? © 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. 124 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. © 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. 125 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. © 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. 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 © 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. 127 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 © 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. 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 © 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. 129 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 © 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. 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. © 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. 131 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. © 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. 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? © 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. 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? © 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. 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 © 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. 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 © 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. 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 © 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. 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? © 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. 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. © 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. 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. © 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. 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 © 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. 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 © 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. 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 © 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. 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? © 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. 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 © 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. 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. © 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. 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 © 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. 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 © 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. 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. © 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. 149 © 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. 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 © 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. 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 © 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. 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 © 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. 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 © 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. 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). © 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. 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 © 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. 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. © 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. 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.