ICD-10-CM and CPT® Codes for Various Medical Procedures, Exams of Nursing

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AAPC CPC Exam Questions and Answers with Rationale.

1. While whittling a piece of wood, the patient sustained an avulsion injury to a portion of his left index finger and underwent formation of a direct pedicle graft with transfer from his left middle finger. Immobilization was accomplished with a plaster splint. What CPT® code is reported? a. 15574 c. 15750 b. 15740 d. 15758 ANS: A Rationale: In the CPT® Index look for Pedicle Flap/Formation, you are directed to 15570-15576. Code selection is based on location. Subsection guidelines for Flaps state the codes refer to the recipient site not the donor site. The term pedicle indicates this is a flap not a direct graft, where skin is removed from one site and transferred to another. Instead, a flap of skin is raised, leaving it attached to its source location to maintain blood supply until it is established sufficiently in the new site. Code 15574 describes a direct pedicle graft of the hands with or without transfer. 2. A 3 year-old is brought to the burn unit after pulling a pot of hot soup off the stove and spilling it on herself. She sustained 18% second degree burns on her legs and 20% third degree burns on her chest and arms. Total body surface area burned is 38%. What ICD- 10 - CM codes are reported for the burns (do not include external cause codes for the accident)? a. T21.21XA, T22.20XA, T24.209A, T31. b. T21.31, T22.20, T24.209, T31. c. T21.31XA, T22.399A, T24.299A, T31. d. T21.31XA, T22.20XA, T24.209A, T31. ANS: C Rationale: ICD- 10 - CM guideline I.C.19.d.1 states to sequence first the code that reflects the highest degree of burn when more than one burn is present. In this case, the burns on her chest and arms are third degree and are reported first. In the ICD- 10 - CM Alphabetic Index look for Burn/chest wall/third degree, referring you to subcategory T21.31. Because the question indicates arms and legs (plural) we will code multiple sites of the upper and lower limbs. In the Alphabetic Index look for Burn/upper limb/multiple sites/third degree directing you to subcategory T22.399, and Burn/lower/limb/multiple sites/second degree directing you to subcategory T24.299. The Tabular List indicates a 7th^ character is needed for all three of these codes; a placeholder X is required for T21.31. The 7th^ character A is reported for the initial encounter. Refer to ICD- 10 - CM guideline I.C.19.d.6 for instructions on assigning a

code from category T31 to report the extent of body surface involved. The 4th^ character represents the total body surface area (TBSA) (all degrees) that was burned. The 5th^ character represents the percentage of third degree burns to the body. In the scenario, 38% is documented as the TBSA making 3 the appropriate 4th^ character; 20% is third degree burns, making 2 the 5th^ character. In the Alphabetic Index look for Burn/extent (percentage of body surface)/30- 39 percent/with 20 - 29 percent third degree burns directing you to code T31.32. The external cause codes would also be reported for the accident. Verify code selection in the Tabular List.

3. Patient is an 81-year-old male with a biopsy proven basal cell carcinoma of this posterior neck just near his hairline; additionally the patient had two additional areas of concern on his cheek. Informed consent was obtained and the areas were prepped and draped in the usual sterile fashion. Attention was first directed to the basal cell carcinoma of the neck, I excised the lesion measuring 2.6 cm as drawn down to the subcutaneous fat. With extensive undermining of the wound I closed in layers using 4. Monocryl, 5.0 Prolene and 6.0 Prolene; the wound measured 4.5cm. Attention was then directed to the other two suspicious lesions on his cheek; after administering local anesthesia I proceeded to take a 3mm punch biopsy of each lesion and was able to close with 5.0 Prolene. The patient tolerated the procedures well. Pathology later showed the basal cell carcinoma was completely removed and the biopsies indicated actinic keratosis. What CPT® codes should be reported? a. 13132, 11623 - 51, 11100 - 59, 11101 c. 12042, 11623 - 51, 11100 - 59, 11101 b. 13131, 11622 - 51, 11100 - 59, 11100 - 59 d. 13132, 11623 - 51, 11440 - 51, 11440 - 51 ANS: A Rationale: Three lesions were addressed. The first lesion is a malignant neoplasm of the neck (basal cell carcinoma). Look in the CPT® Index for Skin/Excision/Lesion/Malignant. This refers you to code range 11600 - 11646. The range is narrowed by the location (neck, 11620-11626). The excision was 2.6 cm making 11623 the correct code. For this lesion, extensive undermining of the wound and the use of multiple suture materials support use of a complex closure. Complex repairs are indexed under Repair/Skin/Wound/Complex referring you from range 13100-13160. The range is narrowed again by location (neck, 13131-13133). The repair length is 4.5 cm making 13132 the correct code. After the lesion of the neck is removed the provider took two biopsies on the cheek. Look in the CPT® Index for Skin/Biopsy which refers you to codes 11100 and 11101. 11100 is used for the first biopsy and add-on code 11101 for the additional biopsy. Biopsies are typically included in excisions. It is necessary to use modifier 59 for the first biopsy indicating it was performed at a different location than the excision. A modifier 59 is not used on the second biopsy code because it is an add-on code. 4. Patient is a 53 - year-old female who yesterday underwent Mohs surgery with Dr. Smith to remove a basal cell carcinoma of her scalp. Due to the size of the defect Dr. Smith requested a Plastic Surgeon to reconstruct the site. Dr. Jones discussed with the patient his planned closure which was a Ying-Yang type flap. The patient agreed and we proceeded. The area was prepped and draped in a sterile fashion being careful to keep betadine solution out of the open wound. Wound preparation was done by excising an additional 1 mm margin to freshen the wound and excising the wound deeper. Starting on the right, Dr. Jones incised his planned flap, elevating the flap with full-thickness and subcutaneous fat, staying superior to the galea; then Dr. Jones incised his planned flap on the left elevating the flap with full-thickness and subcutaneous fat. Both flaps were rotated together and the wound was temporarily

closed using the skin stapler. Once it was determined there was minimal tension on the wound; the galea was approximated using 4.0 Monocryl. The wound was then closed in layers using 5-0 Monocryl and a 35R skin stapler. Meticulous hemostasis was achieved through-out the procedure with the Bovie cautery. Final measurements of the wound were 36.25 cm squared. What CPT® code(s) is/are reported? a. 14021 - 22 c. 14301 b. 14021, 15004 - 51 d. 14301, 15004 - 51 ANS: D Rationale: A Ying Yang flap is a rotation flap coded using Adjacent Tissue Transfer codes. In the CPT® Index, look for Skin Graft and Flap/Tissue Transfer and you are directed to codes 14000-14350. When the defect size is less than 30 sq. cm, it is coded based on location and size. When it is more than 30 sq. cm, it is coded using 14301 and 14302. In this case, we have a flap 36.25 sq. cm. 14301 is reported for the first 30 sq. cm – 60.0 sq. cm. Wound preparation was also performed, in the CPT® index look for Integumentary System/Skin Replacement Surgery and Skin Substitutes/Surgical Preparation referring you to codes 15002-15005. Code 15004 is reported for the scalp. Modifier 51 is used to indicate multiple procedures were performed.

5. Patient presents to the emergency department with multiple lacerations due to a knife fight at the local bar. After examination it was determined these lacerations could be closed using local anesthesia. The areas were prepped and draped in the usual sterile fashion. The surgeon documented the following closures: 7.6 cm simple closure of the right forearm; 5.7 cm intermediate closure of the upper right arm; 4.7 cm complex closure of the right neck; 10.3 cm intermediate closure of the upper chest. What CPT® codes are reported? a. 13132, 12035 - 59, 12004 - 59 b. 13132, 12034 - 59, 12032 - 59, 12004 - 59 c. 13132, 12036 - 59 d. 13152, 12035 - 59, 12004 - 59 ANS: A Rationale: Four lacerations are repaired. The lacerations are separated first by classification (simple, intermediate, complex); then by location. There is one simple closure which is 7.6 for the right forearm (12004). Next the intermediate closures are performed on the arm measuring 5.7 cm and the upper chest measuring 10.3 cm. Trunk (chest) and extremities (arm) are in the same classification and are both intermediate, so the lengths are added together to total 16 cm (12035). The last repair is a complex repair of the neck, 4.7 cm (13132). Subsection guidelines state to append Modifier 59 to indicate that multiple repair procedures are performed. These codes are indexed in CPT® under Skin/Wound Repair. 6. Patient presents to the operative suite with a biopsy proven squamous cell carcinoma of the left ankle. A decision was made to remove the lesion and apply a split thickness skin graft on the site. The lesion was excised as drawn and documented as measuring 2.4 cm with margins. Using the Padgett

dermatome the surgeon harvested a split-thickness skin graft from the left thigh, which was meshed 1. x 1 and then inset into the ankle wound using a skin stapler. Xeroform bolster was then placed on the skin graft using Xeroform and 4-0 nylon and the lower extremity was wrapped with bulky cast padding and double Ace wrap. The skin graft donor site was dressed with OpSite. The surgeon noted the skin graft measured 9cm² in total. What CPT ® and ICD- 10 - CM codes are reported? a. 15100, 11603 - 51, C44.729 c. 15120, 13100 - 51, D22. b. 15100, C44.729 d. 15240, 11603 - 51, C44. ANS: A Rationale: The excision of the lesion is found by looking in the CPT® Index for Skin/Excision/Lesion/Malignant, you are referred to code range 11600 - 11646. The lesion is on the ankle (leg) narrowing the code range to 11600-11606. The lesion is 2.4 cm making the correct code 11603. The guidelines for Excision – Malignant Lesions tell us to report reconstructive closure (15002-15261, 15570 - 15770) separately. In this case a split thickness skin graft was used. Look in the CPT® Index for Skin Graft and Flap/Split Graft which refers us to code range 15100 - 15101, 15120 - 15121. 15100 is the correct code choice. The diagnosis is squamous cell carcinoma. In the Alphabetic Index look for Carcinoma – see also Neoplasm, by site, malignant. Look in the Table of Neoplasms for Neoplasm, neoplastic/skin NOS/ankle and you are referred to see also Neoplasm, skin, limb, lower. Skin/limb NEC/lower/squamous cell carcinoma refers you to C44.72-. In the Tabular List a sixth character is reported for laterality. The code is specific to the left extremity (C44.729).

7. Patient presents with a suspicious lesion on her left arm. With the patient’s permission the physician marked the area for excision. The lesion measured 0.9 cm. The wound measuring 1.2 cm was closed in layers using 4-0 Monocryl and 5-0 Prolene. Pathology later reported the lesion to be a sebaceous cyst. What codes are reported? a. 11401, D22.62 c. 13121, 11401 - 51, D22. b. 12031, 11401 - 51, L72.3 d. 11402, L72. ANS: B Rationale: Understanding a sebaceous cyst is benign, look in the CPT® Index for Skin/Excision/Lesion/Benign referring you to code range 11400 - 11446. The lesion is coded based on size and location for 11401. The note also indicates the wound was closed in layers allowing for intermediate closure, also coded based on location and size, 12031. In the ICD- 10 - CM Alphabetic Index, look for Cyst/sebaceous directs you to L72.3. Verify in the Tabular List.

8. Operative Report: Pre-Operative Diagnoses: Basal Cell Carcinoma, forehead Basal Cell Carcinoma, right cheek Suspicious lesion, left nose Suspicious lesion, left forehead Post-Operative Diagnoses: Basal Cell Carcinoma, forehead with clear margins Basal Cell Carcinoma, right cheek with clear margins Compound nevus, left nose with clear margins Epidermal nevus, left forehead with clear margins INDICATIONS FOR SURGERY: The patient is a 47-year-old white man with a biopsy-proven basal cell carcinoma of his forehead and a biopsy-proven basal cell carcinoma of his right cheek. We were not quite sure of the patient’s location of the basal cell carcinoma of the forehead whether it was a midline lesion or lesion to the left. We felt stronger about the midline lesion, so we marked the area for elliptical excision in relaxed skin tension lines of his forehead with gross normal margins of 1-2 mm and I marked the lesion of the left forehead for biopsy. He also had a lesion of his left alar crease we marked for biopsy and a large basal cell carcinoma of his right cheek, which was more obvious. This was marked for elliptical excision with gross normal margins of 2- 3 mm in the relaxed skin tension lines of his face. I also drew a possible rhomboid flap that we would use if the wound became larger. He observed all these margins in the mirror, so he could understand the surgery and agree on the locations, and we proceeded. DESCRIPTION OF PROCEDURE: All four areas were infiltrated with local anesthetic. The face was prepped and draped in sterile fashion. I excised the lesion of the forehead measuring 6-mm and right cheek measuring 1.3 cm as I had drawn them and sent in for frozen section. The biopsies were taken of the left forehead and left nose using a 2-mm punch, and these wounds were closed with 6-0 Prolene. Meticulous hemostasis was achieved of those wounds using Bovie cautery. I closed the cheek wound first. Defects were created at each end of the wound to facilitate primary closure and because of this I considered a complex repair and the wound was closed in layers using 4 - 0 Monocryl, 5 - 0 Monocryl and 6 - 0 Prolene, with total measurement of 2.1 cm. The forehead wound was closed in layers using 5- 0 Monocryl and 6-0 Prolene, with total measurement of 1.0 cm. Loupe magnification was used and the patient tolerated the procedure well. What ICD- 10 - CM codes are reported? a. C44.310, D04.39, D48.5, D23. b. C44.319, D22. c. C44.202, C44.40, D22.23, D23. d. C44.202, C44.309, D48.5, D49.

ANS: B

Rationale: For basal cell carcinoma, forehead, look in the ICD- 10 - CM Alphabetic Index look for Carcinoma/basal cell – see also Neoplasm, skin, malignant. Go to the Table of Neoplasms, look for Neoplasm, neoplastic, skin NOS/forehead - see also Neoplasm, skin, face. Neoplasm, neoplastic/skin NOS/face NOS/basal cell carcinoma refers you to code C44.319. Next, is basal cell carcinoma, right cheek, which also directs you to see also Neoplasm, skin, face (C44.319). Because, both basal cell carcinomas are coded with the same diagnosis code, it is only reported once. Next look in the Alphabetic Index for Nevus/skin/nose directs you to D22.39. Nevus/skin/forehead directs you to D22.39. Because the codes are the same. The code is reported only once.

9. 56 - year-old pro golfer is having Mohs micrographic surgery for skin cancer on his forehead. The surgeon takes him back for two stages. The first stage has 4 tissue blocks and the second stage has 6 tissue blocks. What is the best way to code for both stages? a. 17311, 17315 c. 17311, 17312, 17315 b. 17313, 17314, 17315 d. 17311, 17312 ANS: C Rationale: Mohs codes are selected based on location and number of stages, each including up to five blocks. There is an add-on code for each additional block after the first five blocks in any stage. In the CPT® Index, see Mohs Micrographic Surgery. Code 17311 is for the first stage and 17312 for the second stage, based on the documentation of the site: “forehead.” The second stage consisted of six tissue blocks; the sixth tissue block is reported with the add-on code 17315. 10. Which statement is TRUE regarding the Neoplasm Table in ICD- 10 - CM? a. The Neoplasm Table is found by looking for “Neoplasm” in the Index to Diseases and Injuries. b. There is not a Neoplasm Table in ICD- 10 - CM. c. The Neoplasm Table is found in the Tabular List. d. There are six columns in the Neoplasm Table; Primary malignancy, secondary malignancy, CA in situ, benign, and uncertain behavior. ANS: D Rationale: The Neoplasm Table in ICD- 10 - CM is broken down into six columns; Primary malignancy, secondary malignancy, CA in situ, benign, unspecified and uncertain behavior.

20000 Series

11. 44 - year-old male with biplanar deformity, acquired limb length discrepancies and tibial nonunion has undergone deformity correction. He now requires exchange of an external fixation strut 45 days postoperatively. The intraoperative mounting parameters, deformity parameters, and initial strut settings are inserted into the computer prior to Jim’s discharge and a daily schedule is generated for him to perform the gradual deformity correction necessary. What CPT® code(s) should be reported?

a. 20696 c. 20694 b. 20697 d. 20692, 20697 ANS: B Rationale: The exchange of a computer assisted external strut is coded with 20697. There is a parenthetical note under code 20697 that it is not to be used in combination with 20672 or 20696. 20697 can be found in the CPT ® Index under External Fixation /Application/Stereotactic Computer Assisted

12. A patient is given Xylocaine, a local anesthetic, by injection in the thigh above the site to be biopsied. A small bore needle is then introduced into the muscle, about 3 inches deep, and a muscle biopsy is taken. What CPT® code is reported for this service? a. 20205 c. 20225 b. 20206 d. 27324 ANS: B Rationale: In the CPT® Index, look for Biopsy/Muscle. You are referred to 20200 - 20206. The biopsy is taken through the skin, or percutaneous with a needle. Although the biopsy is deep, it is performed percutaneous, which is reported with 20206. 13. The patient presents today for closed reduction of the nasal fracture. The depressed right nasal bone was elevated using heavy reduction forceps while the left nasal bone was pushed to the midline. This resulted in good alignment of the external nasal dorsum. What CPT® code is reported for this procedure? a. 21325 c. 21315 b. 21310 d. 21337 ANS: C Rationale: In the CPT® Index, look for Fracture/Nasal Bone/Closed Treatment. You are referred to 21310 - 21320. Review codes to choose the appropriate service. 21315 is the correct code to report a displaced nasal fracture that is manipulated with the forceps to realign the nasal bones. Code 21310 is reported when a non-displaced fracture of the nose requires no manipulation just treatment by prescribing medication and application of ice. 14. A 22 - year-old female has a retained Kirschner wire in the left little finger. Using local anesthesia, the left upper extremity was thoroughly cleansed with Betadine. The end portion of the little finger was opened by a transverse incision through the subcutaneous tissue to the bone. The retained Kirschner wire was located within the distal phalanx. It was removed and closed with sutures. What CPT® code is reported? a. 10120 - F4 c. 20670 - F b. 20680 - F4 d. 10121 - F

ANS: B

Rationale: In the CPT® Index, look for Removal/Fixation Device. You are referred to 20670-20680. Review the codes to choose the appropriate service. 20680 is the correct code because a deep incision was made all the way to the bone to locate the wire for removal. Modifier F4 is reported to indicate the finger the procedure is performed on.

15. The patient has a torn medial meniscus. An arthroscope was placed through the anterolateral portal for the diagnostic procedure. The patellofemoral joint showed grade 2 chondromalacia on the patellar side of the joint only, this was debrided with a 4.0-mm shaver. The medial compartment was also entered and a complex posterior horn tear of the medial meniscus was noted. It was probed to define its borders. A meniscectomy was carried out to a stable rim. What CPT® code(s) is/are reported? a. 29880 c. 29881, 29877 - 59 b. 29870, 29877 - 59 d. 29881 ANS: D Rationale: In the CPT® Index, look for Arthroscopy/Surgical/Knee. You are referred to 29871-29889. Review the codes to choose appropriate service. 29881 is the correct code because the tear was in the “medial meniscus”. A meniscectomy as well as debridement with a shaver (or chondroplasty) were performed. 29877 would not be reported as this is covered with code 29881. 29880 is not appropriate as the procedure would have had to be performed on both the medial and lateral compartments. The surgery started out as a “diagnostic procedure,” but changed when the physician decided to perform surgical procedures on the knee, rather than only examining the knee for diagnostic purposes. 16. A 3-year-old is brought into the ER crying. He cannot bend his left arm after his older brother twisted it. The physician performs an X-ray to diagnose the patient has a dislocated nursemaid’s elbow. The ER physician reduces the elbow successfully. The patient is able to move his arm again. The patient is referred to an orthopedist for follow-up care. What CPT® and ICD- 10 - CM codes are reported? a. 24640 - 54 - LT, S53.032A, W50.2XXA b. 24565 - 54 - LT, S53.194S, Y33.XXXA c. 24640 - 54 - LT, S53.091A, W50.2XXA d. 24600 - 54 - LT, S53.002A, W49.9XXA ANS: A Rationale: In the CPT® Index, look for Elbow/Dislocation/Closed Treatment. You are referred to 24600- 24605, and 24640. Review the codes to choose appropriate service. 24640 is the correct code to report treatment of a dislocated nursemaid’s elbow with manipulation. Modifier 54 is used to report that the ED physician performed the surgical portion of the service only. The patient is referred to an orthopedist for follow-up care. Modifier LT is appended to indicate the procedure was performed on the left side.

In the ICD- 10 - CM Index to Diseases and Injuries, look for Nursemaid’s/elbow. You are referred to S53.03-. Reviewing the subcategory code in the Tabular List the sixth character indicates the selection is based on left or right. Documentation supports this as the left arm. A 7th character is also required to indicate the episode of care. Because the patient is in the ER, this supports initial encounter and A is used. The complete code is S53.032A. In the ICD- 10 - CM External Cause of Injuries Index, look for Twisted by person(s) (accidentally) referring you to W50.2. In the Tabular List this code requires a 7th character, in which the character A is used and X will be used as a placeholder for the fifth and sixth character positions.

17. A 50 year-old male had surgery on his upper leg one day ago to remove an intramuscular tumor and presents with serous drainage from the wound. He was taken back to the operating room for evaluation of a hematoma. His wound was explored down to the rectus femoris muscle, and there was a hematoma which was very carefully evacuated. The wound was irrigated with antibacterial solution, and the wound was closed in multiple layers. What CPT® and ICD- 10 - CM codes are reported? a. 10140 - 79, M96.810 c. 10140 - 76, T81.9XXA b. 27603 - 78, T81.4XXA d. 27301 - 78, M96. ANS: D Rationale: In the CPT® Index look for Hematoma/Leg, Upper. You are referred to 27301. Verify the code for accuracy. Modifier 78 is appended to 27301 to indicate that an unplanned procedure related to the initial procedure was performed during the postoperative period. Use modifier 78 for a return to the OR for a complication in the global period of another procedure. In the ICD- 10 - CM Alphabetic Index look for Complication/surgical procedure (on)/hematoma/post procedural – see Complication, postprocedural, hematoma. Look for Complication/post procedural/hematoma (of)/musculoskeletal structure/following musculoskeletal surgery M96.840. His wound was explored down to the level of the rectus femoris muscle; the excision of the mass was intramuscular. The code selection is specific to the location of the hematoma as well as the body system for which the procedure was performed. Review the code in the Tabular List for accuracy. 18. A 22-year-old female sustained a dislocation of the right elbow with a medial epicondyle fracture while on vacation. The patient was put under general anesthesia and the elbow was reduced and was stable. The medial elbow was held in the appropriate position and was reduced in acceptable position and elevated to treat non-surgically. A long arm splint was applied. The patient is referred to an orthopedist when she returns to her home state in a few days. What CPT® code(s) are reported? a. 24575 - 54 - RT, 24615 - 54 - 51 - RT b. 24576 - 54 - RT, 24620 - 54 - 51 - RT c. 24577 - 54 - RT, 24600 - 54 - 51 - RT d. 24565 - 54 - RT, 24605 - 54 - 51 - RT

ANS: D

Rationale: In the CPT® Index, look for Fracture/Humerus/Epicondyle/Closed Treatment. You are referred to code 24560 - 24565. Review the codes to choose the appropriate service. 24565 is the correct code to report an epicondyle fracture manipulated (reduced) without a surgical incision to perform the procedure. In the CPT® Index, look for Dislocation/Elbow/Closed Treatment. You are referred to 24600,

24605. Review the codes to choose appropriate service. 24605 is the correct code because the patient was put under general anesthesia to perform the procedure. Modifier 54 is used to report the physician performed the surgical portion only. The patient is referred to an orthopedist for follow up or postoperative care. Modifier 51 is used to report multiple procedures were performed. Append modifier RT to indicate the procedure is performed on the right side. 19. A 45-year-old presents to the operating room with a right index trigger finger and left shoulder bursitis. The left shoulder was injected with 1 cc of Xylocaine, 1 cc of Celestone, and 1 cc of Marcaine. An incision was made over the A1 pulley in the distal transverse palmar crease, about an inch in length. This incision was taken through skin and subcutaneous tissue. The Al pulley was identified and released in its entirety. The wound was irrigated with antibiotic saline solution. The subcutaneous tissue was injected with Marcaine without epinephrine. The skin was closed with 4-0 Ethilon suture. Clean dressing was applied. What CPT® codes are reported? a. 26055 - F6, 20610 - 76 - LT c. 26055 - F6, 20610 - 51 - LT b. 20552 - F6, 20605 - 52 - LT d. 20553 - F6, 20610 - 51 - LT ANS: C Rationale: In the CPT® Index, look for Trigger Finger Repair. You are referred to 26055. Review the code to verify accuracy. In the CPT® Index, look for Injection/Joint. You are referred to 20600-20610. Review the codes to choose appropriate service. 20610 is the correct code since the shoulder was injected. Modifier F6 is used to report the right index finger that was repaired. Modifier LT is used to indicate the left shoulder joint. Modifier 51 is used to indicate multiple procedures were performed. 20. What ICD- 10 - CM code is used to report effusion of the right ankle joint? a. M25.471 c. M25. b. M25.474 d. M25. ANS: A Rationale: Look in the Index to Diseases and Injuries for Effusion/joint/ankle. In the Tabular List, code M25.47- Effusion, ankle and foot requires the application of a sixth character to specify the location (foot or ankle) and laterality. M25.471 Effusion, right ankle

30000 Series

21. A patient presents with wheezing and shortness of breath. After evaluating the patient, the physician determines the patient is suffering from an exacerbation of his asthma. The physician orders nebulizer treatments to be administered in his office. According to the ICD- 10 - CM guidelines for coding signs and symptoms, what is/are the correct ICD- 10 - CM code(s)? a. J45.901 c. R06.2, R06. b. J45.902, R06.2, R06.02 d. J45. ANS: A Rationale: Because the type of asthma is not indicated, the correct code is J45.901. In the Index to Diseases and Injuries, look for Asthma, asthmatic/with/exacerbation (acuter) directing you to J45.901. The Tabular List verifies this code choice. Wheezing and shortness of breath are signs and symptoms of an exacerbation of asthma and not reported separately. According to the Official ICD- 10 - CM Guidelines (Sect I. B. 4) do not report signs and symptoms when a definitive diagnosis has been established. 22. The provider performs a diagnostic thoracoscopy followed by the thoracoscopic excision of a pericardial cyst. What CPT® code(s) is/are reported? a. 32601, 32662 - 51 c. 32658 b. 32601, 32661 - 51 d. 32661 ANS: D Rationale: Endoscopy guidelines state that surgical thoracoscopy always includes a diagnostic thoracoscopy and, therefore, is not coded separately. In the CPT® Index, look up Thoracoscopy/Surgical/with Excision Pericardial Cyst, Tumor and/or Mass and you are directed to

23. What ICD- 10 - CM code is reported for COPD with acute bronchitis? a. J44.9, J22.9 c. J b. J44.1 d. J44.0, J20. ANS: D Rationale: COPD stands for Chronic Obstructive Pulmonary Disease. In the ICD- 10 - CM Alphabetic Index look for Disease/lung/obstructive/with/acute bronchitis referring you to J44.0. Verification in the Tabular List confirms code selection and gives additional instruction to use additional code to identify the infection. The infection is reported with a code from category code J20 Acute Bronchitis. Because there is no indication of the infectious agent for the acute bronchitis, an unspecified code is used. Bronchitis/acute or subacute refers you to J20.9.

24. A patient with AML (Acute Myelogenous Leukemia) has just learned his sister is an HLA match for him. Stem cells taken from the donor (the patient’s sister) will be transplanted into the patient to help with his treatment. What CPT® code is used to report the harvesting of the stem cells from the donor, his sister? a. 38204 c. 38206 b. 38205 d. 38207 ANS: B Rationale: In the CPT® Index, look under Stem Cell/Harvesting. This directs you to code range 38205 -

38206. Code selection is based on whether it is allogenic (from a donor) or autologous (from the patient). This is allogenic making 38205 the correct code choice. 25. A patient with recurrent pneumothoraces presents for chemopleurodesis. Under local anesthesia a small incision is made between the ribs. A catheter is inserted into the pleural space between the parietal and pleural viscera. Subsequently, 5g of sterile asbestos-free talc was introduced into the pleural space via the catheter. What CPT® and ICD- 10 - CM codes are reported? a. 32650, J95.811 c. 32601, 32560, J95. b. 32560, J93.81 d. 32650, 32560, J93. ANS: B Rationale: Chemopleurodesis is represented by codes 32560-32562. In the CPT® Index, look for Pleurodesis/Instillation of Agent. Code 32560 is appropriate for the described actions taken to instill the talc used to treat recurrent pneumothorax. Look in the Index to Diseases and Injuries for Pneumothorax NOS/chronic which directs you to code J93.81. Verification in the Tabular List confirms code selection. 26. A physician performs a four-vessel autogenous (one venous, three arterial) coronary bypass on a patient who had a previous CABG two years ago, utilizing the saphenous vein, radial artery and the left and right internal mammary arteries. Select the CPT® codes for this procedure. a. 33535, 33510 - 51, 33530, 35600 c. 33533, 33519, 33530, 35600 b. 33534, 33518, 33530 d. 33535, 33517, 33530, 35600 ANS: D Rationale: Because this is a combo graft, codes 33517-33523 must be coded for the venous portion of the graft. Also, this is a redo more than one month after the original surgery, so the add-on code 33530 is appropriate. This is found in the CPT® Index under Coronary Artery Bypass Graft (CABG)/Arterial- Venous Bypass 33517-33523, and Arterial Bypass 33533-33536. Also listed under this section in the Index is Reoperation 33530. In this same section under CABG is Harvest/Upper Extremity Artery 35600.

Look up the codes in the procedure listing, and you see all additional codes are add-on codes; therefore, no modifiers are required.

27. The cardiologist advances a 6 French catheter into the left renal artery via a right common femoral puncture. It is selectively catheterized and angiographic films are taken. The catheter was then removed and a diagnostic guiding type, RDC catheter was used and the left renal artery was selectively engaged. A 0.014 Supracore wire was used and the lesion was crossed. A 6.0 X 18 mm balloon expandable Racer stent was introduced. This was expanded around 8 atmospheres of pressure which is nominal. Angiography revealed excellent results with no residual stenosis. a. 36245 - LT, 75625 - 26, 37236 b. 36245 - LT, 37236 c. 36245 - LT, 36251, 37236 d. 36246 - LT, 37236 ANS: B Rationale: The left renal artery is a first order vessel as noted in Appendix L of the CPT® codebook (36245-LT). The selective catheterization code is found in the CPT® Index under Artery/Abdomen/Catheterization 36245-36248. Angiography of the left renal vessel was performed; however, there is no mention in the report of the results of the angiography. This is not a diagnostic angiography, rather it is angiography for mapping (checking out known stenosis). The stent was deployed (37236) in the left renal artery; this code also includes the radiologic supervision and interpretation. Code 37236 is found in the CPT® Index under Stent/Placement/Transcatheter/Intravascular. Follow-up renal angiography is bundled with the stent procedure. 28. Preoperative Diagnosis: Aortic valve stenosis with coronary artery disease associated with congestive heart failure Postoperative Diagnosis: Same Anesthesia: General endotracheal Incision: Median sternotomy Description of Procedure: The patient was brought to the operating room and placed in supine position. After the patient was prepared, median sternotomy incision was carried out and conduits were taken from the left arm as well as the right thigh. She was cannulated after the aorta and atrium were exposed and after full heparinization. She went on cardiopulmonary bypass, and the aortic cross-clamp was applied. Cardioplegia was delivered through the coronary sinuses in a retrograde manner. The patient was cooled to 32 degrees. Iced slush was applied to the heart. The aortic valve was then exposed through the aortic root by transverse incision. The valve leaflets were removed, and the #23 St. Jude mechanical valve was secured into position by circumferential pledgeted sutures. At this point, aortotomy was closed.

Attention was turned to the coronary arteries. The first obtuse marginal artery was a very large target and the vein graft to this target indeed produced an excellent amount of flow. Proximal anastomosis was then carried out to the foot of the aorta. The radial artery was anastomosed to the left anterior descending artery target in an end-to-side manner. The proximal anastomosis was then carried out to the root of the aorta. The patient came off cardiopulmonary bypass after aortic cross-clamp was released. She was adequately warmed. Protamine was given without adverse effect. Sternal closure was then done using wires. The subcutaneous layers were closed using Vicryl suture. The skin was approximated using staples. What are the CPT® codes? a. 33900, 33533 - 51, 33510 c. 33405, 33533 - 51, 33510, 35500 b. 33405, 33533 - 51, 33517, 35600 d. 33411, 33533 - 51, 33517, 35600 ANS: B Rationale: A mechanical valve was placed (33405). Look in the CPT® Index for Replacement/Aortic and you are directed to code 33405. A one artery, one venous CABG was performed (33533, 33517). Look in the CPT® Index for Coronary Artery Bypass Graft (CABG)/Arterial-Venous Bypass which directs you to codes 33517-33519, and also look for Arterial Bypass which directs you to codes 33533-33536. The left radial artery is an upper extremity artery and separately reportable (35600), as noted in the guidelines preceding categories Combined Arterial Venous Grafting for Coronary Artery Bypass and preceding Arterial Grafting for Coronary Artery Bypass. Modifier 51 is appended to 33533, because it is an additional procedure performed during the same session. The other codes are add-on codes; therefore, modifier 51 exempt.

29. During an inpatient hospitalization, a patient who suffered myocardial infarction had a combined right and left heart catheterization. Access was achieved through the right femoral artery and the right femoral vein. Selective catheterization of the coronary arteries and selective catheterization of the left ventricle were followed by injections of contrast and angiography. During right heart catheterization, angiography of the right atrium was performed. Imaging supervision, interpretation and report for all angiography was performed during the cardiac catheterization. Select the CPT® code(s) for this procedure by the cardiologist. a. 93453 - 26, c. 93460 b. 93460 - 26, 93566 d. 93460, 93565 ANS: B Rationale: There are three parts to cardiac catheterization: selective catheter placement, injection of contrast, and radiologic supervision and interpretation and report, which are included in most of the cardiac catheterization codes. In the CPT® Index, look for Cardiac Catheterization/Combined Left and Right Heart/with Left Ventriculography 93453, 93460 - 93461. Code 93460 includes right and left heart catheterization, coronary angiography, and left ventriculography. None of the combined right and left heart catheterizations include right atrial angiography; therefore, the add-on code 93566 is reported.

Modifier 26 is required to report the professional service. The add-on code 93566 for the injection procedure is a professional service, and modifier 51 is not required.

30. A 35 - year-old patient presented to the ASC for PTA of an obstructed hemodialysis AV graft in the venous anastomosis and the immediate venous outflow. The procedure was performed under moderate sedation administered by the physician performing the PTA. The physician performed all aspects of the procedure, including radiological supervision and interpretation. Code for all services performed. a. 36905 c. 36902 b. 36901, 36902 d. 36901, 36905 ANS: C Rationale: PTA is the abbreviation for percutaneous transluminal angioplasty. This procedure involves the peripheral dialysis segment, which in the upper extremity extends through the axillary vein or the entire cephalic vein in the case of cephalic venous outflow. The correct code is 36902, which includes angioplasty and all radiological supervision and interpretation. Moderate sedation is not included in this code; however, 99152 is not reported, because the documentation does not indicate who monitored the patient, the medication, the dosage, or the time of the moderate sedation.

40000 Series

31. What is the correct coding for a physician who performs an UGI radiological evaluation of the esophagus, stomach and first portion of the duodenum with barium and double-contrast in the hospital GI lab? (Physician is not employed by the hospital) a. 74246 c. 74246 - 26 b. 74249 d. 74249 - 26 ANS: C Rationale: A radiological evaluation is an X-ray. UGI stands for Upper Gastrointestinal (GI). Look in the CPT® Index for Gastrointestinal Tract/X-ray/with Contrast (for the double-contrast) we are directed to code 74246-74249. Code 74249 represents the same if done with small intestine follow through but here we only performed up to the first portion of duodenum. This is performed in the hospital using hospital equipment. The physician is not indicated to be an employee of the hospital so we must report for the professional services (component) only by appending modifier 26. 32. 40 - year-old male patient is in the surgical suite to have an incarcerated hernia of his belly button repaired. What are the correct CPT® and ICD- 10 - CM codes reported? a. 49582, K42.0 c. 49590, K42. b. 49587, K42.0 d. 49572, K42. ANS: B

Rationale: In the CPT® Index look for Repair/Hernia/Umbilical/Incarcerated. This directs you to codes 49582, 49587 and 49653. Code 49587 represents this procedure is performed on a patient 5-years-old and above. Look in the ICD- 10 - CM Index to Diseases and Injuries for Hernia, hernia (acquired) (recurrent)/umbilicus, umbilical/with obstruction, directing you to K42.0. Verification of this code in the Tabular List, confirms code K42.0 represents an incarcerated umbilical hernia.

33. A patient presents with a 2 cm benign lip lesion. The provider decides to remove the lesion with a portion of the lip by performing a wedge excision. Single-layer suture repair is performed. What CPT® code(s) is/are reported for this service? a. 11442, 12011 - 51 c. 40510 b. 11442, 40510 d. 40510, 12011 - 51 ANS: C Rationale: Because the physician is not only removing the lesion, but also removing part of lip along with doing a repair, code 11422 is not reported. The lesion along with a portion of the lip is removed by a transverse wedge technique. Look in the CPT® Index for Wedge Excision/Lip referring you to code

40510. The code description for code 40510 includes primary closure (suture repair), indicating the suture repair is included in code 40510 and therefore, an integumentary system repair code (12011) is not reported separately. 34. What CPT® and ICD- 10 - CM codes are reported for a gastric restriction by placing a gastric band via laparoscopic surgery for an adult patient diagnosed as morbidly obese having a BMI of 43 with type 2 uncontrolled diabetes with blood sugar readings continually very high each day? a. 43771, E66.01, Z68.41, E10.9 c. 43770, E66.01, Z68.41, E11. b. 43842, E66.01, Z68.41, E11.9 d. 43644, E66.9, Z68.41, E10. ANS: C Rationale: In the CPT® Index, look for Laparoscopy/Stomach (represented by the word gastric)/Gastric Restrictive Procedures or Laparoscopy/Gastric Restrictive Procedures. This directs you to codes 43770 -
40511. In reviewing the codes, 43770 is correct. Look in the Index to Diseases and Injuries for Obesity/morbid directing you to code E66.01. Next look for Body, bodies/mass index (BMI)/adult/40.0-44.9 referring you to Z68.41. Look for Diabetes/type 2, directing you to subcategory code E11.9 Verification of the codes in the Tabular List confirms code selections. 35. What is the correct CPT® coding for a partial distal gastrectomy with Roux-en-Y reconstruction with vagotomy? a. 43621, 43635 c. 43633, 43635 b. 43634, 43635 d. 43633, 43640 - 51 ANS: C Rationale: In CPT® Index look for Gastrectomy/Partial, which directs us to several codes including 43631 - 43635. When reviewing these codes in the main section of CPT®, code 43633 code descriptor

represents a partial gastrectomy with Roux-en-Y reconstruction. Code 43635 represents the vagotomy. Modifier 51 is not used, as code 43635 is an add-on code and is modifier 51 exempt.

36. How do you report a screening colonoscopy performed on a 65-year-old Medicare patient with a family history of colon cancer? The patient’s 72 - year-old brother was just diagnosed with colon cancer. The physician was able to pass the scope to the cecum. What CPT® or HCPCS Level II and ICD- 10 - CM codes are reported? a. G0104, Z13.818, Z85.038 c. 45378, Z12.11, Z85. b. G0105, Z12.11, Z80.0 d. 45330, Z13.818, Z80. ANS: B Rationale: For a Medicare patient, the preferred code to report a screening colonoscopy is HCPCS code G0105 Colonoscopy/cancer screening/ patient at high risk. In the ICD- 10 - CM Index to Diseases and Injuries look for Screening/colonoscopy leads to Z12.11. The patient is high risk due to a family history of colon cancer, which is reported with Z80.0. Look in the Index to Diseases and Injures for History/family (of)/malignant neoplasm/gastrointestinal tract. 37. 56 - year-old patient complains of occasional rectal bleeding. His physician decides to perform a rigid proctosigmoidoscopy. During the procedure, two polyps are found in the rectum. The polyps are removed by a snare. What CPT® and ICD- 10 - CM codes are reported? a. 45320, K62.1 c. 45309, 45309, K63. b. 45385, K63.5 d. 45315, K62. ANS: D Rationale: CPT® code 45315 is the correct code for the removal of more than one polyp by snare technique. In the CPT® Index, look for Proctosigmoidoscopy/Removal/Polyp directing you to 45308 -

45315. During the proctosigmoidoscopy, polyps were removed by snare technique. The correct ICD- 10 - CM code is K62.1 because the polyps are located in the rectum. In the Index to Diseases and Injuries, look for Polyp, polypus/rectum directing you to K62.1. K63.5 is for polyps that are located in the large intestine. 38. 42 - year-old patient is brought to the operating room for a repair of a recurrent incarcerated incisional hernia using mesh. What CPT® and ICD- 10 - CM codes are reported? a. 49561, K40.90 c. 49566, 49568, K43. b. 49566, K43.0 d. 49561, 49568, K43. ANS: C Rationale: An incisional hernia (ventral hernia) is a bulging of the abdominal wall at the site of a past surgical incision. This is an incarcerated incisional hernia, which means that intestine is protruding through an abnormal opening in the abdominal wall. This repair was performed by an open approach, because it is not documented that the procedure was performed laparoscopically. The code is indexed under Hernia Repair/Incisional/Recurrent/Incarcerated referring you to code 49566. When a recurrent

incisional hernia is repaired, the age of the patient is not a factor in choosing the correct CPT® code for the repair. Mesh was used in the repair. Coding Tip note under code 49566 in the CPT® codebook states the use of mesh (49568) can be reported with incisional hernia repair codes. The ICD- 10 - CM diagnosis code is indexed under Hernia/incisional/with obstruction, coding is K43.0. Review of the Tabular List will verify that code K43.0 is reported for an incarcerated incisional hernia with obstruction. The inclusion terms under this include: irreducible, strangulated or causing obstruction.

39. 11 - year-old patient is seen in the OR for a secondary palatoplasty for complete unilateral cleft palate. Shortly after general anesthesia is administered, the patient begins to seize. The surgeon quickly terminates the surgery in order to stabilize the patient. What CPT® and ICD- 10 - CM codes are reported for the surgeon? a. 42220 - 52, Q35.7, R56.9 c. 42215 - 53, Q35.9, R56. b. 42220 - 53, Q35.9, R56.9 d. 42215 - 76, Q35.7, R56. ANS: B Rationale: In the CPT® Index, look for Palatoplasty. Code 42220 represents a secondary repair to a cleft palate. Modifier 53 is appended because the procedure was terminated after anesthesia due to extenuating circumstances. The diagnosis of a complete unilateral cleft palate is indexed in ICD- 10 - CM under Cleft/palate referring you to code Q35.9. Code R56.9 is reported because the patient began to seize after administering the general anesthesia. This is indexed in the ICD- 10 - CM under Seizure(s). 40. A patient is admitted for a simple primary examination of the gastrointestinal system to rule out GI cancer. An EGD is performed that includes the esophagus, stomach, and portions of the small intestine. During the examination, a stricture of the esophagus is identified and subsequently dilated via balloon dilation (20 mm). What CPT® and ICD- 10 - CM codes are reported? a. 43235, C15.9 c. 43249, K22. b. 43248, Q39.3 d. 43235, K22. ANS: C Rationale: In the CPT®^ Index, look for Esophagogastroduodenoscopy/Flexible Transoral/Dilation of Esophagus which directs you to 43233, 43249. The procedure began as a diagnostic EGD which is represented by code 43235. During the exam, a stricture of the esophagus is identified and a surgical endoscopic balloon dilation is performed. The stricture of the esophagus is dilated 20 mm confirming 43249 is the correct code for the procedure. Surgical endoscopy always includes diagnostic endoscopy. Look in the ICD- 10 - CM Alphabetic Index for Stricture/esophagus referring you to K22.2. Reviewing the code descriptor in the Tabular List indicates stricture of esophagus as one of the conditions listed. We do not code GI cancer because it has not been established as a definitive diagnosis and rule-out diagnoses are not reported in outpatient coding.

50000 Series

41. A 63 - year-old gentleman comes into the ED complaining of the urge to urinate but has been unable to empty his bladder. The physician decides to place a Foley catheter to relieve the urine retention due to prostate hypertrophy. What is the code selection for the procedure and diagnosis codes? a. 51701, R33.8, N40.1 c. 51702, R33.9, N40. b. 51702, N40.1, R33.8 d. 51701, N40.1, R33. ANS: B Rationale: In the CPT® Index look for Catheter/Bladder referring you to codes 51701-51703. CPT® code 51702 is correct to report for this scenario since an indwelling catheter (for example a Foley catheter) is left in the bladder and urine is drained. Code 51701 is used when a non- indwelling catheter is inserted to determine post void residual urine; this is sometimes called a straight cath. The patient is diagnosed with urine retention and prostate hypertrophy. In the ICD- 10 - CM Alphabetic Index look for Enlargement, enlarged/prostate/with lower urinary retention guiding you to code N40.1. In the Tabular List locate N40.1 and you are directed to use additional code for associated symptoms. Code R33.8 is used to describe urinary retention. Verify code selection in the Tabular List. 42. Cystoscopy, left ureteroscopy, holmium laser lithotripsy, stone manipulation, stent removal and replacement are performed. The holmium laser was used to break up a cluster of stones at the UP (ureteropelvic) junction, which were removed with a basket and a Gibbons stent was exchanged. Previous CT scan showed stones in the lower right pole, it was decided to proceed with ureteroscopy. Ureteroscope was inserted in the right ureter, confirming multiple stones within the proximal ureter, these were basketed and removed. What CPT® codes are reported for this service? a. 52356 - LT, 52352 - 59 - RT b. 52353 - LT, 52352 - 59 - RT, 52332 - 51 - LT c. 52310, 52353 - 51, 52352 - 59 d. 52353 - LT, 52353 - 59 - RT ANS: A Rationale: When a stent is removed and replaced, the removal of the initial stent is included in the stent replacement and is not reported. One code is reported for performing the lithotripsy and replacement of the stent in the left ureter. In the CPT® Index, look for Lithotripsy/with indwelling Ureteral Stent Insertion directing you to 52356. Usually the basketing of the stones is included with the laser lithotripsy; however, because basketing of stones is performed on a different ureter (RT) than the laser lithotripsy (LT), it is appropriate to add modifier 59 to CPT® 52352. In the CPT® Index, look for Cystourethroscopy/Removal/Calculus directing you to 52352.

43. Circumcision with adjacent tissue transfer was performed on a two month old. What CPT® code(s) is/are reported for this service? a. 14040 c. 54163 b. 54161 - 22 d. 14040, 54161 - 51 ANS: D Rationale: When a circumcision is performed requiring tissue transfer or reconstruction, you report the circumcision and the tissue transfer codes. You do not append modifier 22 to the circumcision code, and reporting only the tissue transfer is incorrect. Reporting repair of an incomplete circumcision is also incorrect, as we have no documentation to support a previous circumcision. In the CPT® Index, look for Circumcision/Surgical Excision directing you to 54161. In the CPT® Index, look for Tissue/Transfer/Adjacent/Skin directing you to 14000-14350. 44. A 32 year-old woman with a previous vertical incision for cesarean delivery presents in spontaneous labor with the baby in cephalic presentation. She has had an uneventful pregnancy and after laboring for 10 hours she delivers a single female child with brief use of a vacuum extractor over an episiotomy that is repaired by the delivering physician. There are no complications. What are the diagnosis codes for this delivery? a. O80, Z3A.00, Z37.0 c. O66.5, O34.212, Z3A.00, Z37. b. O80, O70.9, O66.5, Z3A.00 d. O75.9, O70.9, O82, Z3A.00, Z37. ANS: C Rationale: You do not code a normal delivery, code O80, because a vacuum extractor is used to deliver the baby. In the ICD- 10 - CM Alphabetic Index look for Delivery/complicated/by/attempted vacuum extraction and forceps referring you to code O66.5. ICD- 10 - CM guidelines, I.A.14., state the word “and” should be interpreted as “and” or “or” when appearing in the title. The second code reports the previous cesarean delivery. In the Alphabetic Index look for Delivery/cesarean (for)/previous/cesarean delivery/classical (vertical) scar, guiding you to code O34.212. Instructional note in the beginning of Chapter 15 indicates a code from Z3A is reported with the pregnancy codes. Z3A.00 indicates unspecified weeks. This is found in the Alphabetic Index by looking for Pregnancy/weeks of gestation/not specified. Your last code to report is the outcome of the delivery. Look in the Alphabetic Index for Outcome of delivery/single NEC/liveborn referring you to code Z37.0. Verify all codes in the Tabular List. 45. A 56-year-old woman with biopsy-proven carcinoma of the vulva with metastasis to the lymph nodes has complete removal of the skin and deep subcutaneous tissues of the vulva in addition to removal of her inguinofemoral, iliac and pelvic lymph nodes bilaterally. The diagnosis of carcinoma of the vulva with 7 of the nodes also positive for carcinoma is confirmed on pathologic review. What are the CPT® and ICD- 10 - CM codes reported for this procedure? a. 56637, C51.9, C79.89 c. 56632 - 50, D07. b. 56640 - 50, C51.9, C77.4 d. 56633, 38765 - 50, C51.9, C77.

ANS: B

Rationale: The patient has her vulva removed to treat malignancy (vulvectomy, radical complete). She also has removal of skin and deep subcutaneous tissue from of the vulva, inguinofemoral, iliac and pelvic lymph nodes. In the CPT® Index, look for Vulvectomy/Radical/Complete/ with Inguinofemoral, Iliac, and Pelvic Lymphadenectomy giving you code 56640. All these parts being removed are found in the code description for code 56440. There is a parenthetical note under this code stating: For bilateral procedure, report 56640 with modifier 50. This scenario needs two ICD- 10 - CM codes. The first one is to show the carcinoma of the vulva. This is indexed in the ICD- 10 - CM Index to Diseases under Carcinoma – see also Neoplasm, malignant by site. Go to the Table of Neoplasms look for Neoplasm, neoplastic/vulva/Malignant Primary (column) guiding you to code C51.9. The second diagnosis code is for the metastasis of the cancer to the lymph nodes. This is indexed in the Table of Neoplasms under Neoplasm, neoplastic/lymph, lymphatic channel NEC/inguinal, inguinal/Malignant Secondary (column), guiding you to code C77.4

46. A pregnant patient presents to the hospital in active labor. The obstetrician providing her prenatal care is contacted to perform the delivery. The provider delivers twins. The obstetrician will also provide the postnatal care. What CPT® code(s) describe this procedure? a. 59430 c. 59510 x 2 b. 59400, 59409 - 51 d. 59409 x 2 ANS: B Rationale: The delivery is not specified as vaginal or cesarean and is coded to the lesser RVU, vaginal. In the CPT® Index, look for Vaginal Delivery directing you to codes 59400, 59610-59614. As the physician has provided the prenatal care, the vaginal delivery would be global, described by 59400. The second delivery is coded with 59409 with modifier 51 appended stating this is a multiple procedure. Prenatal and postpartum care applies to the total care of the patient and is not global for both deliveries (59430). 47. 50 - year-old male is diagnosed with a tumor of the skull base just below the occipital tonsils. The neurosurgeon performs a transpetrosal approach to the posterior cranial fossa. He then performs an intradural removal of the tumor of the base of the posterior fossa. Dural repair is done and the area is closed with Neurolon. What CPT® code(s) is/are reported? a. 61521 c. 61598, 61616 - 51 b. 61524 d. 61597, 61608 - 51 ANS: C Rationale: In the CPT® Index, look for Skull Base Surgery/Posterior Cranial Fossa/Transpetrosal Approach (61598) and Skull Base Surgery/Posterior Cranial Fossa/Intradural (61616), which includes the repair. Modifier 51 is added to indicate the same surgeon performed more than one procedure.

48. A patient has a right thyroid lobectomy for a thyroid follicular lesion. An incision is made two cm above the sternal notch and carried through the platysma. The right thyroid was dissected free from the surrounding tissues. The isthmus was divided from the left thyroid lobe. The left thyroid lobe was explored revealing a single nodule. The right thyroid lobe was completely removed from the trachea and surrounding tissues. It was marked and sent off the table as a specimen. What CPT® code is reported? a. 60200 c. 60220 b. 60210 d. 60240 ANS: C Rationale: The patient had a unilateral thyroidectomy. Because only the right side is removed, it is a total unilateral (partial) thyroidectomy. In the CPT® Index, look for Thyroidectomy/Partial and you are directed to code range 60210-60225. 60220 reports a unilateral thyroidectomy with or without an isthmusectomy. 49. 37 - year-old has multilevel lumbar degenerative disc disease and is coming in for an epidural injection. Localizing the skin over the area of L5-S1, the physician uses the transforaminal approach. The spinal needle is inserted, and the patient experienced paresthesias into her left lower extremities. The anesthetic drug is injected into the epidural space. What CPT® code(s) is/are reported for this procedure? a. 64483, 64484 c. 64493, 64494 b. 64493 d. 64483 ANS: D Rationale: In the CPT® index, look for Nerves/Injection/Anesthetic. You are referred to 01991 - 01992 or 64400 - 64530. Review the codes to choose appropriate service. 64483 is the correct code since the anesthetic was injected into the epidural space in one single level (L5-S1) in the transforaminal approach. 50. 36 - year-old male suffered back pain after heavy lifting and was found to have bilateral disc herniation. The patient was placed prone and general anesthesia given. Incision was then made with a 10 - blade knife and dissection was carried downward through the thick adipose tissue to the fascia in a subperiosteal plane. The paraspinous muscles were reflected off L5 and S1. A laminotomy was drilled with the Midas Tex AMB on the inferior end of L5. The thecal sac was retracted medially. The microscope was brought in, direct with microdissection there was a massive disk herniation on the right side underneath the nerve root as well as the left. The disc was incised with an 11-blade knife and was cleaned out with a series of straight and angled curettes and rongeurs. The disc was intertwined with the posterior longitudinal ligament. The space was cleaned out, the foramina were checked and no further compression was found on any of the neural elements. What CPT® codes are reported for this procedure?

a. 63047 - 50, 69990 c. 63030 - 50, 63035 - 50, 69990 b. 63030 - 50, 69990 d. 63005 - 50, 69990 ANS: B Rationale: A laminotomy is also known as a hemilaminectomy. In the CPT® index, look for Hemilaminectomy and you are directed to code range 63020-63044. Code selection is based on the number of interspaces and the section of spine. This is the lumbar spine and only 1 interspace is treated making 63030 the correct code. The parenthetical instructions state to use modifier 50 for a bilateral procedure. This occurred on the left and right side, so modifier 50 is appended. According to CPT®, 69990 is not inclusive to 63030 and should be reported separately. According to NCCI, 69990 is inclusive and cannot be reported separately. For this note, we are following CPT® guidelines. We have included it on all choices to avoid confusion.

60000 Series

51. 89 - year-old patient who has significant partial opacities in the lens of the left eye presents for phacoemulsification and lens implantation. What ICD- 10 - CM code is reported? a. H26.9 c. H26.112 b. H25.9 d. H26.40 ANS: A Rationale: In the ICD- 10 - CM Index to Diseases and Injuries, look for Opacity, opacities/lens-see Cataract. Look for Cataract and you are directed to the default code H26.9. Confirmation in the Tabular List confirms code selection. 52. 6 - year-old female with prominent ears undergoes a bilateral otoplasty. Under conscious sedation, the surgeon makes an incision just behind the ear in the natural fold where the ear is joined to the head exposing the cartilage. Cartilage is trimmed and shaped and the incision is closed. Temporary sutures are placed to secure the ear until healing is accomplished. The procedure is repeated on the other ear. What CPT® code(s) is/are reported? a. 69300 x 2 c. 69310 - 50 b. 69300 - 50 d. 69120 - 22 ANS: B Rationale: In the CPT® Index, look for Otoplasty, it directs you to code 69300 and is confirmed by the code description Auditory System Section. The parenthetical note beneath 69300 instructs us to report the code with modifier - 50 for a bilateral procedure. 53. A patient has heavy skin and muscle (myogenic) that is drooping down and blocking his vision due to ptosis of upper muscular eyelid disorder. The physician performed a bilateral upper blepharoplasty. What ICD- 10 - CM code is reported?

a. H02.423 c. H02.31, H02.34 b. H02.421, H92.422 d. H02.531, H02.534 ANS: A Rationale: Drooping (ptosis) of the upper eyelid is due to a muscle disorder (myogenic). In the ICD- 10 - CM Index to Diseases and Injuries, look for Ptosis/eyelid – see Blepharoptosis. Look for Blepharoptosis/myogenic and you are directed to H02.42-. Tabular List indicates sixth character is needed to indicate laterality. Sixth character of 3 is for bilateral. Only one code is reported for both eyelids, not two separate codes.

54. A patient presents to the emergency room with a severely damaged eye. The injury was sustained when the patient was a passenger in a multi-car accident on the public highway. The patient sustained a large open lacerated wound to the left eye. The posterior chamber was ruptured and significant vitreous and some intraocular tissue was lost. The eyeball was not repairable, and so was removed, en masse. A permanent implant was inserted, but not attached to the extraocular muscles. The patient was released with an occlusive eye patch. What CPT® and ICD- 10 - CM codes are reported? a. 65091 - LT, S05.22XS, V49.59XS, Y92.411 b. 65103 - LT, S05.22XA, V49.59XA, Y92.488 c. 65093 - LT, S05.22XA, V43.92XA, Y92.411 d. 65101 - LT, S05.22XD, V89.2XXD, Y92.488 ANS: B Rationale: Enucleation is the removal of the eye. At the time of surgery, an implant was inserted and extraocular muscles were not attached to it. In the CPT® Index, look for Enucleation/Eye which gives codes 65101, 65103, 65105. Code 65103 best describes this procedure. The LT modifier is appended to indicate that this was the left eye. In the Index to Diseases and Injuries look for Laceration/eye (ball)/with prolapse or loss of intraocular tissue directing you to S05.2-. Tabular List indicates that seven characters are reported to complete the code. The fifth character 2 is reported to indicate left eye. X is used as placeholder for the sixth character position. The seventh character is A to report initial encounter for the patient receiving active treatment in the ED. Documentation does not provide sufficient details of the “multi-car accident” to specify whether the other cars were in motion and if a collision occurred with other objects/persons. Look in the ICD- 10 - CM External Cause of Injuries Index for Accident/transport/passenger/collision (with)/motor vehicle NOS (traffic)/specified type NEC (traffic) V49.59-. The sixth character X as a placeholder and seventh character A for initial encounter in the ED. Look for Place of occurrence/highway (interstate) directing you to Y92.411. 55. Repair of a right eye retinal detachment with a giant tear is performed for an accidental injury sustained from a baseball to the eye at fastball practice. Vitrectomy, drainage of subretinal fluid, silicone oil tamponade, and endolaser photocoagulation are performed to correct the tear. What are the procedure and diagnosis codes for this service?

a. 67113, H33.031, W21.03XA b. 67141 c. 67145, H33.001, T15.01XA d. 67145 ANS: A Rationale: In the CPT® Index look for Retina/Repair/Detachment/with vitrectomy referring you to 67108, 67113. Code 67113 is used for the repair of a giant tear of the retina, with vitrectomy, and endolaser photocoagulation. In the ICD- 10 - CM Alphabetical Index look for Detachment/retina/with retinal/break/giant referring you to H33.03-. In the Tabular List a 6 th^ character 1 is reported for the right eye. In the ICD- 10 - CM External Cause of Injuries Index look for Struck (accidentally) by/ball (hit) (thrown)/baseball. You’re directed to W21.03-. In the Tabular List seven characters are reported to complete the code. The 6th^ character is a placeholder X and the 7th^ character A is used to identify the initial encounter. Surgical management represents an initial encounter.

56. A patient with a cyst-like mass on his left external auditory canal was visualized under the microscope and a microcup forceps was used to obtain a biopsy of tissue along the posterior superior canal wall. What CPT® code is reported? a. 69100 - RT c. 69140 - RT b. 69105 - LT d. 69145 - LT ANS: B Rationale: In the CPT® Index, look for Auditory Canal/External/Biopsy. Verify in the CPT® Auditory System Section. Code 69105 with modifier LT is correct since the biopsy was taken from the left ear in the auditory canal. 57. What CPT® code is reported for a tympanoplasty with mastoidotomy and with ossicular chain reconstruction in the right ear? a. 69644 - RT c. 69646 - RT b. 69636 - RT d. 69632 - RT ANS: B Rationale: In the CPT® Index, look for Tympanoplasty/with Antrotomy or Mastoidotomy/with Ossicular Chain Reconstruction and you are directed to 69636. Append modifier RT to identify the procedure is performed on the right ear. 58. A patient with right and left prominent ears presents for an otoplasty. What CPT® and ICD- 10 - CM codes are reported? a. 69300, Q17.5 c. 69310, H61.113 b. 69300 - 50, Q17.5 d. 69320, H61.113