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Answer Key
Chapter 1
Introduction to Clinical Coding
1.1: Self-Assessment Exercise
- The patient is seen as an outpatient for a bilateral mammogram.
CPT Code: 77055-
Note that the description for code 77055 is for a unilateral (one side) mammogram. 77056 is the correct code for a bilateral mammogram. Use of modifier -50 for bilateral is not appropriate when CPT code descriptions differentiate between unilateral and bilateral.
- Physician performs a closed manipulation of a medial malleolus fracture—left ankle.
CPT Code: 27766-LT
The code represents an open treatment of the fracture, but the physician performed a closed manipulation. Correct code: 27762-LT
- Surgeon performs a cystourethroscopy with dilation of a urethral stricture.
CPT Code: 52341
The documentation states that it was a urethral stricture, but the CPT code identifies treatment of ureteral stricture. Correct code: 52281
- The operative report states that the physician performed Strabismus surgery, requiring resection of the medial rectus muscle.
CPT Code: 67314
The CPT code selection is for resection of one vertical muscle, but the medial rectus muscle is horizontal. Correct code: 67311
- The chiropractor documents that he performed osteopathic manipulation on the neck and back (lumbar/thoracic).
CPT Code: 98925
Note in the paragraph before code 98925, the body regions are identified. The neck would be the cervical region; the thoracic and lumbar regions are identified separately. Therefore, three body regions are identified. Correct code: 98926
- The surgeon performs a colonoscopy with removal of a polyp by hot biopsy forceps.
CPT Code: 45384
The documentation supports this CPT code selection.
7. A 45-year-old patient has a repair of a recurrent, incarcerated inguinal hernia.
CPT Code: 49507
The documentation supports the selection of the code for “recurrent” not “initial.” Correct code: 49521
- The surgeon performs an ERCP with endoscopic retrograde removal of a stone from the biliary duct.
CPT Code: 43269
Code 43269 identifies ERCP for removal of a foreign body. Correct code: 43264
- The surgeon performs an excision of a 1.5 cm deep intramuscular soft tissue tumor of the scalp.
CPT Code: 21011
CPT distinguishes between an “intramuscular” soft tissue tumor excision from subcutaneous. Code 21011 is for a subcutaneous tumor, which does not match the documentation. Correct code: 21013
- The physician performs a fine needle aspiration biopsy of the testis.
CPT Code: 54500
Note the parenthetical statement beneath code 54500 that states: “(For fine needle aspiration, see 10021, 10022).” A coder would need further documentation to determine if the biopsy was performed with imaging guidance (CPT code 10022) or without imaging guidance (10021).
Chapter 2
Application of the CPT System
2.1: Matching Exercise
- ___ Complete list of modifiers (D) A. Appendix B
- ___ Complete list of add-on codes (C) B. Category II code
- ___ 82525 Copper (E) C. Appendix D
- ___ Complete list of recent additions, deletions and revisions (A) D. Appendix A
- ___ 1119F Initial evaluation for condition (B) E. Pathology and Laboratory code
2.2: Referencing CPT Assistant Exercises
- Refer to note below CPT code 29530. In the Professional Edition of CPT t what does the following note indicate?
CPT Assistant Feb 96:3, April 02:
Answer: This note refers the coder to the February 1996 edition of CPT Assistant (page 3) and April 2002 (page 13) for additional information about use of this code.
- The surgeon removed three (3) stones from the ureter. Is it appropriate to report code 50945 ( Laparoscopy, surgical; ureterolithotomy) for each stone removed from the ureter?
Answer: No. Code 50945 is intended to be reported once per surgical session, regardless of the number of stones removed ( CPT Assistant, September 2006).
- If a physician performs an arthroscopy with joint debridement in the anterior compartment (CPT code 29846), and through different portals performed an arthroscopy complete synovectomy in the posterior compartment (CPT code 29845), can both procedures be separately reported during the same operative session appending modifier 59?
Answer: No. From a CPT coding perspective it would not be appropriate to report both codes if performed within the same wrist during the same operative session, regardless of how many times the arthroscope is inserted into the wrist. Arthroscopy of all compartments, radioiulnar, radiocarpal and midcarpal, anterior or posterior, are considered inclusive components of codes 29840-29847. Therefore, it would not be appropriate to report for different compartments ( CPT Assistant, December 2003).
- The surgeon removed a non-tunneled central venous access catheter. CPT provides codes for removal of a tunneled devices (36589-36590), but the note under code 36590 states, “Do not report these codes for removal of non-tunneled central venous catheters.” Should the coder assign an unlisted code?
Answer: No. The work required for non-tunneled central venous access catheter is considered to be inherent in the evaluation and management visit in which it is performed ( CPT Assistant, December 2004).
2.3: Application of CPT Exercises
- The physician performs a synovial biopsy of the metacarpophalangeal joint. Using the Alphabetic Index, what key word(s) lead you to the coding selection? What is the correct code?
Answer (several entries in index): Synovium, Biopsy, Metacarpophalangeal Joint…….. 26105 Biopsy, Metacarpophalangeal Joint…………..……… 26105 Metacarpophalangeal Joint, Biopsy, Synovium…...…… 26105
- The surgeon performed a radical resection of a 0.5cm lesion of the back. The malignant neoplasm extended into the soft tissue. Refer to the term “Lesion” in the alphabetic index. What guidance does the Alphabetic Index provide? What is the correct code?
Answer: Under the term “Lesion,” there is no entry for back. The note under Lesion states to “See Tumor.” From the term “Tumor” in the Alphabetic Index, the coder is directed to Back/Flank and Radical Resection 21936.
- After an injection of Lidocaine, the surgeon performed a percutaneous tenotomy (Achilles tendon). Refer to 27605-27606. What is the correct code assignment?
Answer: Lidocaine is a local anesthesia; therefore, code 27605 is assigned.
- Using cryosurgery, the surgeon removed four (4) dermatofibromas of the leg. Refer to CPT codes 17000-
- What would be the correct code assignment?
Answer: Dermatofibromas are benign. Code 17110 should be assigned.
- Refer to codes 57550-57556. The surgeon performed an excision of a cervical stump, vaginally, with repair of an enterocele. What is the correct code assignment?
Answer: 57556. The description for this code would be: Excision of cervical stump, vaginal approach; with repair of enterocele.
- Insertion of a Foley catheter (temporary)
Index: Insertion, Catheter, urethra (Foley is a type of urinary catheter.)
Code: 51702
- Biopsy of lacrimal sac
Index: Biopsy, lacrimal sac
Code: 68525
Chapter 3
Modifiers
3.1: Matching Exercise
Match the following modifiers with the appropriate description.
- ___ 3P (C) A. Physical status (anesthesia) modifier
- ___ F4 (B) B. HCPCS National modifier
- ___ 73 (D) C. Category II modifier
- ___ P5 (A) D. CPT Modifier Approved for Hospital Outpatient Use only
- ___ 53 (E) E. CPT Modifier not Approved for Hospital Outpatient Use
3.2: Select the Modifier Exercises
- Patient is seen in the physician’s office for his yearly physical (CPT code 99395- Preventive Medicine E/M). During the exam, the patient requests that the physician remove a mole on his shoulder. What CPT modifier would be appended to the 99395 to explain that the E/M service was unrelated to excision of the mole?
Answer: Modifier 25
- Patient is seen in a radiology clinic for an X-ray of the arm (73090). The films are sent to another radiologist (not affiliated with the clinic) to interpret and write the report. What HCPCS Level II modifier would be appended to the CPT code for the services of the radiology clinic?
Answer: TC for Technical Component
- A surgeon performed an esophageal dilation (43453) on a 4-week-old newborn who weighed 3.1 kg. What CPT modifier would be appended to CPT code to describe this special circumstance?
Answer: 63 Procedure Performed on Infants less than 4 kg
- The surgeon performed a tenolysis, extensor tendon of the right index finger (26445). What HCPCS Level II modifier should be appended to the CPT code?
Answer: F6 Right hand, second digit
- A planned arthroscopic meniscectomy of knee was planned for a patient. During the procedure, the scope was inserted but the patient went into respiratory distress and the procedure was terminated. What CPT modifier would be appended to the CPT code (29880) for the physician’s services?
Answer: 53 Discontinued Procedure. This modifier would be appended to the planned procedure for physician services.
3.3: Coding/Modifier Case Studies
Case Study # 1
The surgeon performed a carpal tunnel release (median nerve) on the left and right wrist.
Index: Carpal Tunnel syndrome
Code(s): 64721-50 (modifier for bilateral)
Case Study # 2
A 45-year-old male is brought to the endoscopy suite for diagnostic EGD. Patient is prepped. After moving the patient to the procedure room, and prior to initiation of sedation, he develops significant hypotension, and the physician cancels the procedure. Code for hospital services.
Index: Endoscopy, Gastrointestinal, Upper, Exploration
Code(s): 43235 -73 Diagnostic EGD (modifier for Discontinued outpatient procedure prior to anesthesia administration)
Case Study # 3
The surgeon performed a tonsillectomy and adenoidectomy on a 25-year-old male. Four hours after leaving the surgery center, the patient presents to the clinic with a 1-hour history of bleeding in the throat. The bleeding site was located; however, it was in a location that could not be treated outside the OR. The patient was taken back to the OR for control of postoperative bleeding.
Index: Tonsillectomy and Hemorrhage, Throat
Code(s): 42821: Tonsillectomy and adenoidectomy, age 12 years or older 42962-78 Control oropharyngeal hemorrhage with secondary surgical intervention (modifier for return to OR for a related procedure during the postoperative period)
Case Study # 4
Patient presented for capsule endoscopy of the GI tract. The ileum was not visualized.
Index: Gastrointestinal Tract, Imaging, Intraluminal
Code(s): 91110-52 GI tract imaging, intraluminal (Modifier for reduced services. The capsule endoscopy should include visualization from the esophagus through ileum.)
4.2: Clinical Concepts
Fill in the blanks for the following scenarios. Choose from one of the two answers provided in parentheses.
- The physician uses a laser to remove a lesion of the back. For coding purposes, this would be classified as ___________________ (excision or destruction ).
- The surgeon removes a 2.0 cm seborrheic keratosis of the neck. The lesion would be defined as _____________ ( benign or malignant).
- The physician sutured a 3 cm x 2 cm superficial laceration of the knee. The wound required removal of gravel and dirt. For coding purposes, this would be classified as: ________________ ( simple or intermediate repair).
- The skin graft required harvesting healthy skin from the patient’s right thigh to cover the defect of the arm. This type of graft is called: _____________ ( autograft , allograft or xenograft).
- The 3.0 cm lipoma extended into the tendon of the shoulder. The code for this procedure would be selected from the ____________ chapter (integumentary or musculoskeletal ).
4.3: Integumentary System Coding Drill
For all coding exercises, review the documentation and underline key term(s). Identify the terms used to look up the code selection in the Alphabetic Index. Assign CPT codes to the following cases. If applicable, append CPT/HCPCS Level II modifiers. In some cases, the student will be prompted to answer questions about the case study.
- With the use of a YAG laser, the surgeon removed a 2.0 cm Giant congenital melanocytic nevus of the leg. Pathology confirmed that the lesion was premalignant.
Index: Lesion, Skin, Destruction, Premalignant (Note that laser is classified as destruction and the morphology of the lesion is premalignant.)
Code(s): 17000 Destruction, premalignant; first lesion
- Operative Note: After local anesthesia was administered, the site was cleansed and an incision was made in the center of the sebaceous cyst. The cyst was drained and irrigated with a sterile solution. Diagnosis: sebaceous cyst of back.
Index: Incision and Drainage, Cyst, Skin
Code(s): 10060 Incision and drainage of abscess, cyst; simple
- A surgeon reports that the patient has a 2.0 cm basal cell carcinoma of the chin. The excision required removal of 0.5 cm margins around the lesion.
Index: Lesion, skin, excision, malignant
Code(s): 11643 (size calculated as 2.0 cm + .5 cm + .5 cm = excised diameter)
- A physician performs a simple avulsion of the nail plate, second and third digits of the left foot.
Index: Nails, avulsion
Code(s): 11730-T1, 11732-T2 (11732 is an add-on code, used to identify additional nail plates.)
- Operative Procedure: Shaving of a 0.5 cm pyogenic granuloma of the neck
Index: Lesion, skin, shaving (Note that pyogenic granuloma is a benign lesion; characterized as a red papule.)
Code(s): 11305 Shaving of dermal lesion, single
- A patient is seen in the Emergency Department after an accident. A 3.0 cm deep wound of the upper arm (located in area of non-muscle fascia) required a layered closure and a 1.0 cm superficial laceration of the left cheek was repaired.
Index: Wound, Repair (intermediate and simple). Terms “deep, non-muscle fascia” and “layered” documents an intermediate closure. Superficial indicates a simple repair.
Code(s): 12032 Intermediate repair (extremities) 2.6 to 7.5 cm 12011 Simple repair, face 2.5 or less
- Operative Note: Patient seeking treatment for a cyst of left breast. A 21-gauge needle was inserted into the cyst. The white, cystic fluid was aspirated and the needle withdrawn. Pressure was applied to the wound and the site covered with a bandage.
Index: Breast, Cyst, Puncture Aspiration
Code(s): 19000-LT Puncture aspiration of cyst of breast
- The surgeon fulgurates a .5 cm superficial basal cell carcinoma of the back.
Index: Lesion, Skin, Destruction, Malignant (Fulguration is a destruction technique; basal cell carcinoma is malignant.)
Did the physician close the wound routinely or was there a layered closure? Note: Routine wound closure (included in CPT code), no mention of layered closure.
Time to Code: Index: Lesion, Skin, Excision, Benign (11400-11471)
Code(s): 11406 (Excision, benign lesion, trunk, excised diameter over 4.0)
Operative Report
Preoperative Diagnosis: 1.0 cm malignant melanoma, right heel Postoperative Diagnosis: Same Operation: Wide local excision with split thickness skin graft from the left thigh Anesthesia: Spinal
Indications: This-72-year old patient has a 1.0 cm malignant lesion of the left heel. He has agreed to a wide local excision.
Procedure: The patient was taken to the operating room, prepped and draped in the usual sterile fashion. A 1/20 of an inch thick split-thickness skin graft (7 cm x 7 cm) was harvested from the left thigh and preserved. Next, the lesion, which was on the medial aspect of the right heel, was excised with 2.5 cm margins down to and including some of the plantar fascia. Total excised diameter was 6.0 cm. Hemostasis was achieved with 2-0 Tycron sutures and the cautery. After suitable hemostasis was obtained, the wound margins were advanced with interrupted sutures of 2-0 chromic and then the skin graft was placed.
The skin graft was approximated to the skin using interrupted running sutures of 4-0 chromic, and then holes were punched in the skin graft to permit egress of serous fluid. Then, a bolster dressing of cotton batting wrapped in Owen’s gauze was placed over the skin graft site and secured to the skin with multiple sutures tied over it to 2- Tycron. The skin graft donor site was wrapped with Owen’s gauze, two moistened ABD pads and wrapped with a Kerlix and an Ace wrap. The patient tolerated the procedure well and was transported awake and alert to the recovery room in excellent condition.
Abstract from Documentation: What procedure was performed? Excision of lesion and skin graft to cover the defect
What are the excised diameter, location, and type (malignant/benign) of lesion? Malignant lesion of left heel-lesion was 1.0 cm, but 2.5 cm margins were obtained (1.0 + 2.5 + 2.5 = 6.0 cm lesion)
What is the coding guideline that for coding excision of lesion with subsequent skin replacement surgery? Do you code both or just the skin graft? When an excision of a lesion requires a skin replacement/substitute graft for repair of the defect, the coder should assign the excision of lesion code in addition to the graft.
What type of skin graft was performed? Adjacent? Skin Replacement? Autograft? Cultured tissue? Free (autologous) from thigh to cover defect of heel
Was the skin graft full-thickness or split-thickness? Split-thickness
For coding purposes, identify site of defect, size and type of graft: Split-thickness, autograft, heel and less than 100 sq cm (size of skin removed was 7 x 7 cm)
Time to Code: Index for Excision of Lesion: Lesion, Skin, Excision, Malignant
Index for Skin Graft: Skin, Graft, Free
Code(s): 15120 Split-thickness autograft, feet, first 100 sq. cm or less 11626 Excision, malignant lesion, feet, over 4.0 cm
Emergency Department Record
Chief Complaint: Scalp laceration History of Present Illness: Patient is an 88-year-old white female who lost her balance and fell in her room today, hitting her head and sustaining a laceration of her right scalp. No loss of consciousness. No syncope. No neck pain. No vomiting. She has been acting normally according to her daughter since the injury. Post Medical History: Hypertension; dementia Medications: Colace, iron, hydrochlorothiazide, Paxil Allergies: None. Immunizations: Not up to date.
Physical Examination: General: Alert female in no acute distress. Head, Ears, Eyes, Nose and Throat: There is a 3.5 cm full skin thickness scalp laceration. Minimal swelling. No deformity. Pupils are equal and reactive to light. Extraocular muscles intact. Tympanic membranes normal. Oropharynx negative. Neck: Supple. Nontender Heart: Regular. No murmurs or gallops noted. Lungs: Breath sounds equal bilaterally and clear. Extremities: Atraumatic. Full range of motion.
Time to Code:
Index: Lesion, Skin, Shaving
Code(s): 11307 Shaving of epidermal lesion, 2.0 cm
(Note: The surgeon took a biopsy of the lesion to send to Pathology. CPT guidelines state that if a biopsy and removal is performed on the same lesion, only code the removal.)
Musculoskeletal System Exercises
Source: National Cancer Institute. n.d. VisualsOnline. Unknown photographer/artist. http://visualsonline.cancer.gov/details.cfm?imageid=1766.
4.5: Crossword Puzzle
4.6: Clinical Concepts
Fill in the blanks to the following scenarios. Choose from one of the two answers provided in parentheses.
- The Radiology Report revealed that the fracture was not aligned correctly during the healing process. This fracture would be referred to as _______________ (nonunion or malunion ).
- At bedside, the Emergency Department physician realigned the fracture. The manipulation is known as _________________ ( closed , open).
- The patient has advanced arthritis of the elbow joint. The physician performs a fusion of the joint to provide stability. This procedure is referred to as _____________ ( arthrodesis , tenolysis).
- During the procedure, the surgeon encountered numerous restrictive bands of scar tissue. For this condition, you would expect to see _______________ documented in the health record ( lysis of adhesions , synovectomy).
- Medial malleolus is located in the ____________ (knee, ankle ).
- Surgeon performed an arthroscopy of the right knee, with limited synovectomy and shaving of articular cartilage.
Index: Arthroscopy, surgical, knee
Code(s): 29877-RT (Code 29875 should NOT be assigned; it is a “separate procedure” code and is considered to be an integral part of the procedure.)
- A patient is diagnosed with osteochondroma of the scapula. The surgeon excises the tumor.
Index: Tumor, Scapula, Excision (Osteochondroma is benign)
Code(s): 23140 Excision or curettage of bone cyst or benign tumor of clavicle or scapula
- The surgeon performs an open reduction with bone screw insertion for internal fixation of the right tibial shaft.
Index: Fracture, Tibia, Shaft, with Manipulation
Code(s): 27758-RT Open treatment of tibial shaft fracture (with or without fibular fracture), with plate/screws, with or without cerclage
- Patient treated for posttraumatic osteoarthritis of right knee. The surgeon performed a total knee arthroplasty. All components were removed and surfaces were irrigated. The components were cemented into place beginning with a femora component and followed by the tibial component and then the patellar component.
Index: Replacement, Knee
Code(s): 27447-RT Arthroplasty, knee
- Patient has the diagnosis of wet gangrene of the left great toe. The physician performs an amputation of the metatarsophalangeal joint with removal of the left great toe.
Index: Amputation, toe
Code(s): 28820-LT Amputation, toe; metatarsophalangeal joint
4.8: Case Studies - Musculoskeletal System Operative
and Emergency Department Reports
Emergency Department Report
Chief Complaint: Left wrist injury
History of Present Illness: The patient is a 5-year-old female that presents in the ED after accidentally falling off her bicycle. She tried to brace her fall with her left wrist and now says there is pain that increases with movement. She had no other injuries. There were no head injuries.
Vital Signs: Blood pressure 117/72, temperature 97.8, pulse 106, respirations 20.
General: The patient is alert, oriented x 3 in no acute distress seated in the hospital bed. Extremities: Physical exam of the left upper extremity reveals no deformity. To palpation the patient has tenderness of the distal radius and ulna. No tenderness to palpation of the hand. Range of motion is limited in the wrist but intact in the hand and elbow with no tenderness in the elbow.
Emergency Department Course: X-ray of the left wrist revealed a Buckle fracture of the distal radius and ulna. Volar splint and sling were applied. The patient was discharged.
Assessment: Buckle fracture left distal radius and ulna
Plan: Ice and elevate, return if worse, follow-up with orthopedics in 2-3 days, Tylenol with codeine elixir p.r.n. for pain was prescribed. Abstract from Documentation: What was the treatment for the fracture? Applied volar splint
Time to Code: Index: Splint, arm, short
Code(s): 29125-LT Application of short arm splint (forearm to hand) static (Note: Static is used for immobilizing of the injury; dynamic allows for mobilization.)
