Category Archives: CPT

CPC Practice questions

Practice Questions For CPC Exam 2017 – Part Two

Question 26

General anesthesia is administered to a 9-month-old undergoing a tracheostomy. Code the anesthesia service.

  1. 00320, 99100
  2. 00320
  3. 00326
  4. 00326, 99100

Question 27

65-year-old woman is one year post with B-cell non-Hodgkin’s lymphoma. She is having recurrent fever and pain. Tumor recurrence was confirmed by CT studies and chest X-ray. She has failed prior chemotherapy and radiation treatments. A new treatment is being contemplated and she is referred for a radiopharmaceutical distribution imaging as a requirement before starting this new treatment. The provider injects small amounts of gamma-emitting radioactive material paying particular attention for potential reaction. A gamma camera is used to take planar images of the whole body for three days. Three sets of image data are interpreted. Qualitative assessment of distribution and determination of treatment with monoclonal antibody are provided. A report is dictated and placed in the medical record. Which CPT® code is reported?

  1. 78806-26
  2. 78802-26
  3. 78804-26
  4. 78801-26

Question 28

Due to an elevated CEA level two years following a colon resection, the patient’s oncologist ordered a diagnostic liver ultrasound. Which radiology code is reported for this encounter.

  1. 76700
  2. 78206
  3. 76705
  4. 76970

Question 29

52-year-old male has a 3.2 cm metastasized lung cancer in his left upper lobe. The tumor can not be removed by surgery due to the patient having severe respiratory conditions. He will be receiving sterotactic body radiation therapy management under image guidance. There is a delivery of 25 Gy for four fractions under direct supervision of the radiation oncologist. The patient’s treatment set up is assessed to manage the execution of the treatment to make any adjustments needed for accuracy and safety. The oncologist reviews and approves all the images used to locate the tumor and images of fields arranged to deliver the dose.  What CPT® and ICD-9-CM codes should be reported?

  1. 77373, V58.0, 162.9
  2. 77435, V58.0, 197.0
  3. 77435, 197.0, V58.0
  4. 77402, 162.9, V58.0

Question 30

A 42-year-old has a lesion on his pancreas. The physician passes the biopsy needle through the skin and removes tissue to be sent to pathology. Fluoroscopic guidance is used to obtain the biopsy. Physician’s report and interpretation is placed in the record. Code this encounter.

  1. 48100, 77002-26
  2. 48102, 77002-26
  3. 48120, 76942-26
  4. 48102, 76942-26

Question 31

Patient is undergoing in vitro fertilization to get pregnant. Following the retrieval of follicular fluid from the patient, the physician uses a microscope to examine the fluid to identify the ooctyes. What is the code for the laboratory service?

  1. 89250
  2. 89254
  3. 89255
  4. 89258

Question 32

22-year-old comes into the Emergency Department with convulsions. The ED physician orders a drug screening without identifying any specific drug class to be tested. The lab runs a multiple drug classes screening using an immunoassay. The lab report comes back positive for alcohol and benzodiazepines. The ED physician then orders a confirmatory test to be performed by the lab to confirm both positive results. What CPT® codes are reported?

  1. 80301, 80320, 80346
  2. 80300, 80320, 80346
  3. 80302 x 2, 80320 x 2, 80346 x 2
  4. 80300 x 2, 80320 x 2, 80346 x 2

Question 33

A pathologist performs a comprehensive consultation and report after reviewing a patient’s records, specimens and official findings from other sources. What is the correct code?

  1. 88325
  2. 99244
  3. 80502
  4. 88329

Question 34

Photodynamic therapy involving application of light externally to destroy premalignant lesions on the lower lip was provided to a 63-year-old patient. Code the encounter.

  1. 96570
  2. 96999
  3. 96567
  4. 96913

Question 35

A four-year-old patient presents with pain in the left forearm following a fall from a chair. The injury occurred one hour ago. Her mom applied ice to the injury but it does not appear to help. The ED physician performs a detailed history, expanded problem focused examination and medical decision making of moderate complexity. An X-ray is ordered, which shows a fracture of the distal end of the radius as read by the radiologist. The ED physician consults with an orthopedic surgeon. The ED physician performs moderate conscious sedation with Ketamine for 30 minutes. The fracture is reduced and cast applied by an orthopedic surgeon. The child was monitored with pulse oximetry, cardiac monitor and blood pressure by the ED physician frequently. The patient was discharged with a sling and requested to follow up with the orthopedic surgeon. Code the services performed by the ED physician.

  1. 99284-25, 99148
  2. 99283-25, 99148
  3. 99283-25, 99143
  4. 99284-25, 99143

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Question 36

In the inpatient setting, the psychiatrist provides psychotherapy for 30 minutes to affect a change in the patient’s maladaptive behavior. What is the procedure code?

  1. 90845
  2. 90832
  3. 90847
  4. 90853

Question 37

CKD is a disease of which system?

  1. Circulatory
  2. Genitourinary
  3. Digestive
  4. Musculoskeletal

Question 38

A person who has nephritis has inflammation in what location?

  1. Gallbladder
  2. Nerve
  3. Uterus
  4. Kidney

Question 39

What is ascites?

  1. Fluid in the abdomen
  2. Enlarged liver and spleen
  3. Abdominal malignancy
  4. Abdominal tenderness

Question 40

Which of the following is a disorder of the facial nerve?

  1. Exotropia
  2. Tarsal tunnel syndrome
  3. Brachial plexis lesions
  4. Bell’s palsy

Question 41

Complete this series: Pulmonary, Aortic, Mitral, and ________are valves of the heart.

  1. Tricuspid
  2. Superior Vena Cava
  3. Carotid
  4. Atrium

Question 42

Which of the following terms is one who has an overload of sodium?

  1. Hyperkalemia
  2. Hyperpotassemia
  3. Hypernatremia
  4. Hypercalcemia

Question 43

The term paracentesis found in CPT® code 49082 means:

  1. A procedure performed to drain fluid that has accumulated in the abdominal cavity
  2. An abdominal incision is made to open the abdominal cavity for drainage
  3. Removal of tissue samples from the abdominal cavity by an open approach
  4. Removal of a cyst located in the abdominal cavity

Question 44

A 25-year-old is brought to the burn unit being rescued from a burning house. She sustained 25% second degree burns on her anterior trunk and back and 20% third degree burns on her legs and arms. Total body surface area burned is 45%. What ICD-9-CM code is reported for the burns classified according to the extent of body surface involved?

  1. 948.22
  2. 948.04
  3. 948.24
  4. 948.42

Question 45

The patient is a 75-year-old woman who is here for follow-up after an incident last week in which she had an FB lodged in her throat. An emergency esophagoscopy was performed and the piece of hamburger meat removed and biopsy performed. She is positive for Barrett’s esophagus. She has GERD which is currently being treated by medication and is here today to be evaluated for photodynamic therapy.

What diagnosis codes should be reported for today’s visit?

  1. 530.3, 530.85
  2. 935.1, 530.85, E915
  3. 935.1, 530.85, 530.81 E915
  4. 530.85, 530.81

Question 46

A 78-year-old patient, with known arrhythmia, presented to an outpatient clinic for the insertion of a cardiac event recorder. What is the proper HCPCS Level II code for this device?

  1. C1767
  2. C1764
  3. C1777
  4. E0616

Question 47

The physician performed manipulation of a closed fracture of the distal radius on a 12-year-old male. He placed a short arm fiberglass cast. What is the HCPCS Level II code for the supply?

  1. Q4012
  2. Q4011
  3. Q4010
  4. Q4009

Question 48

Which of the following statements regarding the ICD-9-CM coding conventions is TRUE?

  1. If the same condition is described as both acute and chronic and separate subentries exist in the Alphabetic Index at the same indentation level, code only the acute condition.
  2. Late effect codes are reported for a current acute phase of the injury or illness
  3. An ICD-9-CM code is still valid even if it has not been coded to the full number of digits required for that code.
  4. Signs and symptoms that are integral to the disease process should not be assigned as additional codes, unless otherwise instructed.

Question 49

Which modifier should be append to a CPT®, for which the provider had a patient sign an ABN form because there is a possibility the service may be denied because the patient’s diagnosis might not meet medical necessity for the covered service?

  1. GJ
  2. GA
  3. GB
  4. GY

Question 50

What is the patient’s right when it involves making changes in the personal medical record?

  1. Patient must work through an attorney to revise any portion of the personal medical information.
  2. They should be able to obtain copies of the medical record and request corrections of errors and mistakes.
  3. It is a violation of federal health care law to revise a patient medical record.
  4. Revision of the patient medical record depends solely on the facility’s compliance program policy.

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Find answers of these questions by visiting below link.

Answers – Practice Questions For CPC Exam 2017

How to code burns

How To Code Burn Treatments


A burn is an acute wound, defined as an injury to the skin or other organic tissue primarily caused by thermal or other acute trauma.

Caused By –

  1. Hot liquids (scalds)
  2. Hot solids (contact burns)
  3. Flames (flame burns)
  4. Radiation,
  5. Radioactivity,
  6. Electricity,
  7. Friction or contact with chemicals

Burn Depth and Classification

First Degree (Superficial or Epidermal) Burns These burns involve only the epidermis. They do not blister, but are red and quite painful. Over 2-3 days the erythema and the pain subside. By about day 4, the injured epithelium peels away from the newly healed epidermis underneath, a process which is commonly seen after sunburn.

Second Degree (Partial Thickness) Burns Partial-thickness burns involve the epidermis and portions of the dermis.

  1. Superficial partial-thickness
  2. Deep partial-thickness burns.

Superficial partial-thickness burns – Blisters between the epidermis and dermis.

Deep partial-thickness burns –  Extend into the lower layers of the dermis.

Third Degree (Full-Thickness) Burns Full-thickness burns involve all layers of the dermis and often injure underlying subcutaneous adipose tissue as well. Burn eschar is structurally intact but dead and denatured dermis. Some fullthickness burns involve not only all layers of the skin, but also deeper structures such as muscle, tendon, ligament and bone, and are classified as deep full-thickness or fourth-degree. Grafting may use autologous skin grafts or biologic dressings and skin substitutes or both. Deep full-thickness burns may require amputation or closure with alternative techniques (such as adjacent tissue transfer or microvascular procedures).

Burn Coding

Escharotomy —An escharotomy is defined as a surgical incision through burn eschar (necrotic skin). Technique—Escharotomy (incision through the eschar) releases the constricting tissue allowing the body tissues and organs to maintain their normal perfusion and function.

Debridement of Burn —Debridement is the removal of loose, devitalized, necrotic, and/or contaminated tissue, foreign bodies, and other debris on the wound using mechanical or sharp techniques (such as curetting, scraping, rongeuring, or cutting). The level of debridement is defined by the level of the tissue removed, not the level exposed by the debridement process. Debridement cleans the wound and allows it to heal more rapidly with reduced risk of infection. In general, debridement is performed on shallow burns that are expected to heal without the need for skin grafting.

Excision of Burn Wounds —Excision is a surgical procedure requiring incision through the deep dermis (including subcutaneous and deeper tissues) of open wounds, burn eschar, or burn scars. Excision is typically performed on deep burns that would not heal on their own. The goal is to remove all necrotic and non-viable tissue and to prepare the wound for immediate or delayed wound closure.

Burn debridement (cleaning) and excision (escharectomy) are routinely performed by experienced burn surgeons. Though the techniques and instruments used for debridement and excision are often similar, burn excision is significantly more difficult and requires greater time and physical effort to achieve meticulous burn wound preparation for subsequent grafting with synthetic or biological materials.

Tangential excision (which is usually performed on deep partial thickness burns) Tangential excision involves surgical removal of successive layers of the burn wound down to viable dermis

Full thickness excision —often using electrocautery—involves removal of the burn wound down to viable subcutaneous tissue or to fascia.


Skin Substitutes and Skin Replacements

Skin substitute : A biomaterial, engineered tissue or combination of materials and cells or tissues that can be substituted for skin autograft or allograft in a clinical procedure.

Skin replacement: A tissue or graft that permanently replaces lost skin with healthy skin.

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The procedure codes (16020 – 16030) are used to report the local treatment of the burn wound itself. These codes do not include evaluation and management services. The usual pre- and post-procedural services (e.g., explaining procedures to the patient/family, supervising the positioning and prepping of patient; monitoring stability of the patient, as appropriate; and after care instruction) are included in the debridement/dressing CPT code and not reported separately.

Surgical preparation  for Burn Surgery codes (15002 – 15005) Vs Burn Debridement/Dressing change codes (16020 – 16030)

Burn coding

Burn Codes

There are several CPT codes related to burn coding that I want to share with you to enhance your coding and reimbursement. These codes refer to local treatment of burned surface area only.

Burn dressing and/or debridement codes (16020-16030) are divided based on whether the dressing or debridement is of a small, medium, or large area. Small is less than 5% of the total body surface area, medium is the whole face or whole extremity, or 5% to 10% of the total body surface area, and large is more than one extremity or greater than 10% of the total body area.

  1. 16000 – Initial treatment, first degree burn, when no more than local treatment is required
  2. 16020 – Dressings and/or debridement, initial or subsequent; without anesthesia, office or hospital, small
  3. 16025– Dressings and/or debridement, initial or subsequent; without anesthesia, medium eg, whole face or whole extremity)
  4. 16030– Dressings and/or debridement, initial or subsequent; without anesthesia, large eg, more than one extremity)
  5. 16035 – Escharotomy
  6. 16036 – Escharotomy, each additional incision List separately in addition to code for primary procedure

When using these burns codes, remember to document percentage of body surface involved and depth of burn. Remember your “Rule of Nines” in calculating Total Body Surface Area.

Rule of Nines for Burns
Rule of Nines for Burns

These codes can be used in addition to an office visit; however, the office visit must be medically necessary and a modifier -25 must be appended to the office visit. An example of a medically necessary office visit would be to prescribe medications (such as antibiotics and/or pain medication, for example).

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How To Code – Adjacent Tissue Transfer, Skin Replacement and Flaps

Adjacent Tissue Transfer and Skin Replacement Procedures

  1. Recipient site – The area of defect that receive a graft
  2. Donor Site – The area from which healthy skin has been taken for grafting.

Skin Grafting –  To correct a defect site. Various types –

  1. Adjacent Tissue Transfer (1400-14350)
  2. Skin Replacement Surgeries (15002-15278)
  3. Flaps

Adjacent Tissue Transfer:  Various types of ATT like – Z Plasty, W Plasty, V-Y Plasty.

ATT includes moving a part of skin from one area to an adjacent area, while leaving at least one side of the flap (moved skin) intact to retain blood supply to the graft. Incisions are made, and the skin is undermined and moved over to cover the defective area, leaving connected portion intact. The flap is then sutured into place.

ATT Coding Guidelines:

  1. Codes are categorised as Size (in Sq Cm) and Location of defect (Recipient Site).
  2. Any excision of a lesion that is repaired by adjacent tissue transfer is always bundled in the tissue transfer code. No need of coding separately.
  3. Simple repair of the donor site is included in the tissue transfer code and is not reported separately.
  4. If a skin graft is required to close the donor site (Complex closure), the closure is reported as an additional procedure.
  5. When skin grafting is required to cover both the primary defect (results from the excision) and the secondary defect (results from the flap design), the measurements of each defect are added together to determine the code selection for the graft.

Always RememberDebridement necessary to perform a tissue transfer procedure is included in the procedure. It is inappropriate to report debridement (e.g., CPT® codes 11000, 11042-11047, 97597, 97598) with adjacent tissue transfer (CPT® codes 14000-14350) for the same lesion/injury.


Skin Replacement :  The grafts are completely freed from the donor site and placed over the recipient site. There is no connection left between the graft and the donor site .

Graft Terminology
Autograft: Graft from the same person
Allograft/Homograft: Graft from another member of the same species (often cadaveric)
Isograft: Graft from another member of the same species who is genetically identical to the patient (identical twin)
Xenograft/Heterograft: Graft from another species (often porcine or bovine)

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  1. Surgical preparation of defect site before repair – 15002-15005 based on the size of repair and site.
  2. Split Thickness Skin Graft (STSG) – Epidermis and part of dermis. E.g – Pinch graft
  3. Full Thickness skin Graft (FTSG) – Epidermis and full of dermis.
  4. Codes are categorized as recipient site, size of defect, and type of repair.
  5. Size of defect in square centimeters and a percentage of body area. The square centimeters measurement is applied to adults and children over 10 years of age, and the percentage of body area is applied to infants and children under the age of 10.

Codes Classification –

  1. Surgical preparation codes- 15002 – 15005
  2. Pinch Graft – 15050
  3. Epidermal Autografts – 15110- 15116
  4. Dermal Autografts – 15130-15136
  5. Tissue cultured skin autografts are grafts that are cultured (grown) from the patient’s own skin cells, thereby reducing the chances of rejection – 15150-15157.
  6. Acellular dermal replacement and temporary allograft – 15271-15278.
Skin Substitute Grafts Coding by Site and Size
Trunk, arms, legs Face, scalp, neck, ears, genitalia, hands, feet, digits
Total wound surface area by anatomical grouping less than 100 cm2
1-25 cm2 15271 15275
26-50 cm2 +15272 x 1 +15276 x 1
51-75 cm2 +15272 x 2 +15276 x 2
76-99 cm2 +15272 x 3 +15276 x 3
Total wound surface area by anatomical grouping greater than or equal to 100 cm2
100 cm2 15273 15277
101-200 cm2 +15274 x 1 +15278 x 1
201-300 cm2 +15274 x 2 +15278 x 2
301-400 cm2 +15274 x 3 +15278 x 3


Always RememberCPT® specifies codes in this section (15002-+15278) be reported for topical application of a skin graft. That is, 15002-+15278 do not include use of skin replacement materials as soft tissue reinforcement. To report skin replacement materials used for soft tissue reinforcement, CPT® 2012 includes a new add-on code, +15777 Implantation of biologic implant



  1. Sometimes physician develop a donor site far away from the recipient site (so grafting needs to complete in stages).
  2. when reporting transfer flaps (in several stages), report the donor site when a tube graft is formed for later use or when a delayed flap is formed before it is transferred .
  3. The recipient site is reported when the graft is attached to its final site.
  4. Delayed graft – a portion of the skin is lifted and separated from the tissue below, but it stays connected to blood vessels at one end.
  5. This keeps the skin viable while it is being moved from one area to another, and at the same time, it allows the graft to get used to living on a small supply of blood. It is hoped that living on a small blood supply will give the graft a better chance of survival when inserted into the recipient site.

Codes Classification:

  1. 15570-15738 – based on the type of flap (i.e., pedicle, cross finger, delayed, or muscle flaps) and then by the location of the flap (scalp, trunk, or lips)
  2. 15740-15777 – based on the type of flap (free muscle, free skin, fascial, or hair transplant).


Clinical Example:

A mechanic was admitted to hospital with burns on both arms and hands, after his gasoline-saturated clothing was ignited from a spark. Surgical excision of the burn tissue from his right hand beginning at the wrist was performed two days ago (reported separately). He now undergoes application of 250 sq cm of skin substitute graft on his arms and 180 sq cm of skin substitute graft on his hands and fingers.

The reportable procedures in this case are as follows:

15273, Skin substitute graft, trunk, arms, legs, first 100 sq cm
+15274, Skin substitute graft, trunk, arms, legs, additional 100 sq cm, or part thereof
+15274-59,     Skin substitute graft, trunk, arms, legs, additional 100 sq cm, or part thereof

Hands, fingers:
15277, Skin substitute graft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits, first 100 sq cm
+15278, Skin substitute graft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits, additional 100 sq cm, or part thereof

The arms and hands and fingers are listed in different anatomic locations; thus, it would not be appropriate to add the wound sizes together. Procedures involving the wrist and/or ankle are reported with codes that include arm or leg in the descriptor. Instead, report 15273 and 15274 for the application of skin grafts of the arm, and codes 15277 and 15278 for application of skin grafts of the hands and fingers.


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How to Code CABG

Coronary artery bypass grafts (CABG) is a surgical procedure performed in order to go around (bypass) blockages in the coronary arteries to improve blood flow.  This post will address why the procedure is performed, how the procedure is performed, and how to code the procedure.Coronary_artery_bypass_grafting

A healthy vessel is taken from elsewhere in the patient’s body.  This is known as harvesting or procurement.  The surgeon may harvest an artery, a vein, or both.  The saphenous vein from the leg is one of the more common vessels harvested for use in bypass grafts.

There are two types of CABGs performed.  One is the traditional open chest bypass surgery and the keyhole procedures (minimally invasive).  Here we are addressing open chest procedure.

CABG coding rules

In order to properly code a CABG procedure, a coder needs the following information:

  • How many grafts were performed?
  • How many were arterial? Which artery(ies)?
  • How many were venous? Which Vein(s)?
  • How were they procured?
  • Did the patient have a previous CABG procedure performed?

Here are the codes:
33510-33516 – Venous only
33533-33536 Arterial with or without veins
+33517-33523 venous add on codes to be used with 33533-33536 for combined A-V grafting.

Here are the Rules:
33510-33536 are used based on type of bypass graft and the number of coronary arteries bypassed.
Types of vessels (harvesting them is usually global to the procedure) used for graft: saphenous vein, left internal mammary (LIMA), upper extremity vein (can bill for that one-35500), or femoropopliteal vein (can bill for that one-35572).
Venous grafts codes 33510-33516 are for venous by pass only. They would never be reported with 33533-33536, that is an arterial by pass code. If arteries and veins used together, then use arterial by pass codes and add on codes +33517 – +33523 for the veins.
Add-on codes A-V codes +33517 – +33523 are never used alone. They represent the venous graft in the combined arterial-venous CABG procedures are can be used with 33533-33536.
To determine the number of bypass grafts in a CABG, count the number of distal anastomoses, where the bypass graft artery or vein is sutured to the coronary artery.
If any of the veins are harvest endoscopy use add on code +33508

+ 33530 – REOPERATION, CABG or valve procedure, more than one month after original operation. 

CPT Assistant:

“When performing a “redo” operation, a repeat sternotomy is performed. This requires removal of previously placed wire sutures, which may have become embedded in the bony portion of the sternum. The anterior cardiac chambers, great vessels and other mediastinal structures may be densely adherent to the posterior table of the sternum, so the sternal incision must be made with extreme care so as to avoid potentially catastrophic hemorrhage. Once the mediastinum has been entered, the scarring and adhesions from prior surgery may obscure the anatomic landmarks and make dissection both difficult and hazardous. Code 33530 is intended to describe this increased technical difficulty associated with the reoperation”

CABG Coding Tips…

  1. Procurement of a venous graft is integral to the performance of a coronary artery bypass using venous bypasses. CPT codes 37700-37735 (ligation of saphenous veins) are not to be separately reported in addition to CPT codes 33510-33523 (coronary artery bypass).  
  1. When a coronary artery bypass is performed, the more comprehensive code describing the procedure performed should be used. When venous grafting only is performed, only one code in the group of the coronary artery bypass CPT codes 33510-33516 (venous graft only) can be reported; no other bypass codes should be reported with these codes.  One code in the group of CPT codes 33517-33523 (combined arterial-venous grafting) and one code in the group of CPT codes 33533-33536 (arterial grafting) can be reported together to accurately describe combined arterial-venous bypass.  When only arterial grafting is performed, only one code in the group of CPT codes 33533-33536 (arterial grafting) is coded.
  1. During venous or combined arterial venous coronary artery bypass grafting procedures (CPT codes 33510-33523), it is occasionally necessary to perform epi-aortic ultrasound. This procedure may be reported with CPT code 76986 (ultrasonic guidance, intraoperative) appending modifier -59CPT code 76986 should not be reported for ultrasound guidance utilized to procure the vascular graft.
  1. 4. When an intervascular shunt procedure is performed as a part of another procedure at the same site requiring vascular revision, a service for a shunt procedure is not separately reported from CPT codes 36800-36861 (intervascular cannulization/shunt). By CPT Manual definition, this series of codes represents “separate procedures” (see separate procedure policy in Chapter I, Section J).
  1. An aneurysm repair may require direct repair with or without graft insertion, thromboendarterectomy and/or bypass. When a thromboendarterectomy is undertaken at the site of the aneurysm and it is necessary for an aneurysm repair or graft insertion, a separate service is not reported for the thromboendarterectomy.  Additionally, if only a bypass is placed, which may require an endarterectomy to place the bypass graft, only the code describing the bypass can be reported.  If both an aneurysm repair (e.g. after rupture) and a bypass are performed at separate non-contiguous sites, the aneurysm repair code and the bypass code should be reported with an anatomic modifier or modifier -59.

If a thromboendarterectomy is medically necessary, due to vascular occlusion on a different vessel at the same session, the appropriate code may be reported, but should include an anatomic modifier or modifier -59, indicating that this represents non-contiguous vessels.  At a given site, only one type of bypass (venous, non-venous) code can be reported. If different vessels are bypassed by different methodology, separate codes may be reported.  If the same vessel has multiple obstructions and requires different types of bypass in different areas, separate codes may be reported; however, it will be necessary to indicate that multiple procedures were performed by using an anatomic modifier or modifier -59.

  1. When an open vascular procedure (e.g. thromboendarterectomy) is performed, the closure and repair are included in the description of the vascular procedure. Accordingly, the CPT codes 35201-35286 (repair of blood vessel) are not to be reported in addition to the primary vascular procedure.
  1. When an unsuccessful percutaneous vascular procedure is followed by an open procedure at the same session/same physician (e.g. percutaneous transluminal angioplasty, thrombectomy, embolectomy, etc. followed by a similar open procedure such as thromboendarterectomy), only the service for the successful procedure, which is usually the more extensive, open procedure is reported (see sequential procedure policy, Chapter I, Section M). In the case where a percutaneous procedure is performed at the site of one lesion, and an open procedure is performed at a separate lesion, the services for the percutaneous procedure should be reported with modifier -59 only if the lesions are in distinct anatomical vessels.
  1. The HCPCS/CPT codes 36000, 36406, 36410, etc. represent very common procedures performed to gain venous access for phlebotomy, prophylactic intravenous access, infusion therapy, chemotherapy, hydration, transfusion, drug administration, etc. When intravenous access is routinely obtained in the course of performing other medical/diagnostic/surgical procedures, or is necessary to accomplish the procedure (e.g. infusion therapy, chemotherapy), it is inappropriate to bill separately for the venous access services.  The work of gaining routine vascular access is integral to and therefore included in the work value of the procedure.  HCPCS/CPT codes G0345, G0346 (90760-90761 in 2006) should not be reported for infusions to maintain patency of a vascular access site.
  1. When a (non-coronary) percutaneous intravascular interventional procedure is performed at the same session/site as diagnostic angiography (arteriogram/venogram), only one selective catheter placement code for the involved site should be reported. If the angiogram and the percutaneous intravascular interventional procedure are not performed in immediate sequence and the catheters are left in place during the interim, a second selective catheter placement or access code should not be reported. Additionally, dye injections to position the catheter should not be reported as a second angiography procedure.
  1. Diagnostic angiograms performed on the same date of service as a percutaneous intravascular interventional procedure should be reported with modifier -59. If a diagnostic angiogram (fluoroscopic or computed tomographic) was performed prior to the date of the percutaneous intravascular interventional procedure, a second diagnostic angiogram cannot be reported on the date of the percutaneous intravascular interventional procedure unless it is medically reasonable and necessary to repeat the study to further define the anatomy and pathology.  Report the repeat angiogram with modifier -59.  If it is medically reasonable and necessary to repeat only a portion of the diagnostic angiogram, append modifier -52 to the angiogram CPT code.  If the prior diagnostic angiogram (fluoroscopic or computed tomographic) was complete, the provider should not report a second angiogram for the dye injections necessary to perform the percutaneous intravascular interventional procedure.
  1. When a median sternotomy is performed to accomplish cardiothoracic procedures, the repair of the sternal incision is part of the primary procedure. The CPT codes 21820-21825 (treatment of sternum fracture) are not separately reported nor should the removal of embedded wires be reported if a repeat procedure or return to the operating room (e.g. postoperative hemorrhage on the day of surgery) is necessary.
  1. When existing vascular access lines or selectively placed catheters are used to procure arterial or venous samples, billing for the sample collection separately is inappropriate.
  1. Peripheral vascular bypass CPT codes describe bypass procedures using venous grafts (CPT codes 35501-35587) and using other types of bypass procedures (arterial reconstruction, composite). Because, at a given site of obstruction, only one type of bypass is performed, these groups of codes are mutually exclusive.  When different sites are treated with different bypass procedures in the same operative session, the different bypass procedures may be separately reported, using an anatomic modifier or modifier -59.
  1. Vascular obstruction may be caused by thrombosis, embolism and/or atherosclerosis as well as other conditions. Treatment may, therefore, include thrombectomy, embolectomy and/or endarterectomy; these procedures may be performed alone or in combination.  CPT codes are available describing the separate services (CPT codes 34001 – 34203) and describing these services with thromboendarterectomy (CPT codes 35301 – 35381).  Only the more comprehensive code describing the services performed for a given site can be reported; therefore, for a given site, a code from both of the above groups cannot be reported together.  Additionally, in accordance with the sequential procedure policy, if a balloon thrombectomy fails, and requires a performance of an open thromboendarterectomy, only the more comprehensive service that was performed (generally the open procedure) is reported.
  1. When percutaneous angioplasty of a vascular lesion is followed at the same session by a percutaneous or open atherectomy, generally due to insufficient improvement in vascular flow with angioplasty alone, only the column one atherectomy procedure that was performed (generally the open procedure) is reported (see sequential procedure policy, Chapter I, Section M).
  1. CPT codes 35800-35860 are to be used when a return to the operating room is necessary for exploration for postoperative hemorrhage; accordingly, these codes are not to be coded for bleeding that occurs during the initial operative session. Generally, when these codes are used, they are to be reported with modifier -78 indicating that the service represents a return to the operating room for a related procedure during the postoperative period.

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Modifier 22

Modifier 22 – Procedural Service

  • The purpose of this modifier is to report services (surgical or nonsurgical) when the work required to provide a service is substantially greater than typically required.
  • This modifier must be used only when additional work factors requiring the physician’s technical skill involve significantly increased physician work, time, and complexity of than when the procedure is normally performed.

o   “Substantially Greater” refers to increased intensity, time, technical difficulty of procedure, severity of patient’s condition, and physical and mental effort required, etc.

o   Trauma extensive enough to complicate the procedure and cannot be reported with additional procedures.

o Significant scarring requiring extra time and work.

o Extra work resulting from morbid obesity.

o Increased time resulting from extra work by the physician.

  • Procedure codes with modifier 22 appended will price at 120% of the allowable charge.
  • This modifier may be used with codes in the following sections:

o Anesthesia (00100-01999)

o Surgery (11100-69990)

o Radiology (70010-79999)

o Laboratory and pathology (80047-89356)

o Medicine (90281-99607)

  • This modifier is not appended to ELM services (99201-99499).

Clinical Information Requirements:

  • Medical records must be available upon request.
  • Clinical information documented in the patient’s medical records must support the use of this modifier.


Operative Note Practice Scenario – 7

Preoperative diagnoses: Rhegm atogenous retinal detachment and nuclear sclerotic cataract, both to the right eye.

Name of Procedures: A 25-gauge pars plana vitrectomy, retinal detachment repair, air fluid exchange, air gas exchange with SF6 24%, indirect ophthalmoscope-delivered laser, all to the right eye.

Description of Procedure: The patient was seen in the pre-operative holding area and all questions about the procedure answered. Right eye was identified as the correct operative site and informed consent was confirmed. The patient was rolled in the supine position to the operative suite where appropriate cardiac and pulmonary monitoring devices were applied per anesthesia. The patient was placed under general anesthesia without complication. Right eye was prepped and draped in normal sterile fashion. Sterile lid speculum was placed. A standard 3-port 25-guage vitrectomy unit was used after placing the infusion cannula 4 mm posterior to the infratemporal limbus. Correct position was visualized before turning it on. Additional 2 ports were placed without complication. Initial vitrectomy was performed and carried out into the periphery with the aid of scleral depression. A posterior vitreous detachment was already present. The retinal detachment extended from 12 o’clock temporally down to 6:30 o’clock. Directly temporally there was an old demarcation line with a small horseshoe retinal tear in the middle near the aura. This was trimmed free from vitreous. A drainage retinotomy was then created along the superior temporal arcade with electric diathermy. Air fluid exchange was then performed with drainage of subretinal fluid using a 25-guage backflush cannula. The retina was seen to lay flat. Plugs were placed and indirect ophthalmoscope was used to place laser retinopexy around the retinotomy site, the previously marked retinal hole and in a 360 degree retinopexy fashion. Drainage was performed one more time before placing SF6 24% into the posterior segment. Sclerotomy ports were removed in sequential fashion. All wounds were found to be airtight. The patient was given subconjunctival injections of Ancef and Decadron. A sterile led speculum was removed. A light pressure patch was placed. The patient was taken to recovery room in stable condition after being awakened form general anesthesia in stable condition. He was to remain face down overnight and follow up tomorrow for post-operative exam and instructions.


Operative Note Practice Scenario – 6

Pre-operative diagnosis: Right knee medial meniscus tear

Post-operative diagnosis:

  1. Right knee medial meniscus tear
  2. Right knee lateral meniscus tear
  3. Tricompartmental arthritis of the knee

Name of Procedure: Video arthroscopy of right knee with arthroscopic partial medial and lateral meniscectomies and chondroplasty.

Description of Procedure: Once consent was obtained, the patient was brought to the operating theater and placed on the operating room table in the supine position. Following smooth induction of general anesthesia, a tourniquet was placed around the patient’s right thigh. The right lower extremity was then prepped and draped in the usual sterile orthopedic fashion. The extremity was elevated and exsanguinated and tourniquet was inflated. A superomedial portal was made as an outflow portal and a cannula was introduced in the knee. An anterolateral portal was made and the camera was placed in the knee. Upon inspecting the knee the patient was noted to have a large amount of synovitis throughout the knee. The patellofemoral joint was first visualized. The patient had outerbridge grade 3, fraying of the patella and 2 of the trochlea. There was some fraying of the cartilage there. The camera was then passed around the medial femoral condyle to the medial compartment of the knee. The patient had a grade 3 wear involving the entire medial femoral condyle and some of the tibial condyle as well. However, he did have a large complex fragmented tear of the posterior horn of the medial meniscus. The arthroscopic portal was made after localizing it with a spinal needle. Using a combination of biters, the shaver and the ArthroCare wand, the posterior horn of the medial meniscus was debrided to a stable base. The medial meniscus was sealed with ArthroCare wand to prevent further fraying. Next, the notch was visualized and the ACL was inspected. The ACL was intact. The knee was placed into a figure 4 position and the lateral compartment was visualized. The lateral femoral condyle was intact. However, there was some grade 2 wear of the lateral tibial plateau. The patient did have a tear of the lateral meniscus as well. This was debrided with the biter and the shaver. The knee was then extended and a chondroplasty of the patellofemoral joint was performed using the shaver. The free edge of the fibrillations was debrided to prevent any further fraying or breakdown of the articular cartilage. The instruments were then removed. The wound was infiltrated with Marcaine for postoperative analgesia and the arthroscopic portals were closed primarily with 4-0 Monocryl. Anesthesia was then reversed and the patient was awakened and taken to recovery room in stable condition


Operative Note Practice Scenario – 5

Pre-operative diagnosis: Lipoma of right upper arm

Post-operative diagnosis: Lipoma of right upper arm

Name of procedure: Excision of lipoma from right upper arm with layered closure of 6 cm incision.

Indications: The patient is a 70 year-old female who has a mass on the upper right arm which has been present for several years and has slowly increased in size. She now comes in for elective resection.

Description of Procedure: The patient was taken to the operating room and placed in the supine position on the operating room table. The right arm was supported on a pillow and secured to the bed. The skin overlying the mass of the upper arm was prepped with Betadine and then draped in sterile fashion. The skin overlying the mass was then anesthetized with 1% lidocaine with epinephrine. A transverse 6 cm incision was made. Subcutaneous tissue was divided with electocautery down through subcutaneous fat until the capsule of the lipoma could be identified. The lipoma was then easily dissected free from all surrounding tissue. There was a feeder vessel exiting the deltoid muscle beneath it. This was treated with electrocautery. The mass was removed intact without problems and appeared to be a typical lipoma. The wound was inspected for hemostasis and with this assured, the subdermal tissues were closed with interrupted 3-0 Vicryl and the skin was closed with a running subcuticular stitch of 5-0 Monocryl. Steri-Strips, Telfa and Tegadem dressings were applied. The patient tolerated the procedure very well and was able to ambulate from the minor surgery room without difficulty.