A healthy 11-month-old patient with bilateral cleft lip and palate undergoes surgery. The surgeon performs a bilateral cleft lip repair, single stage. Code the anesthesia service.
Answer – 00102-P1, 99100
A 78-year-old with lower back pain and leg pain is scheduled for a MRI of lumbar spine without contrast. Following the MRI, the patient is diagnosed with spinal stenosis of the lumbar region. What are the procedure and diagnosis codes?
72020-26, 724.2, 729.5, 724.02
72158-26, 724.02, 724.2, 729.5
Answer – 72148-26, 724.02
22-year-old driver loss control of her car and crashed into a light pole on the highway. She arrived to the hospital by ambulance in an unconscious state. She had CT scans without contrast of the brain and chest. She had X-rays of AP and PA views of her left ribs and AP and PA views of her right ribs with a posterioanterior view of the chest. The CT scan of the brain showed a fracture of the skull base with no hemorrhage of the brain. The CT of the lung showed no puncture of the lungs. The X-ray showed fractures in her second, third, and fifth ribs. What CPT® and ICD-9-CM codes should be reported.
Indications: 15-year-old boy was burned in a fire and assessed to have received burns to 75 percent of his total body surface area. He was transferred to a burn center for definitive treatment. Once stable, he was brought to the OR. Procedure: Due to extent of the patient’s burns and lack of sufficient donor sites, his full-thickness burns will be excised and covered with xenograft (skin substitute graft), and a split-thickness skin biopsy will be harvested for preparation of autologous grafts to be applied in the coming weeks, when available. After induction of anesthesia, extensive debridement of the full-thickness burns was undertaken. Attention was first directed to the patient’s face, neck, and scalp. A total of 500 sq cm in this area received full-thickness burns. The eschar involving this area was excised down to viable tissue. Hemostasis was achieved using electrocautery. Attention was then turned to the trunk. A total of 950 sq cm in this area received full-thickness burns. The eschar involving this area was excised down to viable tissue. Hemostasis was achieved. Attention was then turned to the arms and legs. A total of 725 sq cm received full-thickness burns. The eschar involving this area was excised down to viable tissue. Hemostasis was achieved. Attention was then turned to the hands and feet. A total of 300 sq cm in this area received full-thickness burns. The eschar involving this area was excised down to viable tissue. All involved areas were then covered with xenograft. Finally a split thickness skin graft of 0.015 inches in depth was harvested using a dermatome from a separate donor site. A total of 85 sq cm was recovered. What procedures codes would be reported service?
15200, 15201 x 123, 15004, 15005, 15002, 15003
15275, 15276 x 31, 15271, 15272 x 66, 15004, 15005 x 16, 15002, 15003 x 7
15277, 15278 x 7, 15273, 15274 x 16, 15004, 15005 x 7, 15002, 15003 x 16, 15040
15130, 15131 x 7, 15135, 15136 x 16, 15004, 15005 x 7, 15002, 15003 x 16
Answer – 15277, 15278 x 7, 15273, 15274 x 16, 15004, 15005 x 7, 15002, 15003 x 16, 15040
What is/are the code(s) for thawing 4 units of fresh frozen plasma?
86927 x 4
86931 x 4
The code for sweat collection by iontophoresis can be found in what section of the Pathology Chapter of CPT®?
A patient will be undergoing a transplant and needs HLA tissue typing with DR/DQ multiple antigen and lymphocyte mixed culture. How will these services be coded?
A physician orders a quantitative FDP. What CPT® code is reported?
A patient’s mother and sister have been treated for breast cancer. She has blood drawn for cancer gene analysis with molecular pathology testing. She has previously received genetic counseling. Blood will be tested for full sequence analysis and common duplication or deletion variants (mutations) in BRCA1, BRCA2 (breast cancer 1 and 2). What CPT® code is reported for this molecular pathology procedure?
A patient with AIDS presents for follow up care. An NK (natural killer cell) total count is ordered. What CPT® code(s) is/are reported?
A patient has partial removal of his lung. The surgeon also biopsies several lymph nodes in the patient’s chest which are examined intraoperatively by frozen section and sent with the lung tissue for Pathologic examination. The pathologist also performs a trichrome stain. What CPT® codes are reported for the lab tests performed?
88309 x 2, 88313
88307, 88305×2, 88332
88309, 88305, 88313, 88331
88309, 88307, 88313
A couple with inability to conceive has fertility testing. The semen specimen is tested for volume, count, motility and a differential is calculated. The findings indicate infertility due to oligospermia. What CPT® and ICD-9-CM codes are reported?
89310, 89320, V26.21
89257, 606.9, V26.21
In a legal hearing to determine child support there is a dispute about the child’s paternity. The court orders a paternity test, and a nasal smear is taken from the plaintiff and the child. The plaintiff is confirmed as the father of the child. Choose the CPT®, ICD-9-CM codes and modifier for the paternity testing.
A virus is identified by observing growth patterns on cultured media. What is this type of identification is called?
A female patient fell on the floor as she got out of bed. She has no known head trauma. She noticed some slight stiffness in her joints and weakness in her lower extremity muscles, with slight stiffness in her arm joints. The physician decided to test for possible multiple sclerosis (MS). She was sent to a clinic providing somatosensory studies. The testing included upper and lower limbs. What CPT® codes are reported?
64-year-old patient came to the emergency department complaining of chest pressure. The physician evaluated the patient and ordered a 12 lead EKG. Findings included signs of acute cardiac damage. Appropriate initial management was continued by the ED physician who contacted the cardiologist on call in the hospital. Admission to the cardiac unit was ordered. No beds were available in the cardiac unit and the patient was held in the ED. The cardiologist left the ED after completing the evaluation of the patient.
Several hours passed and the patient was still in the ED. During an 80-minute period, the patient experienced acute breathing difficulty, increased chest pain, arrhythmias, and cardiac arrest. The patient was managed by the ED physician during this 80-minute period. Included in the physician management were a new 12 lead EKG, endotracheal intubation and efforts to restore the patient’s breathing and circulation for 20 minutes. CPR was unsuccessful, the patient was pronounced dead after a total of 44 minutes critical care time, exclusive of other separately billable services. What CPT® codes are reported by the physician?
A patient with Sickle cell anemia with painful sickle crisis received normal saline IV, 100 cc per hour to run over 5 hours for hydration in the physician’s office. She will be given Morphine & Phenergan, prn (as needed). What codes are reported?
96360, 96361 x 4, J7050 x 2
96360, 96361 x 3, J7030
96360 x 5, J7050
A patient with bilateral sensory hearing loss is fitted with a digital, binaural, behind the ear hearing aid. What HCPCS Level II and ICD-9-CM codes should be reported?
V5140, 389.11, V53.2
V5261, V53.2, 389.11
V5261, V72.11, 389.11
5-year-old is brought in to see an allergist for generalized urticaria. The family just recently visited a family membe that had a cat and dog. The mother wants to know if her son is allergic to cats and dogs. The child’s skin was scratched with two different allergens. The physician waited 15 minutes to check the results. There was a flare up reaction to the cat allergen, but there was no flare up to the dog allergen. The physician included the test interpretation and report in the record.
95024 x 2
95027 x 2
95004 x 2
95018 x 2
42-year-old patient presented to the urgent care center with complaints of slight dizziness. He had received services at the clinic about 2 years ago. The patient related this episode happened once previously and his 51-year-old brother has a pacemaker. A chest X-ray with 2 views and an EKG with rhythm strip were ordered (equipment owned by the urgent care center). The physician detected no obvious abnormalities, but the patient was advised to see a cardiologist within the next 2 – 3 days. The physician interpreted and provided a report for the rhythm strip and Chest X-ray. What CPT® and ICD-9-CM codes are reported for the physician employed by the urgent care center who performed a Level 3 office visit in addition to the ancillary services?
99213-25, 71020, 93040
99283-25, 71010-26, 93010,
99213-25, 71020-26, 93042
99203-25, 71010, 93000
55-year-old male has had several episodes of tightness in the chest. His physician ordered a PTCA (percutaneous transluminal coronary angioplasty) of the left anterior descending coronary artery. The procedure revealed atherosclerosis in the native vessel. It was determined a stent would be required to keep the artery open. The stent was inserted during the procedure.
A pregnant female is Rh negative and at 28 weeks gestation. The child’s father is Rh positive. The mother is given an injection of a high-titer Rho (D) immune globulin, 300 mcg, IM. What CPT® codes are reported?
A patient with hypertensive end stage renal failure, stage V, and secondary hyperparathyroidism is evaluated by the physician and receives peritoneal dialysis. The physician evaluates the patient once before dialysis begins. What CPT® and ICD-9-CM codes are reported?
90945, 401.9, 585.5, 588.81
90945, 403.91, 585.6, 588.81
90947, 403.91, 588.81
90947, 403.91, 585.5
A patient with congestive heart failure and chronic respiratory failure is placed on home oxygen. Prescribed treatment is 2 L nasal cannula oxygen at all times. A home care nurse visited the patient to assist with his oxygen management. What CPT® and ICD-9-CM codes are reported?
99503, 428.0, 518.83
99504, 428.40, 518.83
99503, 428.9, 518.82
99503, 428.0, 518.82
The meaning of the root “blephar/o” is:
The meaning of heteropsia (or anisometropia) is:
Blindness in half the visual field
Unequal vision in the two eyes
Blindness in both eye
The radiology term “fluoroscopy” is described as:
Technique using magnetism, radio waves and a computer to produce images
An X-ray procedure allowing the visualization of internal organs in motion
A scan using an X-ray beam rotating around the patient
Use of high-frequency sound waves to image anatomic structures
Sialography is an X-ray of :
Ventricles of the brain
A projection is the path of the X-ray beam. If the projection is front to back it would be:
Cytopathology is the study of:
The process of preserving cells or whole tissues at extremely low temperatures is known as:
Cryotherapy c. Cryalgesia b. Cryopexy d. Cryopreservation
A gonioscopy is an examination of what part of the eye:
Anterior chamber of the eye c. Lacrimal duct b. Interior surface of the eye
Which cells produce hormones to regulate blood sugar?
Which part of the brain controls blood pressure, heart rate and respiration?
What are chemicals which relay, amplify and modulate signals between a neuron and another cell?
Which of the following conditions results from an injury to the head? The symptoms include headache, dizziness and vomiting.
Lacrimal glands are responsible for which of the following?
Production of tears
Production of vitreous
Production of zonules
Production of mydriatic agents
Which of the following does NOT contribute to refraction in the eye?
A patient diagnosed with glaucoma has:
A lens that is no longer clear
Abnormally high intraocular pressure
Bleeding vessels on the retina
Which of the following is true about the tympanic membrane?
Dr. Inez discharges Mr. Blancos from the pulmonary service after a bout of pneumococcal pneumonia. She spends 45 minutes at the bedside explaining to Mr. Blancos and his wife the medications and IPPB therapy she ordered. Mr. Blancos is a resident of the Shady Valley Nursing Home due to his advanced Alzheimer’s disease and will return to the nursing home after discharge. On the same day Dr. Inez re-admits Mr. Blancos to the nursing facility. She obtains a detailed interval history, does comprehensive examination and the medical decision making is moderate complexity. What is/are the appropriate evaluation and management code(s) for this visit?
37-year-old female is seen in the clinic for follow-up of lower extremity swelling.
HPI: Patient is here today for follow-up of bilateral lower extremity swelling. The swelling responded to hydrochlorothiazide.
DATA REVIEW: I reviewed her lab and echocardiogram. The patient does have moderate pulmonary hypertension.
Exam: Patient is in no acute distress.
Bilateral lower extremity swelling. This has resolved with diuretics, it may be secondary to problem #2.
Pulmonary hypertension: Etiology is not clear at this time, will work up and possibly refer to a pulmonologist.
PLAN: Will evaluate the pulmonary hypertension. Patient will be scheduled for a sleep study.
45-year-old established, female patient is seen today at her doctor’s office. She is complaining of severe dizziness and feels like the room is spinning. She has had palpitations on and off for the past 12 months. For the ROS, she reports chest tightness and dyspnea but denies nausea, edema, or arm pain. She drinks two cups of coffee per day. Her sister has WPW (Wolff-Parkinson-White) syndrome. An extended exam of five organ systems are performed. This is a new problem. An EKG is ordered and labs are drawn, and the physician documents a moderate complexity MDM. What CPT® code should be reported for this visit?
33 year-old male was admitted to the hospital on 12/17/XX from the ER, following a motor vehicle accident. His spleen was severely damaged and a splenectomy was performed. The patient is being discharged from the hospital on 12/20/XX. During his hospitalization the patient experienced pain and shortness of breath, but with an antibiotic regimen of Levaquin, he improved. The attending physician performed a final examination and reviewed the chest X-ray revealing possible infiltrates and a CT of the abdomen ruled out any abscess. He was given a prescription of Zosyn. The patient was told to follow up with his PCP or return to the ER for any pain or bleeding. The physician spent 20 minutes on the date of discharge. What CPT® code is reported for the 12/20 visit?
60-year-old woman is seeking help to quit smoking. She makes an appointment to see Dr. Lung for an initial visit. The patient has a constant cough due to smoking and some shortness of breath. No night sweats, weight loss, night fever, CP, headache, or dizziness. She has tried patches and nicotine gum, which has not helped. Patient has been smoking for 40 years and smokes 2 packs per day. She has a family history of emphysema. A limited three system exam was performed. Dr Lung discussed in detail the pros and cons of medications used to quit smoking. Counseling and education was done for 20 minutes of the 30 minute visit. Prescriptions for Chantrix and Tetracylcine were given. The patient to follow up in 1 month. A chest X-ray and cardiac work up was ordered. Select the appropriate CPT code(s) for this visit.
A pre-anesthesia assessment was performed and signed at 10:21 a.m. Anesthesia start time is reported as 12:26 pm, and the surgery began at 12:37 pm. The surgery finished at 15:12 pm and the patient was turned over to PACU at 15:26 pm, which was reported as the ending anesthesia time. What is the anesthesia time reported?
10:21 am to 15:12 pm (291 minutes)
12:26 am to 15:12 pm (146 minutes)
12:26 am to 15:26 pm (180 minutes)
12:37 am to 15:26 pm (169 minutes)
Code 00350 Anesthesia for procedures on the major vessels of the neck; not otherwise specified has a base value of ten (10) units. The patient is a P3 status, which allows one (1) extra base unit. Anesthesia start time is reported as 11:02 am, and the surgery began at 11:14 am. The surgery finished at 12:34 am and the patient was turned over to PACU at 12:47 am, which was reported as the ending anesthesia time. Using fifteen-minute time increments and a conversion factor of $100, what is the correct anesthesia charge?
Code 00940, anesthesia for vaginal procedures, has a base value of three (3) units. The patient was admitted under emergency circumstances, qualifying circumstance code 99140, which allows two (2) extra base units. A pre-anesthesia assessment was performed and signed at 2:00 a.m. Anesthesia start time is reported as 2:21 am, and the surgery began at 2:28 am. The surgery finished at 3:25 am and the patient was turned over to PACU at 3:36 am, which was reported as the ending anesthesia time. Using fifteen-minute time increments and a conversion factor of $100, what is the correct anesthesia charge?
94-year-old patient is having surgery to remove his parotid gland, with dissection and preservation of the facial nerve. The surgeon has requested the anesthesia department place an arterial line. What CPT® code(s) is/are reported for anesthesia?
00100, 36620, 99100
5- year-old patient is experiencing atrial fibrillation with rapid ventricular rate. The anesthesia department is called to insert a non-tunneled central venous (CV) catheter. What CPT® code is reported?
43-year-old patient with a severe systemic disease is having surgery to remove an integumentary mass from his neck. What CPT® code and modifier are reported for the anesthesia service?
An 11-month-old patient presented for emergency surgery to repair a severely broken arm after falling from a third story window. What qualifying circumstance code(s) may be reported in addition to the anesthesia code?
59-year-old patient is having surgery on the pericardial sac, without use of a pump oxygenator. The perfusionist placed an arterial line. What CPT® code(s) is/are reported for anesthesia?
41-year-old male is in his doctor’s office for a follow up of an abnormality, which was noted, on an abdominal CT scan. He is to have a chest X-ray due to chest tightness. He otherwise states he feels well and is here to go over the results of his chest X-ray (PA and Lateral) performed in the office and the CT scan performed at the diagnostic center. The results of the chest X-ray were normal. CT scan was sent to the office and the physician interpreted and documented that the CT scan of the abdomen showed a small mass in his right upper quadrant. What CPT® codes are reported for the doctor’s office radiological services?
A patient has a history of chronic venous embolism in the superior vena cava (SVC) and is having a radiographic study to visualize any abnormalities. In outpatient surgery the physician accesses the subclavian vein and the catheter is advanced to the superior vena cava for injection and imaging. The supervision and interpretation of the images is performed by the physician. What codes are reported for this procedure?
70-year-old female presents with a complaint of right knee pain with weight bearing activities. She is also developing pain at rest. She denies any recent injury. There is pain with stair climbing and start up pain. An AP, Lateral and Sunrise views of the right knee are ordered and interpreted. They reveal calcification within the vascular structures. There is decreased joint space through the medial compartment where she has near bone-on-bone contact, flattening of the femoral condyles, no fractures noted. The diagnosis is right knee pain secondary to underlying localized degenerative arthritis. What CPT® codes are reported?
Myocardial Perfusion Imaging—Office Based Test
Indications: Chest pain.
Procedure: Resting tomographic myocardial perfusion images were obtained following injection of 10 mCi of intravenous cardiolite. At peak exercise, 30 mCi of intravenous cardiolite was injected, and post-stress tomographic myocardial perfusion images were obtained. Post stress gated images of the left ventricle were also acquired.
Myocardial perfusion images were compared in the standard fashion.
Findings: This is a technically fair study. There were no stress induced electrocardiographic changes noted. There are no significant reversible or fixed perfusion defects noted. Gated images of the left ventricle reveal normal left ventricular volumes, normal left ventricular wall motion, and an estimated left ventricular ejection fraction of 50%.
Impression: No evidence of myocardial ischemia or infarction. Normal left ventricular ejection fraction. What CPT® code(s) is/are reported?
78451, A9500 x 30
After intravenous administration of 5.1 millicuries Tc-99m DTPA, flow imaging of the kidneys was performed for approximately 30 minutes. Flow imaging demonstrated markedly reduced flow to both kidneys bilaterally. What CPT® code is reported?
An oncology patient is having weekly radiation treatments with a total of seven conventional fractionated treatments. Two fractionated treatments daily for Monday, Tuesday and Wednesday and one treatment on Thursday. What radiology code(s) is/are appropriate for the clinical management of the radiation treatment?
77427 x 2
77427 x 7
Magnetic resonance imaging of the chest is first done without contrast medium enhancement and then is performed with an injection of contrast. What CPT® code(s) is/are reported for the radiological services?
A CT scan confirms improper ossification of cartilages in the upper jawbone and left side of the face area for a patient with facial defects. The CT is performed with contrast material in the hospital. What CPT® code is reported by an independent radiologist contracted by the hospital?
A patient is positioned on the scanning table headfirst with arms at the side for an MRI of the thoracic spine and spinal canal. A contrast agent is used to improve the quality of the images. The scan confirms the size and depth of a previously biopsied leiomyosarcoma metastasized to the thoracic spinal cord. What CPT® codes are reported?
A young child is taken to the OR to reduce a meconium plug bowel obstruction. A therapeutic enema is performed with fluoroscopy. The patient is in position and barium is instilled into the colon through the anus for the reduction. What CPT® code is reported by the independent radiologist for the radiological service?
67-year-old gentleman with localized prostate cancer will be receiving brachytherapy treatment. Following calculation of the planned transrectal ultrasound, guidance was provided for percutaneous placement of 1-125 seeds into the prostate tissue. What CPT® code is reported for needle placement to insert the radioactive seeds into the prostate?
Benign prostatic hypertrophy with outlet obstruction and hematuria.
Description of procedure: The patient was placed on the operating room table in sitting position and spinal anesthesia induced. He was placed in the lithotomy position, prepped and draped appropriately. Resection was begun at the posterior bladder neck and extended to the verumontanum (a crest near the wall of the urethra). Posterior tissue was resected first from the left lateral lobe, then right lateral lobe, then anterior. Depth of resection was carried to the level of the circular fibers. Bleeding vessels were electrocauterized as encountered. Care was taken to not resect distal to the verumontanum, thus protecting the external sphincter. At the end of the procedure, prostatic chips were evacuated from the bladder. Final inspection showed good hemostasis and intact verumontanum. The instruments were removed, Foley catheter inserted, the patient returned to the recovery area in satisfactory condition. What CPT® code is reported for this service?
The patient presents to the office for CMG (cystometrogram). Complex CMG cystometrogram with voiding pressure studies is done, intraabdominal voiding pressure studies, and complex uroflow are also performed. What CPT® code(s) is/are reported for this service?
51728, 51797, 51741-51
51726, 51728-51, 51797
51728-26, 51797-26, 51741-51-26
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® codes reported for this procedure?
A woman with a long history of rectocele and perineal scarring from multiple episiotomies develops a rectovaginal fistula with perineal body relaxation. She has transperineal repair with perineal body reconstruction and plication of the levator muscles. What are the CPT® codes reported for this procedure?
An 88-year-old widow with uterine prolapse and multiple comorbid conditions has been unsuccessful in the use of a pessary for treatment elects to receive colpocleisis (LeFort type) to prevent further prolapse and avoid more significant surgery like hysterectomy. The treatment is successful. What are the CPT® codes reported for this procedure?
A 37 year old woman presents with abdominal pain, bleeding unrelated to menses and an abnormal pap showing LGSIL (low grade squamous intraepithelial lesion). Treatment is hysteroscopy with thermoablation of the endometrium and cryocautery of the cervix. This is performed without difficulty. What are the CPT® codes reported for this procedure?
A patient is diagnosed with an injury to the facial nerve. The surgeon performs a neurorrhaphy with nerve graft to restore innervation to the face using microscopic repair. The surgeon created a 2 cm incision over the damaged nerve, dissected the tissues and located the nerve. The damaged nerve was resected and removed. The 3.0 cm graft taken from the sural nerve was sutured to the proximal and distal ends of the damaged nerve. What CPT® codes are reported?
47-year-old male presents with chronic back pain, and lower left leg radiculitis. A laminectomy is performed on the inferior end of L5. The microscope is used to perform microdissection. There was a large extradural cystic structure on the right side underneath the nerve root as well as the left. The entire intraspinal lesion was evacuated. What CPT® code(s) is/are reported for this procedure?
A patient with primary hyperparathyroidism undergoes parathyroid sestamibi (nuclear medicine scan) and ultrasound and is found to have only one diseased parathyroid. A minimally invasive parathyroidectomy is performed. What CPT® and ICD-9-CM codes are reported for the surgery?
51 . A physician uses cryotherapy for removal trichiasis. What CPT® codes are reported?
A patient receives chemodenervation with Botulinum toxin injections to stop blepharospasms of the right eye. What are the procedure and diagnosis codes?
The surgeon performed an insertion of an intraocular lens prosthesis discussed with the patient before the six-week earlier cataract removal (by the same surgeon). What CPT® code is reported?
The physician performs an iridotomy using laser on both eyes for chronic angle closure glaucoma; procedure includes local anesthesia. What CPT® and ICD-9-CM codes are reported?
66710-50, 365.11, 365.9
66762-50, 66990, 365.01, 365.9
66625, 365.23, 365.70
66761-50, 365.23, 365.70
A physician extracts a tumor, using a frontal approach, from the lacrimal gland of a 14-year-old patient. What CPT® are reported?
72-year-old patient is undergoing a corneal transplant. An anesthesiologist is personally performing monitored anesthesia care. What CPT® code and modifier(s) are reported for anesthesia?
A CRNA is personally performing a case, with medical direction from an anesthesiologist. What modifier is appropriately reported for the CRNA services?
An anesthesiologist is medically supervising six cases concurrently. What modifier is reported for the anesthesiologist’s service?
When an anesthesiologist is medically supervising six cases, what modifier is reported for the CRNA’s medically directed service?
30-year-old patient had anesthesia for an extensive spinal procedure with instrumentation under general anesthesia. The anesthesiologist performed all required steps for medical direction and was not medically directing any other services at the time. What modifier(s) and CPT® code(s) are reported for the anesthesiologist and CRNA services?
00670-QK and 00670-QZ
00670-QK and 00670-QX
00670-QY and 00670-QX
Evaluation & Management
Subjective: Six-year-old girl twisted her arm on the play ground. She is seen in the ED complaining of pain in her wrist.
Objective: Vital Signs: stable. Wrist: Significant tenderness laterally. X-ray is normal
Assessment: Wrist sprain
Plan: Over the counter Anaprox. give twice daily with hot packs. Recheck if no improvement.
What is the E/M code for this visit?
An infant is born six weeks premature in rural Arizona and the pediatrician in attendance intubates the child and administers surfactant in the ET tube while waiting in the ER for the air ambulance. During the 45 minute wait, he continues to bag the critically ill patient on 100 percent oxygen while monitoring VS, ECG, pulse oximetry and temperature. The infant is in a warming unit and an umbilical vein line was placed for fluids and in case of emergent need for medications. How is this coded?
99291, 31500, 36510, 94610
99471, 94610, 36510
Mr. Trumph loses his yacht in a poker game and experiences a sudden onset of chest pain which radiates down his left arm. The paramedics are called to the casino he owns in Atlantic City to stabilize him and transport him to the hospital. Dr. H. Art is in the ER to direct the activities of the paramedics. He spends 30 minutes in two-way communication directing the care of Mr. Trumph. When EMS reached the hospital Emergency Department, Mr. Trumph is in full arrest with torsades de pointes (ventricular tachycardia). Dr. H. Art spends another hour stabilizing the patient and performing CPR. What are the appropriate procedure codes for this encounter?
99288, 99291, 92950
99291, 92950, 92960
Patient comes in today at four months of age for a checkup. She is growing and developing well. Her mother is concerned because she seems to cry a lot when lying down but when she is picked up she is fine. She is on breast milk but her mother has returned to work and is using a breast pump, but hasn’t seemed to produce enough milk.
PHYSICAL EXAM: Weight 12 lbs 11 oz, Height 25in., OFC 41.5 cm. HEENT: Eye: Red reflex normal. Right eardrum is minimally pink, left eardrum is normal. Nose: slight mucous Throat with slight thrush on the inside of the cheeks and on the tongue. LUNGS: clear. HEART: w/o murmur. ABDOMEN: soft. Hip exam normal. GENITALIA normal although her mother says there was a diaper rash earlier in the week.
Four month old well check
Okay to advance to baby foods
Okay to supplement with Similac
Nystatin suspension for the thrush and creams for the diaper rash if it recurs
Mother will bring child back after the cold symptoms resolve for her DPT, HIB and polio
Breast procedures (19000-19499) are divided according to category of procedure.
Incision – 19000 – 19030
Excision – 19081- 19272
Introduction – 19281 – 19298
Mastectomy – 19300 – 19307
Repair and Reconstruction – 19316 – 19396
Percutaneous breast biopsies are reported with 19081-19086 based on the guidance method.
A location device (clip, metallic pellet, wire, needle, radioactive seed) placed without a biopsy is reported with 19281-19288 based on the guidance method.
Mastectomy – There are many mastectomy codes, and you need to carefully review the operative report to confirm whether pectoral muscles, axillary lymph nodes, or internal mammary lymph nodes were also removed. This information will be necessary to determine the correct mastectomy code.
Mastectomy for gynecomastia — This procedure is performed for treatment of gynecomastia. Gynecomastia is an abnormal condition of large breasts in males. In this procedure, the excess breast tissue is removed. Use code 19300 to report mastectomy for gynecomastia. This is a gender specific code and should be coded for male patients only.
Partial mastectomy – 19301 when only a portion of the breast tissue is removed. The surgeon may also refer to a partial mastectomy as a lumpectomy, quadrantectomy , tylectomy or segmentectomy
If an axillary lymphadenectomy (sentinel node or other axillary node excision)is performed with a partial mastectomy, report the service with 19302.
Simple or complete mastectomy – 19303 when all of the subcutaneous tissue and breast tissue are removed and the nipple and skin may or may not be removed. skin and muscle is left but all the breast tissue is removed.
Radical mastectomy – 19305 when entire breast is removed in addition to the pectoral muscles and axillary lymph nodes. Code 19306 reports another type of radical mastectomy that includes the internal mammary lymph nodes and is also known as an Urban type operation. When both axillary lymph nodes and the internal mammary lymph nodes are taken during this operative session, the pectoralis major and minor can be spared
Modified radical mastectomy – 19307 when breast is removed in addition to the axillary lymph nodes, and the pectoralis minor muscle may or may not be removed. The pectoralis major muscle is not removed in the modified radical mastectomy.
19316-19396 – For Breats Repair and reconstruction.
Breast reduction – 19318
Augmentation ,Breast enlargement – 19324, 19325
Breast reconstruction – 19357-19369
Reconstruction for 19357 includes the insertion of a tissue expander and the subsequent expansion. The tissue expander is placed to stretch the skin overlying the breast to allow for insertion of a permanent prosthesis.
Latissimus dorsi flap (19361) describes a procedure during which muscle and skin are taken from the patient’s back and used to reconstruct a breast. The tissue is attached to the chest wall and surrounding muscles to allow for a complete and more natural appearance.
TRAM reconstruction involves using the skin and muscles from the abdomen to create a breast. The advantage to this technique is that the tissue remains attached to its blood supply. For a single pedicle flap, report 19367. If the surgeon uses two pedicles of the rectus abdominis, report 19369. When the flaps are performed with microvascular anastomsis for the connection of additional blood vessels, you should call on 19368. Note that these codes include closure of the donor site.
Lastly, a free flap reconstruction (19364) occurs when skin, fat and muscle from any other area of the patient are taken to construct an aesthetically pleasing breast.
Mastectomy procedures are unilateral procedures. To report bilateral performance, add modifier 50.
Placement of fiducial marker is inclusive to code 19301.
Reporting of axillary lymph node dissection during partial mastectomy (code 19302) does not depend on the incision made for axillary dissection but the extent of axillary node dissection.
38500, Biopsy or excision of lymph node(s); open, superficial and 38525, Biopsy or excision of lymph node(s); open, deep axillary node(s) should be reported for removal/sampling of few sentinel nodes without complete axillary dissection, as appropriate.
A patient underwent bilateral nasal/sinus diagnostic endoscopy. Finding the airway obstructed the physician fractures the middle turbinates to perform the surgical endoscopy with total ethmoidectomy and bilateral nasal septoplasty. What CPT® codes are reported?
30930, 31255-51, 30520-51
31231, 30130-51, 31255-50
55-year-old female smoker presents with cough, hemoptysis, slurred speech, and weight loss. Chest X-ray done today demonstrates a large, unresectable right upper lobe mass, and brain scan is suspicious for metastasis. Under fluoroscopic guidance in an outpatient facility, a percutaneous needle biopsy of the lung lesion is performed for histopathology and tumor markers. A diagnosis of small cell carcinoma is made and chemoradiotherapy is planned. What CPT® and ICD-9-CM codes are reported?
A surgeon performs a high thoracotomy with resection of a single lung segment on a 57-year-old heavy smoker who had presented with a six-month history of right shoulder pain. An apical lung biopsy had confirmed lung cancer. What CPT® and ICD-9-CM codes are reported?
A 3-year-old girl is playing with a marble and sticks it in her nose. Her mother is unable to dislodge the marble so she takes her to the physician’s office. The physician removes the marble with hemostats. What CPT® codes are reported?
An ICU diabetic patient who has been in a coma for weeks as the result of a head injury becomes conscious and begins to improve. The physician performs a tracheostomy closure and since the scar tissue is minimal, the plastic surgeon is not needed. What CPT® and ICD-9-CM codes are reported for this procedure?
31820, 250.30, V44.0
31825, V55.0, 250.30, 959.01
31820, V55.0, 959.01, 250.00
31825, V55.0, 250.00, 959.01
A patient has a complete TTE performed to assess her mitral valve prolapse (congenital). The physician performs the study in his cardiac clinic.
A patient has a Transtelephonic rhythm strip pacemaker evaluation for his dual chamber pacemaker. It has been more than two months from his last evaluation due to him moving. The physician evaluates remotely retrieved information, checking the device’s current programming, battery, lead, capture and sensing function, and heart rhythm. The monitoring period has been 35 days. What can the physician report for the service?
A patient is brought to the operating suite when she experiences a large output of blood in her chest tubes post CABG. The physician performing the original CABG yesterday is concerned about the post-operative bleeding. He explores the chest and finds a leaking anastomosis site and he resutured.
MAZE procedure is performed on a patient with atrial fibrillation. The physician isolates and ablates the electric paths of the pulmonary veins in the left atrium, the right atrium, and the atrioventricular annulus while on cardiopulmonary bypass.
Patient undergoes a mitral valve repair with a ring insertion and an aortic valve replacement, on cardiopulmonary bypass.
66-year-old female is admitted to the hospital with a diagnosis of stomach cancer. The surgeon performs a total gastrectomy with formation of an intestinal pouch. Due to the spread of the disease, the physician also performs a total en bloc splenectomy. What CPT® codes are reported?
A patient suffering from cirrhosis of the liver presents with a history of coffee ground emesis. The surgeon diagnoses the patient with esophageal gastric varices. Two days later, in the hospital GI lab, the surgeon ligates the varices with bands via an UGI endoscopy. What CPT® codes are reported?
A patient was taken to the emergency room for severe abdominal pain, nausea and vomiting. A WBC (white blood cell count) was taken and the results showed an elevated WBC count. The general surgeon suspected appendicitis and performed an emergent appendectomy. The patient had extensive adhesions secondary to two previous Cesarean-deliveries. Dissection of this altered anatomical field and required the surgeon to spend 40 additional intraoperative minutes. The surgeon discovered that the appendix was not ruptured nor was it hot. Extra time was documented in order to thoroughly irrigate the peritoneum. What CPT® codes are reported?
The patient was taken to the operating room and placed in the dorsal lithotomy position, prepped and draped in the usual sterile fashion. A vertical paramedian incision was made along the left side of the umbilicus from the symphysis and taken up to above the umbilicus. This incision was carried down to the rectus muscles, which were separated in the midline. The peritoneal cavity was entered with findings as described. The ascitic fluid was removed and hand-held retractors were used to assist in surgical exposure.
The tumor was resected from the hepatic flexure into the mid transverse colon. The resection was extended into the left upper quadrant and the attachments were also clamped, cut and suture ligated with 2-0 silk sutures in a stepwise fashion until mobilization of the tumor mass could be brought medial and hemostasis was obtained. Attempts to find a dissection plane between the tumor mass and the transverse colon were unsuccessful as it appeared that the tumor mass was invading into the wall of the bowel with extrinsic compression and distortion of the bowel lumen.
Given the mass could not be resected without removal of bowel, attention was directed to mobilization of the splenic flexure. Retroperitoneal dissection was started in the pelvis and continued along the left paracolic gutter. The ligamentous and peritoneal attachments were taken down with Bovie cautery in a stepwise fashion around the splenic flexure of the colon until the entire left colon was mobilized medially. Similar steps were then carried on the right side as the right colon and hepatic flexure were mobilized. The peritoneal and ligamentous attachments were taken down with Bovie cautery. Vascular attachments were clamped, cut, and suture ligated with 2-0 silk until the right colon was mobilized satisfactorily. The GIA stapler was introduced and fired at both ends to dissect the tumorous bowel free. The bowel was delivered off the operative field.
Attention was then directed towards re-anastomosis of the colon. Linen-shod clamps were used to gently clamp the proximal and distal segments of the large bowel. The staple line was removed with Metzenbaum scissors, and the colon lumen was irrigated. The silk sutures were used to divide the circumference of the bowel into equal thirds, and the proximal and distal edges of the bowel were reapproximated with silk sutures. The posterior segment of the bowel was then retracted and secured with a TA stapler, ensuring a full thickness bowel wall insertion into the staple line. The additional two thirds were also isolated and, with the TA stapler, clamped, ensuring that all layers of the bowel wall were incorporated into the anastomosis. A third staple line was fired and the integrity of the anastomosis was checked. First complete hemostasis was noted. There was well beyond a finger width lumen within the large bowel. The linen-shod clamps were released and gas and bowel fluid were moved through the anastomosis aggressively with intact staple line, no leakage of gas or fluid. The abdomen was then irrigated and water was left over the anastomosis. The anastomosis was manipulated with no extravasation of air. The abdomen and pelvis were then irrigated aggressively. The Mesenteric trap was then reapproximated with interrupted 3-0 silk suture ligatures. All sites were inspected and noted to be hemostatic. Attention was directed towards closing. What is the correct CPT® coding for this report?
Margaret has a cholecystoenterostomy with a Roux-en-Y; five hours later she has an enormous amount of pain, abdominal swelling and a spike in her temperature. She is returned to the OR for an exploratory laparotomy and subsequent removal of a sponge that remained behind from surgery earlier that day. The area had become inflamed and peritonitis was setting in. What is the correct coding for the subsequent services on this date of service? The same surgeon took her back to the OR as the one who performed the original operation.
What CPT® code is reported?
Indications: This is a third follow-up EGD dilation on this patient for a pyloric channel ulcer which has been slow to heal with resulting pyloric stricture. This is a repeat evaluation and dilation.
Procedure: With the patient in the left lateral decubitus position, the Olympus GIFXQ10 was inserted into the proximal esophagus and advanced to the Z-line. The esophageal mucosa was unremarkable. Stomach was entered revealing normal gastric mucosa. Mild erythema was seen in the antrum. The pyloric channel was again widened. However, the ulcer as previously seen was well healed with a scar. The pyloric stricture was still present. With some probing, the 11 mm endoscope could be introduced into the second portion of the duodenum revealing normal mucosa. Marked deformity and scarring was seen in the proximal bulb. Following the diagnostic exam, a 15 mm balloon was placed across the stricture, dilated to maximum pressure, and withdrawn. There was minimal bleeding post-op. Much easier access into the duodenum was accomplished after the dilation. Follow-up biopsies were also taken to evaluate Helicobacter noted on a previous exam. The patient tolerated the procedure well.
Impressions: Pyloric stricture secondary to healed pyloric channel ulcer, dilated.
Plan: Check on biopsy, continue Prilosec for at least another 30 days. At that time, a repeat endoscopy and final dilation will be accomplished. He will almost certainly need chronic H2 blocker therapy to avoid recurrence of this divesting complicated ulcer. What CPT® codes are reported?
A patient with hypertension presents to the same day surgery department for removal of her gallbladder due to chronic gallstones. She is examined preoperatively by her cardiologist to be cleared for surgery. What ICD-10-CM codes are reported?
574.21, V72.83, 401.9
V72.81, 574.20, 401.9
574.20, 401.9, V72.81
401.9, V72.84, 574.20
A patient presents for esophageal dilation. The physician begins dilation by using a bougie. This attempt was unsuccessful. The physician then dilates the esophagus transendoscopically using a balloon (25mm). What CPT® code(s) is/are reported?
Surgical laparoscopy with a cholecystectomy and exploration of the common bile duct, for cholelithiasis. What CPT® codes are reported?
45-year-old patient with liver cancer is scheduled for a liver transplant. The patient’s brother is a perfect match and will be donating a portion of his liver for a graft. Segments II and III will be taken from the brother and then the backbench reconstruction of the graft will be performed, both a venous and arterial anastomosis. The orthotopic allotransplantation will then be performed on the patient. What CPT® codes are reported?
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 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 patient presents with a healed fracture of the left ankle. The patient was placed on the OR table in the supine position. After satisfactory induction of general anesthesia, the patient’s left ankle was prepped and draped. A small incision about 1 cm long was made in the previous incision. The lower screws were removed. Another small incision was made just lateral about 1 cm long. The upper screws were removed from the plate. Both wounds were thoroughly irrigated with copious amounts of antibiotic containing saline. Skin was closed in a layered fashion and sterile dressing applied. What CPT® code(s) should be reported?
A patient is seen in the hospital’s outpatient surgical area with a diagnosis of a displaced comminuted fracture of the lateral condyle, right elbow. An ORIF (open reduction) procedure was performed and included the following techniques: An incision was made in the area of the lateral epicondyle. This was carried through subcutaneous tissue, and the fracture site was easily exposed. Inspection revealed the fragment to be rotated in two places about 90 degrees. It was possible to manually reduce this quite easily, and the manipulation resulted in an almost anatomic reduction. This was fixed with two pins driven across the humerus. The pins were cut off below skin level. The wound was closed with plain catgut subcutaneously and 5-0 nylon for the skin. Dressings and a long arm cast were applied. What CPT® codes are reported?
A 47-year-old patient was previously treated with external fixation for a Grade III left tibial fracture. There is now nonunion of the left proximal tibia and he is admitted for open reduction of tibia with bone grafting. Approximately 30 grams of cancellous bone was harvested from the iliac crest. The fracture site was exposed and the area of nonunion was osteotomized, cleaned, and repositioned. Intrafragmentary compression was applied with three screws. The harvested bone graft was packed into the fracture site. What CPT® codes are reported?
A Grade I, high velocity open right femur shaft fracture was incurred when a 15-year-old female pedestrian was hit by a car. She was taken to the operating room within four hours of her injury for thorough irrigation and debridement, including excision of devitalized bone. The patient was prepped, draped, and positioned. Intramedullary rodding was carried out with proximal and distal locking screws. What CPT® codes should be reported?
A 49-year-old female had two previous rotator cuff procedures and now has difficulty with shoulder function, deltoid muscle function, and axillary nerve function. An arthrogram is scheduled. After preparation, the shoulder is anesthetized with 1% lidocaine, 8 cc without epinephrine. The needle was placed into the shoulder area posteriorly under image intensification. It appeared as if the dye was in the shoulder joint. She was moved and a good return of flow was obtained. The shoulder was then mobilized and there was no evidence of any cuff tear from the posterior arthrogram. What CPT® codes are reported?
A 31-year-old secretary returns to the office with continued complaints of numbness involving three radial digits of the upper right extremity. Upon examination, she has a positive Tinel’s test of the median nerve in the left wrist. Anti-inflammatory medication has not relieved her pain. Previous electrodiagnostic studies show sensory mononeuropathy. She has clinical findings consistent with carpal tunnel syndrome. She has failed physical therapy and presents for injection of the left carpal canal. The left carpal area is prepped sterilely. A 1.5 inch 25 or 22 gauge needle is inserted radial to the palmaris longus or ulnar to the carpi radialis tendon at an oblique angle of approximately 30 degrees. The needle is advanced a short distance about 1 or 2 cm observing for any complaints of paresthesias or pain in a median nerve distribution. The mixture of 1 cc of 1% lidocaine and 40 mg of Kenalog-10 is injected slowly along the median nerve. The injection area is cleansed and a bandage is applied to the site. What codes are reported?
20526, J3301 x 4
20551, J3301 x 4
An elderly female presented with increasing pain in her left dorsal foot. The patient was brought to the operating room, and placed under general anesthesia. A curvilinear incision was centered over the lesion itself. Soft tissue dissection was carried through to the ganglion. The ganglion was clearly identified as a gelatinous material. It was excised directly off the bone and sent to pathology. There was noted to be a large bony spur at the level of the head of the 1st metatarsal. Using double action rongeurs, the spur itself was removed and sequestrectomy was performed. A rasp was utilized to smooth the bone surface. The eburnated bony surface was then covered, utilizing bone wax. The wound was irrigated and closed in layers. What CPT® codes are reported?
Under general anesthesia, a 45-year-old patient was sterilely prepped. The wrist joint was injected with Marcaine and epinephrine. Three arthroscopic portals were created. The articulating surface between the scaphoid and the lunate clearly showed disruption of the ligamentous structures. We could see soft tissue pouching out into the joint; this was debrided. There was abnormal motion noted within the scapholunate articulation. At this point the C-arm was brought in; arthroscopic instruments were placed in the joint and confirmed the location of the shaver as a probe in the scapholunate ligament. There was a significant gap between the capitate and lunate. K-wire was utilized from the dorsal surface into the lunate, restoring the space. Further examination revealed gross instability between the capitate and lunate. With the wrist in neutral position, a K-wire was passed through the scaphoid, through the capitate and into the hamate. This provided stabilization of the wrist joint. Stitches were placed, and a thumb spica cast was applied. What CPT® code(s) should be reported?