Tag Archives: Surgery

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

Codes:

CPT Questions – Surgery Section

DOWNLOADABLE CPC®PRACTICE EXAM QUESTIONS

Integumentary (9 questions)

1. Sam had six actinic keratoses destroyed. How would you report this service?

  • 17004
  • 17000, 17003
  • 17000, 17003  x 5
  • 17110, 17111  x 5

2. History: A 41-year-old male with an open wound to the left upper leg presents for debridement and preparation of the skin graft site, followed by a split-thickness skin graft.

Procedure: After informed consent was obtained, the patient was taken to the operating room, where he

was prepped and draped in a sterile fashion. The VAC machine was disconnected. The wound was malodorous. Tissue was debrided on the surface, and some of the hypertrophic skin around the edge was also debrided. The total size is now 150 sq cm prepped and ready. Skin was harvested at 15/1000ths of an inch, at the patient’s request, from the trunk. An epinephrine-soaked gauze, 1/10,000 dilution, as well as Marcaine 0.5% with

1:200,000 dilution of epinephrine, was applied to the wound. Injection around the donor site was carried out with the same Marcaine solution. Marcaine 0.5% with 1:200,000 dilution of epinephrine was infiltrated around the left upper leg. Next, the skin graft was meshed at a 1.5:1 ratio. The skin graft, 150 sq cm, was applied to the left upper leg, and a 4-0 chromic suture was used. Next, the VAC sponge was placed over the skin graft. The skin graft area was secured with Stomahesive dressing around the edge. The patient’s donor site was dressed with Xeroform gauze and a Telfa, Kerlix gauze, ABD, and tape. The patient tolerated the procedure well and left the operating room in good condition. Needle and sponge counts were correct.

How would you report the professional services for this case?

  • a. 15004, 15005-51, 15170-51, 15171-59
  • b.   15002, 15100, 15101-51
  • c. 15004, 15005, 15170, 15171
  • d. 15100, 15101, 15002-51, 15003
  1. 3. A patient had a left breast reconstruction with free flap. The surgeon used a microsurgical technique, requiring an operating microscope during the procedure. How would you report this procedure?
  • a. 19364 -LT, 69990
  • b. 19357
  • c. 19361, 69990
  • d.   19364 -LT
  1. 4. A patient underwent an incision and drainage of a seroma without imaging and guidance. How would you report these professional services?
  • a. 10140, 76942-26
  • b. 10140
  • c.   10080
  • d. 10060, 76942-26
  1. 5. Dr. Shars took skin biopsies of three lesions from Laura’s back. How would you report Dr. Shars’ services?
  • a. 11100, 11101-51
  • b. 11056, 11100, 11101-51
  • c.   11100, 11101  x 2
  • d. Biopsy codes are not reported unless the lesions are removed
  1. 6. Dr. Dan excised a lesion from Sara’s left arm and one from her right leg. The excised diameter lesion on the arm was 2 cm and the excised diameter lesion on the leg was 2 cm. How would you report this service?
  • a. 11406, 11402-59
  • b. 11406
  • c. 11602, 11606-59
  • d. 11406, 11402
  1. 7. Dr. Dan completed a 4 cm simple defect closure to the excision on the arm and a 10.4  cm intermediate wound defect closure to the leg. How would the closures be reported?
  • a. 12034, 12002-59
  • b.   12034
  • c. 12002, 12045
  • d. All closures are bundled  with excision procedures
  1. 8. According to CPT guidelines for repair (closure), which modifier is reported when more than one classification of wounds is repaired?
  1. a. -54 b. -25 c.   -51 d.   -59
  1. 9. Dr. Craig completed a malignant lesion removal and an adjacent tissue transfer on the trunk of a patient. The lesion defect was 1 sq cm and the transfer defect was 2 sq cm. How would you report this procedure?
  • a. 11400
  • b. 11601, 11400-51
  • c.   11601, 11400-59
  • d.   11402, 11401

Musculoskeletal System (10 Questions)

  1. 10. A patient amputated her thumb in an automobile accident. A surgeon performed a replantation of the thumb, including carpometacarpal joint to the MP joint. How would you report this procedure?
  1. a. 20824 b. 20827 c.   20822
  2. d. 20808, 20824-59
  1. 11. A patient underwent a right surgical arthroscopic medial meniscal transplant, which required a remnant of the meniscus to be removed. How would you report this procedure?
  1. a. 29866, 29868-59 b.   29868-RT
  2. c. 29868
  3. d. 29870-RT
  1. 12. A patient had four artificial cervical discs removed by total disc arthroplasty in an anterior approach. What is the appropriate code to report the three additional interspaces?
  1. a. 22527  x 3 b.   0095T  x 3 c.   22534  x 3 d.   22585  x 3
  1. 13. When coding for spinal procedures, how is segmental instrumentation defined?
  1. a. Fixation  at each end of the construct and no additional interposed bony attachment
  2. b. Fixation at each end of the construct and may span four vertebral segments with attachment to

the intervening  segments

  1. c. Fixation at each end of the construct and at least one additional interposed bony attachment
  2. d. Fixation at each end of the construct and may span several vertebral segments without attachment

to the intervening  segments

  1. 14. What is the appropriate code for application of a body cast including one thigh?
  1. a. 29035 b. 29450 c.   29044 d.   29000
  1. 15. A patient underwent a percutaneous repair of an Achilles tendon with graft. How would you report this?
  1. a. 27680, 20824-59 b.   27654
  2. c. 27652, 20824 d.   27652
  1. 16. While shopping at the mall, Renee dislocated her patella when she fell from the escalator. The surgeon documented an open dislocation and performed an open treatment with total patellectomy to repair the patella. How would you code this treatment and diagnosis?
  1. a. 27840, 27562-51, 836.3,  E884.9 b.   27566, 836.4,  E880.0,  E849.6
  2. c. 27562, 836.4
  3. d. 27566, 27560-51, 836.4, E880.0, E884.9
  1. 17. A patient suffered a penetrating wound to his abdomen when he fell into a plate glass window. A surgeon performed wound exploration with enlargement, debridement, and removal of glass from the site. The surgeon decided a laparotomy procedure was not necessary at this time. How would this procedure be reported?
  1. a. 20102
  2. b. 49000, 97602-51, 20102-59 c.   20100, 49000-59
  3. d. This procedure is bundled  with the laparotomy
  1. 18. Dr. Roberts’ patient suffered an open fracture to his left elbow. The elbow was repaired surgically with several pins. Two weeks after the repair, Dr. Roberts had to re-reduce the fracture. Which modifier would describe this procedure?
  1. a. -76 b. -78 c.   -58 d.   -52
  1. 19. Tom suffered a burst fracture to his lumbar spine when he fell from a ladder at work. Dr. Bill performed  a partial corpectomy to L2 by a transperitoneal approach, followed by anterior arthrodesis of L1–L3. He also positioned anterior instrumentation and placed a structural allograft to L1–L3. How would Dr. Bill report this procedure?
  1. a. 22558, 22858-51, 22845-51, 20931-59 b.   63085, 22533, 22585-51, 22808-59
  2. c. 22612  x 2, 22808, 22840-51, 20931
  3. d. 63090, 22558-51, 22585, 22845, 20931

Respiratory/Cardiovascular Systems (10 Questions)

  1. 20. A patient had a dual temporary pacemaker inserted. Which code captures this service?
  1. a. 33210 b. 33211 c.   33212 d.   33213
  1. Alice’s heart condition is worsening and she is scheduled for an upgraded system change from a single to a dual chamber system. Today, Dr. Smith removed Alice’s single chamber pacemaker, pulse generator, and electrodes. He then inserted a dual chamber system with insertion of new electrodes. Assign the correct code(s) for today’s service.
  1. a. 33208, 33217
  2. b. 33233, 33234-51, 33208-51 c.   33214
  3. d. 33214, 33208-51, 33233-51, 33234-51
  1. 22. If an electrode needed to be repositioned in the right ventricle, which code would describe this service?
  1. a. 33218 b. 33226 c.   33215
  2. d. This service is bundled  with all pacemaker services
  1. 23. Three years after a double bypass, Tom’s heart condition deteriorated and he had to have another bypass surgery. Today, he had a triple arterial and a double venous graft surgery with harvesting of a radial artery. How would today’s procedure be reported?
  1. a. 33511, 35500, 33518, 33534
  2. b. 33535, 33518-51, 33530-51, 35600-51 c.   33511, 33518, 33530
  3. d. 33535, 33518, 33530, 35600
  1. Dr. Nector performed a direct thrombectomy to the iliac vein by abdominal and leg incision. How would Dr. Nector report her professional services?
  1. a. 34401 b. 34451 c.   34421 d.   34201
  1. 25. A 62-year-old patient had her non-tunneled, centrally inserted  CVAD without a port or pump replaced with the same type of system. The removal and replacement was completed through the same access site. How would you report this procedure?
  1. a. 36580
  2. b. 36589, 36580-51 c.   36581, 36589-59 d.   36578
  1. 26. What vascular order branch is the right internal carotid if the starting point of the catheterization is the aorta?
  1. a. First order  branch
  2. b. Second order  branch c.   Third  order  branch
  3. d. Beyond the third  order
  1. 27. A patient had a biopsy of the temporal artery. What is the appropriate code to identify this service?
  1. a. 37650 b.   37609 c.   37700 d.   37565
  1. 28. How many times can codes 38207–38215 be reported per day?
  1. a. Once per day
  2. b. As many times as the procedure is completed  within  one service day c.   Twice per day
  3. d. None  of the above
  1. 29. How would you report a diagnostic bronchoscopy with fluoroscopic guidance and a cervical approach mediastinotomy with biopsy?
  1. a. 39000, 31622-51
  2. b. 39000, 31622-51, 71034 c.   31635, 71034
  3. d. 39000, 31630-59, 71034

Digestive System (10 Questions)

  1. 30. A 45-year-old female patient with mild hypertension underwent a proctosigmoidoscopy with ablation of three lesions under moderate sedation. Dr. Terry performed the procedure and the sedation in her office suite. The intraservice time for the procedure was 45 minutes. How would you report these services?
  1. a. 45320
  2. b. 45320, 99144, 99145
  3. c. 45309, 45320  x 3, 00810-P2 d.   45320  x 3
  1. 31. Juan, a 42-year-old healthy male patient, had a laparoscopic cholecystectomy with cholangiography. Select the appropriate CPT code(s) to report these services.
  1. a. 47605
  2. b. 47562, 47605-51 c.   47563
  3. d. 47560, 47563-59
  1. 32. Jennifer underwent a hernioplasty to repair a strangulated, recurrent ventral hernia, which required implantation of mesh for successful closure. Additionally, the surgeon completed debridement for necrotizing soft tissue due to infection. How would the professional services be reported in this procedure?
  1. a. 49566, 11005-51, 49568-51 b.   49561, 49568
  2. c. 49566, 11005-51, 49568
  3. d. 49565, 11004-59, 49568
  1. 33. A 16-year-old patient underwent an adenoidectomy. During the same surgical session, his chronic nose bleeding on the left side was addressed. The surgeon found an abnormal vasculature in this area and cauterized using suction cautery in the left nasal septum to control this problem. Next, the inferior turbinates were reduced using the Coblation device. How would you report these procedures?
  1. a. 30140, 42831-51
  2. b. 42835, 30999-51, 30901-50 c.   42830, 30140, 30901
  3. d. 42831, 30140-52, 30901-59-LT
  1. 34. How would Dr. Ross report a 2 cm complex closure for a laceration to the vestibule of the mouth that he completed on a 12-year-old patient?
  1. a. 13132
  2. b. 40831, 13132-51 c.   40830
  3. d. 40831
  1. 35. Dr. Manual completed the following service for a 22-year-old male:

Preoperative note: The patient has a history of diabetes, smokes, and does not exercise. However, the patient states that he is in excellent health. Prior to the surgery, the patient signed consent forms and indicates that he understands the surgery and risks.

Procedure: The patient was prepped and taken into the operating room, where a diagnostic endoscopic retrograde cholangiopancreatography with endoscopic retrograde and insertion of nasobiliary drainage tube were completed. Within the same operative session, we also performed a sphincterotomy. I completed the radiological supervision and interpretation with this procedure.

How would Dr. Manual report her professional services?

  1. a. 43260, 74330, 43262-52, 43267-59
  2. b. 43260, 43267-51, 43262-51, 74330-26 c.   43260, 99144, 74330-26
  3. d. 43259, 99144, 74330-26, 43260-51, 43267-59
  1. If a diagnostic esophagoscopy is completed on the same patient, for the same condition, in the same session as a surgical esophagoscopy,  how is it coded?
  1. a. A surgical endoscopy  always includes a diagnostic  endoscopy
  2. b. Code both  procedures with a modifier -59 on the surgical endoscopy
  3. c. Code both  procedures with a modifier -51 on the diagnostic  endoscopy d.   A surgical endoscopy  always includes a diagnostic  open excision
  1. 37. Select the appropriate CPT code(s) to report a laparoscopic surgical repair of an incisional reducible hernia with mesh.
  1. a. 49655 b.   49654
  2. c. 49654, 49568 d.   49560, 49568
  1. 38. A 22-year-old patient pulled out his gastrostomy tube while trying to fix it. An interventional radiologist, Dr.

Milk, took him into an angiography suite, administered moderate sedation where she probed the site with a catheter, and injected contrast medium to provide assessment and tube placement. Dr. Milk documented that the entry site was open, and she replaced the tube in the proper position. This procedure was completed via the same percutaneous access site. The intraservice time for the procedure was 30 minutes. How would you report the professional services for this case?

  1. a. 49450, 99144 b.   49450
  2. c. 49440, 99148
  3. d. 49440
  1. 39. Usually, an incidental appendectomy during an intra-abdominal surgery is not coded separately. However, if it is necessary to report this as a separate procedure, which modifier best describes this situation?
  1. a. -52 b.   -59 c.   -51 d.   -58

Urinary System, Male and Female Genital Systems (11 Questions)

  1. 40. Indication for procedure: The patient has a known history of bladder tumor. She presents today for bladder biopsy and fulguration, as well as instillation of Mitomycin C. She understands the treatment and risks and agrees by signed consent to the procedure.

Procedure: The patient was taken to the operating room and induced under general anesthesia with appropriate lines and monitoring placed. The patient was in a dorsal lithotomy position. A 23-French cystourethroscope was advanced per urethra into the bladder. The bladder was carefully inspected, with no evidence of abnormalities noted other than two previously noted lesions for transitional cell carcinoma—one near the right ureteral orifice and one inferior to the left ureteral orifice. These lesions were biopsied and cauterized without difficulty. The lesions were noted at approximately 7–8 mm in size. A 20-French Foley catheter was inserted per urethra into the bladder without difficulty and noted to be draining clear urine. Next, instillation of Mitomycin  C was completed with a plan

to keep in place for 45–50  minutes. The patient tolerated the procedure well. There were no complications. She was taken from the operating room to recovery in satisfactory condition. How would you report this procedure?

  1. a. 52000, 52204-59
  2. b. 51720, 51715-51, 52000-59 c.   52204, 51720-51
  3. d. 51720
  1. 41. Steven, a 52-year-old male patient, underwent an extracorporeal shockwave lithotripsy and cystourethroscopy with removal of a double-J stent. How would you report this procedure?
  1. a. 50590
  2. b. 50590, 52310-51 c.   50590, 52315-59 d.   52317, 52310-51
  1. 42. What are the three distinct components of physician work for renal allotransplantation?
  1. a. Cadaver or living donor nephrectomy (unilateral or bilateral), backbench work, and recipient renal

allotransplantation

  1. b. Cadaver donor nephrectomy (unilateral or bilateral), backbench work, and recipient renal

autotransplantation

  1. c. No donor nephrectomy (unilateral or bilateral), backbench work, and recipient renal

allotransplantation

  1. d. Cadaver donor nephrectomy (unilateral or bilateral), forward bench-set work, and recipient renal

allotransplantation

  1. 43. A patient had an open cryosurgical ablation of two renal mass lesions. The surgeon used an intraoperative ultrasound for the procedure. Select the appropriate code for this procedure.
  1. a. 50250  x 2 b.   50593
  2. c. 50542 d.  50250
  1. 44. Sally has been unable to become pregnant and has undergone extensive testing. She is now scheduled for an in vitro fertilization procedure. She underwent a follicle puncture to retrieve 12 eggs. The surgeon then injected one egg into the right fallopian tube. Which codes capture this procedure?
  1. a. 58970, 58976-51 b.   58970, 58976-59 c.   58660, 58661-51 d.   58660, 58976-59
  1. 45. Which modifiers should be appended when multiple investigative procedures are performed in the same urodynamic session and the physician only interprets the results and/or operates the equipment?
  1. a. -51, TC b. -51, -26 c.   -59, TC
  2. d. No modifiers are necessary
  1. 46. A 65-year-old male patient underwent a repair of the tunica vaginalis hydrocele, Bottle type. Which CPT code is appropriate to report this procedure?
  1. a. 55041 b. 55000 c.   55060 d.   54865
  1. 47. A patient had a vulvectomy with removal of greater than 80% of the vulvar area and a bilateral inguinofemoral lymphadenectomy. Which CPT code is appropriate to report this procedure?
  1. a. 56634 b. 56620 c.   56637 d.   56632
  1. 48. Dr. Level delivered a healthy baby boy via routine cesarean delivery. He also provided all the antepartum and postpartum care for this patient. How would you report this procedure?
  1. a. 59510, 59425-59, 59430-59 b.   59400
  2. c. 59618 d.   59510
  1. 49. A patient had a laparoscopic treatment of ectopic pregnancy with a salpingectomy and an oophorectomy.

Which code captures this procedure?

  1. a. 59150 b. 59136 c.   59120 d.   59151
  1. 50. A physician inserts a catheter into a renal abscess using radiologic guidance, then drains the abscess. How would you code the physician’s professional services?
  1. a. 50020, 75989
  2. b. 50021, 75989-26 c.   50021, 75989-TC
  3. d. 50021, 50020-51, 75989-TC

Nervous System, Eye and Ocular Adnexa, and Auditory System (10 questions)

  1. 51. A patient had a 2 cm lesion excised from conjunctiva in the right eye. How would you report this procedure?
  1. a. 68135-RT b. 68115-RT c.   68330-RT d.   68110-RT
  1. 52. A patient underwent a phacoemulsification extra-capsular cataract extraction with an Alcon 0 mm optic 21.6 diopter posterior chamber intraocular lens inserted into the capsular bag. This procedure was completed with a surgical microscope. How would you report this service?
  1. a. 66982
  2. b. 66982, 69990 c.   66984, 69990 d.   66984
  1. 53. A patient had four prophylaxis photocoagulation treatments for lattice degeneration. These treatments were completed over a one-week time period. How many units of code 67145 would be reported?
  1. a. One b.   Two
  2. c. Three d.   Four
  1. 54. How would you report an endolymphatic sac operation with shunt?
  1. a. 69806 b. 69801 c.   69949
  2. d. 69949, 69990-51
  1. 55. Bob, a healthy 12-year-old patient, had bilateral removal of ventilating tubes. An anesthesiologist administered general anesthesia for the procedure. How would the surgeon report her services?
  1. a. 69424- 47, 00120-P1 b.   69200-50
  2. c. 69424-50
  3. d. 69200, 00120-P1
  1. 56. The code range 65710–65757 should not be reported in conjunction with which of the following?
  1. a. Sensorimotor examination with single measurement, unilateral or bilateral, with interpretation

and report

  1. b. Any codes in the E/M section
  2. c. Computerized corneal topography, unilateral or bilateral,  with interpretation and report d.   There is not a code for reporting a restriction
  1. 57. Dr. Smith injected 12 cc of 5% Marcaine in the occipital nerve for a patient suffering from occipital neuralgia/

headache. How would you report this professional service?

  1. a. 64653 b. 64408 c.   64405 d.   64650
  1. Select the appropriate codes to report a supratentorial craniectomy for excision of a brain tumor and implantation of brain intracavitary chemotherapy agent.
  1. a. 61510, 61517 b.   61518, 61517
  2. c. 61512, 61517-59 d.   61510, 61316-59
  1. 59. A patient with spondylosis and lumbar degenerative disc disease underwent bilateral steroid paravertebral facet joint injections to L3 and L4. Additionally, a transforaminal epidural injection of anesthetic was done to the right side at T2. These procedures were completed under fluoroscopic guidance. How would you report these professional services?
  1. a. 64490-50, 64491-50, 64479-59-RT
  2. b. 64490, 64491, 64483, 77003
  3. c. 64494, 64480-59-RT, 77003-26
  4. d. 64483-50, 54475, 64479-59-RT, 64480-59, 77003-26
  5. 60. Ted had a neuroplasty of the ulnar nerve at the elbow. How would you report this procedure?
  1. a. 64719 b. 64718 c.   64822 d.   64836

CPT – SURGERY GUIDELINES (20000-29999)

DOWNLOADABLE CPC®PRACTICE EXAM QUESTIONS

  • Code 21076-21089 should only be used when the physician actually designs and prepares the prosthesis (i.e., not prepared by an outside laboratory)
  • To report bone graft performed after arthrodesis, see 20930-20938. Do not append modifier 62 to bone graft codes 20900-20938
  • Within the spine section, instrumentation is reported separately and in addition to arthrodesis. To report instrumentation procedures performed with definitive vertebral procedures, see 22840-22855.
  • Modifier 62 may not be applied to the definitive or add on spinal instrumentation procedure codes like 22840-22848 and 22850-22852
  • When arthrodesis is performed in addition to another procedure, the arthrodesis should be reported in addition to the original procedure with modifier 51.
  • Spinal osteotomy procedures are reported when a portion of the vertebral segments is cut and removal in preparation for realigning the spine as part of spinal deformity correction.
  • For excision of an intrinsic lesion of vertebra without deformity correction, see 22100-22116. For decompression of the spinal cord and/or nerve roots, see 63001-63308
  • The three columns are defined as anterior ( anterior two-thirds of the vertebral body), middle (posterior third of the vertebral body and the pedicle), and posterior (articular facets, lamina and spinous process)
  • Procedure codes 22554-22558 are for Single interspace.
  • For additional interspaces use 22585. A vertebral interspace is the non-bony compartment between two adjacent vertebral bodies, which contain the intervertebral discs and includes the nucleus pulposus, annulus fibrosus and two cartilaginous endplates.
  • When instrumentation reinsertion or removal is reported in conjunction with other definitive procedures including arthrodesis, decompression and exploration of fusion, append modifier 51 to 22849, 22850, 22852 and 22855.
  • Code 22849 should not be reported with 22850, 22852 and 22855 at the same spinal levels.
  • To report exploration of fusion, see 22830. When exploration is reported in conjunction with other definitive procedures, including arthrodesis and decompression, append 51 modifier to 22830.
  • Application of casts and strapping procedure are coded when the cast application or strapping is a replacement procedure used during or after the period of follow-up care, or when the cast application or strapping is an initial service performed without a restorative treatment or procedure to stabilize or protect a fracture, injury or dislocation and/or to afford comfort to a patient.
  • Restorative treatment or procedure rendered by another physician following the application of the initial cast/splint/strap may be reported with a treatment of fracture and/or dislocation code.
  • Initial cast/strap/splint procedure is always included in the treatment of fracture/dislocation codes.
  • Temporary cast/strap/splint is not considered to be part of the preoperative care and the use of the modifier 56 is not applicable.
  • Supply code for cast/strap/splint is 99070; it can be used in addition to evaluation and management code as appropriate.

CPT – SURGERY GUIDELINES (CARDIOVASCULAR SYSTEM) – PART 2

DOWNLOADABLE CPC®PRACTICE EXAM QUESTIONS

Cardiovascular system:

  • Procurement of the saphenous vein graft is included in the description of the work for 33510-33516 and should not be reported as a separate service or co-surgery.
  • To report harvesting of an upper extremity vein, use 35500 in addition to the bypass procedure.
  • To report harvesting of a femoropopliteal vein segment, report 35572 in addition to the bypass procedure.
  • Same guideline applies to combined arterial-venous grafting and arterial grafting.
  • Codes 33880-33891 represent a family of procedures to report placement of an endovascular graft for repair of the descending thoracic aorta. These codes include all device introduction, manipulation, positioning and deployment.
  • All balloon angioplasty and/or stent deployment within the target treatment zone for the endoprosthesis, either before or after endograft deployment are not separately reportable.
  • Open arterial exposure and associated closure of the arteriotomy sites (eg, 34812, 34820, 34833, 34834), introduction of guidewires and catheters (eg, 36140, 36200-36218), and extensive repair or replacement of an artery (eg, 35226, 35286) should be additionally reported.
  • Transposition of subclavian artery to carotid and carotid-carotid bypass performed in conjunction with endovascular repair of the descending thoracic aorta (eg, 33889, 33891) should be separately reported.
  • The primary codes, 33880 and 33881 include placement of all distal extensions. If required proximal extension can be reported separately.
  • For fluoroscopic guidance in conjunction with endovascular repair of the thoracic aorta, use code 75956-75959 as appropriate.
  • Codes 75956 and 75957 include all angiography of the thoracic aorta and its branches for diagnostic imaging prior to deployment of the primary endovascular devices, fluoroscopic guidance in the delivery of the endovascular components and intra-procedural arterial angiography (eg, confirm position, detect endoleak, and evaluate runoff).
  • Code 75958 includes the analogous services for placement of each proximal thoracic endovascular extension.
  • Code 75959 includes the analogous services for placement of a distal thoracic endovascular extensions paced during a procedure after the primary repair.
  • Other interventional procedures performed at the time of endovascular repair of the descending thoracic aorta should be additionally reported (eg, innominate, carotid, subclavian, visceral, or iliac artery transluminal angioplasty or stenting, arterial embolization, intravascular ultrasound, when performed before or after deployment of the aortic prostheses.
  • Same guideline applied to Endovascular repair of abdominal aortic aneurysm and iliac aneurysm.
  • Use 0048T to report the insertion of a ventricular assist device (VAD) performed via percutaneous.
  • Use 33975, 33976, 33979 to report the insertion of VAD performed via transthoracic approach.
  • Use 33977, 33978, 33980, 0050T to report the removal of VAD which also includes removal of the entire device, including the cannulas.
  • Use 33981-33983 to report the replacement of ventricular assist device pump which includes the removal of the pump and insertion of new pump, connection, de-airing and initiation of the new pump.
  • Use insertion code 33975, 33976, 33979 to report replacement of the entire VAD system. Removal of previous placed VAD is not separately reported.
  • Adjuvant technique maybe required at the time a bypass graft is created to improve patency of the lower extremity autogenous or synthetic bypass graft (eg, femoral-popliteal, femoral-tibial, or popliteal-tibial arteries.
  • Code 35685 should be reported in addition to the primary synthetic bypass graft procedure, when an interposition of venous tissue id placed at the anastomosis between the synthetic bypass conduit and the involved artery. This procedure includes harvesting.
  • Code 35686 should be reported in addition to the primary bypass graft procedure, when autogenous vein is used to create a fistula between the tibial or peroneal artery and vein at or beyond the distal bypass anastomosis site of the involved artery.
  • Code 35879 and 35881 describe open revision of graft threatening stenosis of lower extremity arterial bypass graft using vein patch angioplasty or segmental vein interposition techniques.
  • For thrombectomy with open revision of graft other than hemodialysis graft or fistula, use 35876
  • For direct repair of a lower extremity blood vessel (with or without patch angioplasty), use 35226.
  • For repair of lower extremity blood vessels using a vein graft use 35256.
  • Venipuncture collection of a specimen from an established catheter use 36592
  • Venipuncture collection of a specimen form capillary blood, use 36416
  • Venipunture collection of a specimen from a completely implantable venous access device use 36591
  • Venipuncture collection of a specimen form venous blood, use 36415

CPT – SURGERY GUIDELINES (Cardiovascular System) – Part 1

DOWNLOADABLE CPC®PRACTICE EXAM QUESTIONS

Cardiovascular system:

  • Selective vascular catheterizations should be coded to include introduction and all lesser order selective catheterizations used in the approach (eg, the description for a selective right middle cerebral artery catheterization includes the introduction and placement catheterization of the right common and internal carotid arteries)
  • Additional second and/or third order arterial catheterizations within the same family of arteries supplied by a single first order should be expressed by 36218 or 36248.
  • Additional first order or higher order vessel different from a previously selected and coded family should be separately coded.
  • A pacemaker or pacing cardioverter defibrillator includes a pulse generator containing electronics, a battery and one or more electrodes (leads).
  • A dual chamber pacemaker system includes a pulse generator and one electrode inserted in the right atrium and one electrode inserted in the right ventricle. In certain circumstances, an additional electrode may be required to achieve pacing of the left ventricle (bi-ventricular pacing), in this event, transvenous placement of the electrode should be separately reported using code 33224 or 33225. Epicardial placement of the electrode should be separately reported using 33202-33203.
  • Electrode positioning on the epicardial surface of the heart requires a thoractomy, or thoracosopic placement of the leads.
  • Removal of electrodes may first be attempted by transvenous extraction (33234. 33235 or 33244). However, if transvenous extraction is unsuccessful, a thoracotomy may be required to remove the electrodes (33238 or 33243).
  • Use 33212, 33213, 33221. 33230, 33231, 33240 as appropriate in addition to the thoracotomy or endoscopic epicardial lead placement codes (33202 or 33203) to report the insertion of the generator if done by the same physician during the same session.
  • Use 33213 to report insert transvenous single lead only without pulse generator.
  • Use 33217 to report insert transvenous dual lead only without pulse generator.
  • Use 33217 and 33224 to report insert transvenous multiple lead only without pulse generator.
  • Use 33212 or 33240 to report initial pulse generator insertion only with existing single lead.
  • Use 33213 or 33230 to report initial pulse generator insertion only with existing dual lead.
  • Use 33221 or 33231 to report initial pulse generator insertion only with existing multiple lead.
  • Use 33206 (atrial) or 33207 (ventricular) or 33249 to report initial pulse generator insertion or replacement plus insertion of transvenous single lead.
  • Use 33208 or 33249 to report initial pulse generator insertion or replacement plus insertion of transvenous dual lead.
  • Use 33208 and 33225 or 33249 and 33225 to report initial pulse generator insertion or replacement plus insertion of transvenous multiple lead.
  • Use 33214 or 33241 and 33249 to report Upgrade single chamber system to dual chamber system which includes removal of existing pulse generator.
  • Use 33233 or 33241 to report removal pulse generator only without replacement.
  • Use 33227 or 33262 to report removal pulse generator with replacement pulse generator only single lead (transvenous)
  • Use 33228 or 33263 to report removal pulse generator with replacement pulse generator only dual lead (transvenous)
  • Use 33229 or 33264 to report removal pulse generator with replacement pulse generator only multiple lead (transvenous)
  • Use 33234 or 33244 to report removal transvenous electrode only single lead system.
  • Use 33235 or 33244 to report removal transvenous electrode only dual lead system.
  • Use 33233 + (33234 or 33235) + (33206 or 33207 or 33208) and 33225, when appropriate to report removal and replacement of pulse generator and transvenous electrodes for pacemaker.
  • Use 33241 + 33244 + 33249 and 33225, when appropriate to report removal and replacement of pulse generator and transvenous electrodes for Implantable cardioverter defibrillator.
  • Codes 33254-33256 are only to be reported when there is no concurrently performed procedure that requires median sternotomy or cardiopulmonary bypass.
  • The appropriate atrial tissue ablation add-on code, 33257, 33258 and 33259 should be reported in addition to an open cardiac procedure requiring sternotomy or cardiopulmonary bypass if performed concurrently.
  • Limited electrophysiological operative ablation and reconstruction includes:
    • Surgical isolation of triggers of supraventricular dysrhythmias by operative ablation that isolates the pulmonary veins or other anatomically defined triggers in the left or right atrium.
  • Extensive electrophysiological operative ablation and reconstruction includes:
    • Surgical isolation of triggers of supraventricular dysrhythmias by operative ablation that isolates the pulmonary veins or other anatomically defined triggers in the left or right atrium.
    • Additional ablation of atrial tissue to eliminate sustained supraventricular dysrhythmias. This must include operative ablation that involves either the right atrium, the atrial septum, or left atrium in continuity with the atrioventricular annulus.
  • Surgical vascular endoscopy always includes diagnostic endoscopy.

CPT – Surgery Guidelines (30000-39999)

DOWNLOADABLE CPC®PRACTICE EXAM QUESTIONS

  • A surgical sinus endoscopy includes a sinusotomy and diagnostic endoscopy.
  • Codes 31295-31297 describe dilation of sinus ostia by displacement of tissue, any method, and include fluoroscopy if performed.
  • Codes 31233-31297 are used to report unilateral procedures unless otherwise specified.
  • Codes 31231-31235 for diagnostic evaluation refer to employing a nasal/sinus endoscope to inspect the interior of the nasal cavity and the spheno-ethmoid recess. Anytime a diagnostic evaluation is performed all these areas would be inspected and a separate code is not reported for each area.
  • Surgical bronchoscopy always includes diagnostic bronchoscopy when performed by the same physician.
  • Codes 31622-31646 include fluoroscopic guidance, when performed.
  • Pleural cavity and lung biopsy procedures may be accomplished using a percutaneous, Video Assisted Thoracoscopic Surgery (VATS), or thoracotomy approach. They involve the removal of differing amounts of tissue for diagnosis.
  • Lung resection procedures include diagnosis and therapeutic procedures, including the removal of blebs, bullae, cysts and benign or malignant tumors or lesions. These procedures may involve the removal of small portions of the lung or even an entire lung. Additionally lung resection procedure may require the removal of the adjacent structures.
  • A diagnostic wedge resection technique requires only that tissue sample be obtained without particular attention to resection margins.
  • Therapeutic wedge resections require attention to margins and complete resection even when the wedge resection is ultimately followed by a more extensive resection.
  • In the case of a wedge resection where intra-operative pathology consultation determines that a more extensive resection is required in the same anatomic location, it becomes classified as a diagnostic wedge resection. (32507, 32668). When no more extensive resection is required, the same procedure is a therapeutic wedge resection (32505, 32666).
  • More extensive anatomic lung resection procedures, which can be performed with either thoracotomy or Thoracoscopic approaches includes segmentectomy, lobectomy, bilobectomy and pneumonectomy.
  • Diagnostic biopsy of lung is included in surgical resection procedure.
  • The therapeutic wedge resection codes should not be reported in addition to the more extensive lung procedure unless the therapeutic wedge is performed on the different lobe or on the contra lateral lung.
  • When a diagnostic wedge resection is followed by a more extensive procedure on the same anatomical location, report add-on codes 32507 or 32668 with the more extensive procedure.
  • When a therapeutic wedge resection (32505, 32506, 32666 or 32667) is performed in a different lobe than the more extensive lung, report the therapeutic wedge resection with modifier 59.
  • The instillation of a fibrinolytic agent may be performed multiple times per day over the course of several days. Code 32561 should be reported only once on the initial day treatment. Code 32562 should be reported only once on each subsequent day of treatments
  • Cadaver donor pneumonectomy, includes harvesting the allograft and cold preservation of the allograft (perfusing with cold preservation solution and cold maintenance) (use 32850)
  • Recipient lung allotransplantation includes transplantation of a single or double lung allograft and care of the recipient (See 32851-32854).