Solution Manual For Medical Coding Certification Exam Preparation A Comprehensive Guide Release 2025

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INSTRUCTOR’S MANUAL For Medical Coding Certification Exam Preparation: A Comprehensive Guide Chapter 1-21 Cynthia L. Stewart-Vandagriff, CPC, COC, CPMA, CPC-I, CCS-P Cynthia L. Ward, CPC, COC, CPMA, CEMC, CCC, CDEO CPT five-digit codes, nomenclature, and other data are copyright ©2025 American Medical Association.

All rights reserved. No fee schedules, basic unit, relative values or related listings are included in CPT. The AMA assumes no liability for the data contained herein.

CPT codes are based on CPT 2025.

ICD-10-CM codes are based on ICD-10-CM 2025.

CONTENTS INTRODUCTION LESSON PLANS AND ANSWERS Unit One: Fundamental Coding Guidelines Chapter 1: The Certified Professional Coder Chapter 2: Foundations of ICD-10-CM Chapter 3: ICD Chapter-Specific Guidelines Chapter 4: Foundations of CPT Unit 1 Exam Answer Key Unit Two: Coding for Evaluation and Management, Anesthesia, and Surgery Section Chapter 5: Evaluation and Management Chapter 6: Anesthesia Chapter 7: Surgery Section Unit 2 Exam Answer Key Unit Three: Coding for Surgical Procedures on Integumentary, Musculoskeletal, Respiratory, and Cardiovascular/Lymphatic Systems Chapter 8: Surgery Section: Integumentary System Chapter 9: Surgery Section: Musculoskeletal System Chapter 10: Surgery Section: Respiratory System

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2 Chapter 11: Surgery Section: Cardiovascular and Lymphatic System Unit 3 Exam Answer Key Unit Four: Coding for Surgical Procedures on Digestive, Urinary, Male and Female Reproductive Systems, Maternity Care, Nervous System, and Eyes, Ears, and Endocrine System Chapter 12: Surgery Section: Digestive System Chapter 13: Surgery Section: Urinary System and Male Reproductive System Chapter 14: Surgery Section: Female Reproductive System and Maternity Care and Delivery Chapter 15: Surgery Section: Nervous System Chapter 16: Surgery Section: Eyes, Ears, and Endocrine System Unit 4 Exam Answer Key Unit Five: Coding for Radiology, Pathology/Laboratory, General Medicine, HCPCS Category II and III, and Practice Management Chapter 17: Radiology Chapter 18: Pathology/Laboratory Chapter 19: Medicine Chapter 20: HCPCS Level II: Category II and Category III Codes Chapter 21: Practice Management Unit 5 Exam Answer Key Appendix A Answer Key

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INTRODUCTION Note to the Instructor You may have found in your experience, as did we, that preparing medical coding students for a certification exam by routinely going through numerous case studies did not benefit the student in developing a true understanding of why the codes selected were correct or how the documentation supported the codes reported.

During our tenure as instructors, we heard the lament ―I’ve read the note five times and still don’t know what I’m looking for‖ many times over. Although disappointing to hear, this familiar grumble taught us that students need the tools to understand how to break down documentation into a series of questions which aid them in translating services, procedures, and diagnoses into codes. Using these tools, our students have maintained a consistently high certification exam pass rate.

Our purpose in writing Medical Coding Certification Exam Preparation: A Comprehensive Guide was twofold. Our first purpose was to aid the student in developing the skills to not only pass the certification exam but to also prepare them for their career in medical coding. Our second purpose was to aid the instructor in bringing all of the individually-learned pieces together for the student to complete the process of medical coding.

In this Instructor’s Manual The instructor’s manual includes answers and rationales for the end-of-section exercises, as well as the end-of-chapter exercises, including Using Terminology, Checking Your Understanding, and Applying Your Knowledge. Answers and rationales are also included for the end-of-unit exams for Units 1-5, as well as the Final Exam in Appendix A. Lesson plans and PowerPoints with teaching notes have been included for each chapter.

The importance of understanding the guidelines inherent to the ICD, CPT, and HCPCS coding manuals and knowing how to located and use them is stressed throughout this text in the form of Spotlight on Guidelines and Mentor Coding and Practice Management tips.

These tips are also listed in the instructor’s manual for each chapter under ―Teaching Tips‖ and are listed under the learning outcome with which they appear in the text for ease in reviewing this information with the student.

Organization of Medical Coding Certification Exam Preparation Here is an overview of the five units of the book:

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Key Points about the Book The importance of understanding the guidelines inherent to the ICD, CPT, and HCPCS coding manuals and knowing how to locate and use them is stressed throughout this text by the frequent use of specialfeature boxes: • Spotlights within each chapter refer the coder to or provide additional information and direction on specific procedures, conditions, guidelines, and practice management issues.

• Mentor Coding Tips are tips and shortcuts the authors have accumulated over the years and learned from other experienced coders in the trenches. These tips aid the coder in breaking down and retaining information necessary for the exam and everyday coding. While all of the chapters in this text are presented differently from what you might find in other review guides, four chapters in particular should be noted: • Chapter Three, Foundations of ICD-10-CM Information about the ICD-10-CM code set is included in Chapters 9 through 20 to help coders gain familiarity with these codes.

• Chapter Three, ICD Chapter-Specific Guidelines This chapter includes the four ICD-10-CM coding guidelines that the authors have found to be the most difficult for students and coders to interpret and use: those pertaining to human immunodeficiency virus; septicemia, systemic inflammatory response syndrome (SIRS), sepsis, severe sepsis, and septic shock; neoplasms; and diabetes mellitus. Chapterspecific guidelines pertaining to other ICD chapters are included in the relevant CPT surgery subsection chapters, Chapters 9 through 20.

• Chapter Eight, Surgery This chapter begins the Surgery section of CPT. Included is a step-by-step process of documentation analysis. This series of questions maps out many of the thought processes that experienced coders engage in when reviewing operative reports and other documentation. Walking through this process for each case study will help instill this approach in the coder.

It is important to note that not everything within the CPT, ICD, and HCPCS coding manuals is addressed in this text. The authors did address concepts and guidelines that in their experience as instructors tended to be difficult for examinees and new coders to master. Taking into account the various learning types, they created and added decision trees for a few of the most difficult coding concepts: human immunodeficiency. Each chapter contains tables that outline the sections of the ICD-10-CM and CPT code sets.

From a pedagogical standpoint, a variety of methods have been included for students to practice applying and developing their skills: review exercises at the end of each chapter section, end-of-chapter reviews and cases studies utilizing the documentation analysis tool where appropriate, and a cumulative unit exam at the end of each unit, designed to prepare students for the final exam at the end of the book (covering ICD-10-CM). The questions in both the unit exams and the final exam are presented in the style of the actual CPC exam questions.

Key Content Highlights Pedagogy • Learning outcomes and key terms are listed at the beginning of each chapter to set the stage for the content to come.

• Major chapter heads are structured to reflect the numbered learning outcomes.

• Key terms are defined in the margins for easy reference, and they are also listed in the Glossary near the end of the book.

• Tips, Spotlights, and Examples help students navigate through the material.

• Chapter summaries, organized by learning outcomes, are presented in a tabular, step-by-step format to help with review of the material.

• End-of-chapter elements are tagged with corresponding learning-outcome numbers.

• The Chapter Review section includes: • Using Terminology—matching questions with key terms and definitions.

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6 • Checking Your Understanding—multiple-choice questions.

• Applying Your Knowledge—case studies.

Chapter by Chapter • Chapter One: the language and roles of medical coding, benefits of credentialing your knowledge, and CPC exam format and test-taking skills.

• • Chapter Two: ICD-10-CM manual format, abbreviations, coding conventions, and punctuation; ICD10-CM chapter, general, section and chapter specific guidelines; and new conventions in ICD-10-CM default codes, extenders, and placeholders.

• Chapter Three: ICD chapter-specific general guidelines related to human immunodeficiency virus (HIV) infections; septicemia, systemic inflammatory response syndrome (SIRS), sepsis, severe sepsis, and septic shock; neoplasms; and diabetes mellitus.

• Chapter Four: CPT format, conventions, instructional notes, guidelines, and symbols; CPT modifiers; CPT and ICD linkage; and translation of provider documentation to codes.

• Chapter Five: Evaluation and management (E/M) guidelines, modifiers, and types of services; and components and levels of an E/M code.

• Chapter Six: anesthesia reimbursement formula and terminology; physical status, qualifyingcircumstance modifiers, and HCPCS Level II modifiers; and locating of anesthesia terms in the CPT manual index.

• ChapterSeven: general guidelines and format of the Surgery section of the CPT manual; global surgical package and Surgery section modifiers; and use of the index to locate codes for surgical procedures.

• Chapter Eight: anatomy of the integumentary system; ICD-10-CM and CPT guidelines for diseases of the skin and subcutaneous tissue; Integumentary subsection modifiers; and common medical and procedural terms used in operative reports.

• Chapter Nine: anatomy of the musculoskeletal system; ICD-10-CM and CPT guidelines for diseases of the musculoskeletal system; musculoskeletal system modifiers; and common medical and procedural terms used in operative reports.

• Chapter Ten: anatomy of the respiratory system; ICD-10-CM and CPT guidelines for diseases of the respiratory system; respiratory system modifiers; and common medical and procedural terms used in operative reports.

• Chapter Eleven: anatomy of the cardiovascular and lymphatic systems; ICD-10-CM and CPT guidelines for diseases of the cardiovascular system; ICD-10-CM and CPT guidelines for diseases of the lymphatic system; cardiovascular and lymphatic system modifiers; and common medical and procedural terms used in operative reports.

• Chapter Twelve: anatomy of the digestive system; ICD-10-CM and CPT guidelines for diseases of the digestive system; digestive system modifiers; and common medical and procedural terms used in operative reports.

• Chapter Thirteen: anatomy of the urinary and male reproductive system; ICD-10-CM and CPT guidelines for diseases of the urinary system; ICD-10-CM and CPT guidelines for diseases of the male reproductive system; urinary and male reproductive system modifiers; and common medical and procedural terms used in operative reports.

• Chapter Fourteen: anatomy of the female reproductive system; ICD guidelines and format for complications of pregnancy, childbirth, and the puerperium; CPT guidelines for the female genital system and maternity care and delivery; subsection modifiers; and common medical and procedural terms used in operative reports.

• Chapter Fifteen: anatomy of the nervous system; ICD-10-CM and CPT guidelines for diseases of the nervous system; nervous system modifiers; and common medical and procedural terms used in operative reports.

• Chapter Sixteen: anatomy of the endocrine system, eye, ocular adnexa, and auditory system; ICD-10CM guidelines for diseases of the eye, ocular adnexa, and auditory system; CPT guidelines for diseases of the endocrine system, eye, ocular adnexa, and auditory system; endocrine system, eye, ocular adnexa, and auditory system modifiers; and common medical and procedural terms used in operative reports.

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7 • Chapter Seventeen: CPT guidelines for the Diagnostic Imaging, Ultrasound, Mammography, and Bone/Joint Studies subsection of the Radiology section; CPT guidelines for the Radiation Oncology and Nuclear Medicine subsections.

• Chapter Eighteen: CPT guidelines for pathology/laboratory coding; modifiers most commonly used with codes in the Pathology/Laboratory section of CPT; and common medical and procedural terms used in lab and operative reports.

• Chapter Nineteen: CPT guidelines for the Medicine section; medical and procedural terms; and modifiers most commonly used with codes in the Medicine section.

• Chapter Twenty: HCPCS II guidelines and modifiers; common abbreviations and acronyms used in HCPCS Level II; CPT guidelines and format of category II and category III codes.

• Chapter Twenty-One: AAPC professional code of ethics; definitions of providers and payers, including Medicare, Medicaid, TRICARE, and managed care entities; regulations and the parties responsible for maintaining and enforcing the regulations.

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Chapter 1 – The Certified Professional Coder LESSON PLANS Class Preparation: Teaching Focus and Resources Chapter 1 discusses the process of translating provider documentation and medical terminology into diagnosis and procedure codes and introduces the role and responsibilities of a certified professional coder. Also, the national certification exam format and test preparation recommendations for the examinee are reviewed.

Learning Outcomes After completing Chapter 1, students will be able to: LO 1.1 Differentiate between the various languages used in medical coding.

LO 1.2 Determine the many roles a coder plays in the reimbursement and compliance process.

LO 1.3 Recognize the benefits of obtaining medical coding credentials and the importance of AAPC to the medical coder.

LO 1.4 Understand the basic format of the CPC exam.

LO 1.5 Acquire beneficial test-taking skills.

Class Presentation LO 1.1 Differentiate between the various languages used in medical coding.

Slides 1-1 through 1-3



Chapter Introduction and Key Terms

Slide 1-4



Introduction to the language of Medical Coding

Slide 1-5



The various languages used in Medical Coding

Slide 1-6



Standardized communication of CPT, HCPCS, and ICD

LO 1.2 Determine the many roles a coder plays in the reimbursement and compliance process.

Slide 1-7



Certified coders role in reimbursement

Slide 1-8



Coder’s impact on revenue cycle

Slide 1-9



Coder’s role in accurate claim form completion

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LO 1.3 Recognize the benefits of obtaining medical coding credentials and the importance of AAPC to the medical coder.

Slide 1-10



Additional positive impacts to the practice provided by certified coders

Slide 1-11



Compliance and the certified medical coder

Slide 1-12



The value of credentials and the AAPC

Slide 1-13



The value of credentials and the AAPC - continued

LO 1.4 Understand the basic format of the CPC exam.

Slide 1-14



CPC exam format

Slide 1-15



Areas tested on the CPC exam

LO 1.5 Acquire beneficial test-taking skills.

Slide 1-16



Tips to improve test-taking skills

Slide 1-17



Tips to improve test-taking skills - continued

Summary Slides Slides 1-18 to 1-19



Synopsis of Chapter 1

Teaching Tips LO 1.1:  Coding is a form of translating billing, compliance, payer, and provider language into standardized billing/reimbursement data.

LO 1.2:  To achieve consistent and accurate communication, providers as well as billing and coding personnel must fully understand coding guidelines and regulations. As guidelines and regulations are frequently updated and may change annually, coders must be diligent in maintaining and updating their knowledge of medical coding and billing policies, requirements, and procedures to be of value to the practices or organizations they work for and the healthcare field in general.

LO 1.3:

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The reasons for becoming certified include increased salary and employment opportunities for the coder and coding and compliance accuracy, as well as increased revenue, for the practice. AAPC is the credentialing organization for professional coders.

LO 1.4:  The CPC exam consists of 100 questions, is 4 hours length, and tests the coder’s skills in ICD, CPT, HCPCS Level II, anatomy, and medical terminology.

LO 1.5:  Test-taking tips include getting plenty of rest the night before the test, listening closely to instructions, and leaving no answer blank.

Coding Tips and Guidelines o Cramming the night before the test does not help. You know the material by then. Go to bed early, and get a good night’s rest. o Running out of time during the test is a major reason for failing the test. Complete areas or questions about which you are more confident first, as they will take less time. Do not spend considerable time struggling with questions you find difficult. Make your best attempt to answer a question and move on to the next question.

Chapter 1 Answer Key Exercise 1.1 1. Describe the foundation of a coder’s role.

Ans: The answers may vary but basically should discuss the ability to interpret, translate, and submit correctly the data about the patient encounter onto a CMS-1500 form for reimbursement Feedback: Coding and billing language is used to assist physician offices, hospitals, patients, third-party administrators, and insurance companies in understanding why the patient was seen and what services, procedures, or supplies were provided for the patient and in identifying and submitting the claim as codes.

2. What are the main ―languages‖ coders must be familiar with in order to code accurately?

Ans: Billing, Compliance, Payer, and Provider Feedback: Provider language is built on medical terminology, anatomy, and pathophysiology and describes services, procedures, and the medical necessity of those services and procedures.

Billing language includes terms such as accounts receivable (A/R), clean claims, denials, modifiers, and advanced beneficiary notices (ABNs). Payer language comprises terms such as noncovered services, medical necessity, compliance language, and unbundling. Compliance language brings terms such as unbundling, fraud, false claim, and abuse into the translation.

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Exercise 1.2 1. What are some of the consequences of not submitting a clean claim the first time the claim is submitted to the payer?

Ans: Delay of revenue in the accounts receivable (A/R) cycle due to increased adjudication periods and more staff time spent researching, correcting, and resubmitting the claim. Also potential loss due to failure to comply with claim filing limits.

Feedback: Correcting such errors is costly to medical practices, as they result in more days of revenue in the accounts receivable (A/R) cycle due to longer adjudication periods and more staff time spent researching, correcting, and resubmitting the claims.

As the patient record may not be altered, errors identified must be corrected so that an auditor can recognize both the error and the correction. All corrections or additions to the medical record (addendums) must be dated and legibly signed or initialed.

2. Give an example of how a service or procedure provided is linked to the medical necessity for this service or procedure.

Ans: Answers will vary; however, the student’s concept should include the appropriate sex and age of the patient as well as the reported diagnosis code medically supporting the necessity of the procedure or service reported.

Feedback: An instance of an inaccurate claim would be one in which the patient demographic information does not support the patient’s condition or the nature or type of service performed.

Learning Outcome: Exercise 1.3 1. List three reasons to become a certified coder.

Ans: 1) Increased value to the practice 2) Aid the practice in maintaining coding and billing compliance with federal and state regulations and contracted payer policies 3) Career advancement Feedback: One reason for becoming credentialed is the increased opportunity for employment.

According to findings of the Bureau of Labor Statistics, employers prefer to hire credentialed medical coders rather than non credentialed coders, thereby increasing the chances of employment for CPCs. 2. Identify some of the impact AAPC has on the coding community.

Ans: Provides coding education, assists members by identifying job opportunities, and offers networking opportunities among its members.

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Feedback: The American Academy of Professional Coders (AAPC) is a credentialing organization of more than 100,000 members, approximately 80 percent of whom are credentialed as Certified Professional Coders. The AAPC supports its members by providing coding education, identifying job opportunities, and offering networking opportunities.

Credentials validate the knowledge and expertise of the individual who holds them. The AAPC offers members the opportunity to validate their command of medical coding through testing of the medical code sets (ICD, CPT, and HCPCS), the coding rules and regulations, anatomy, physiology, medical terminology, and documentation guidelines.

Upon successful completion of the exam, the student receives the Certified Professional Coder (CPC) credential, which confirms to future employers and others in the medical field his or her knowledge, experience, and abilities as a physician practice-based medical coder.

Exercise 1.4 1. What is the length of the CPC exam and how many questions are included?

Ans: Four hours and 100 questions Feedback: The Certified Professional Coder (CPC) exam is a grueling 100-question exam that thoroughly tests the coder’s ability within a medical coding subset. As there are multiple versions of this exam, of which any may be administered during examination, the examinee must be prepared to demonstrate her or his knowledge and ability across all code sets: ICD, CPT, and HCPCS Level II codes.

Regardless of the exam version, the time allowed for completing the exam is 4 hours.

2. List the areas in which a coder is tested on the CPC exam.

Ans: Anesthesia, Radiology, Medicine, Musculoskeletal, Endocrine, Digestive, Nervous, Evaluation & Management, Urinary, Respiratory, Cardiovascular, Integumentary, Mediastinum & Diaphragm, Pathology, Male/Female Genital, Laboratory, Maternity & Delivery, Hemic & Lymphatic, Eye & Ocular Adnexa, ICD-10-CM, HCPCS Level II, Compliance and Regulatory, Coding Guidelines, Medical Terminology, Anatomy and Physiology Feedback: Anesthesia, Radiology, Medicine, Musculoskeletal, Endocrine, Digestive, Nervous, Evaluation & Management, Urinary, Respiratory, Integumentary, Mediastinum & Diaphragm, Pathology, Male/Female Genital, Laboratory, Maternity & Delivery, Hemic & Lymphatic, Eye & Ocular Adnexa, ICD-10-CM, HCPCS Level II, Practice Management, Coding Guidelines, Medical Terminology, Anatomy and Physiology Exercise 1.5

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1. What are two of the major factors that can affect a coder’s successful completion of the CPC exam?

Ans: Time and test-taking anxiety Feedback: Occasionally, coders go into the CPC exam very well versed on the subject matter but fail the exam. One of the more common reasons for this is text anxiety: Some students will begin the exam feeling ready, look at the first question, and forget what they had learned due to panic and fear. Running out of time during the test is a major reason for failing the test.

2. List some test-taking tips from the chapter and some of your own test-taking tips.

Ans: Answers will vary but may include the following: Take a mock/practice test a few months before the actual test.

Use available resources to practice specific areas of weakness identified by the mock/practice test, such as ICD or compliance.

Form a study group among your peers.

Know the ICD, CPT, and HCPCS books, and know how to locate codes and use them.

Memorization of the guidelines is not required; however, the more you know without having to reference this information during the exam, the better for time management.

Practice exam time management.

Chapter One Review Using Terminology 1. C

AAPC

7. I

Medical coding

2. H

A/R

8. B

Medical necessity

3. A

CPC

9. E

Payer language

4. D

Billing language

10. G Provider language

5. J

Clean claim

6. F

Compliance language

Checking Your Understanding

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1. The CPC exam has ___________questions and is _________________ in length.

Ans: B. 100 questions; 4 hours0 Feedback: The Certified Professional Coder (CPC) exam is a grueling 100-question exam that thoroughly tests the coder’s ability within a medical coding subset. As there are multiple versions of this exam, of which any may be administered during examination, the examinee must be prepared to demonstrate her or his knowledge and ability across all code sets: ICD, CPT, and HCPCS Level II codes. Regardless of the exam version, the time allowed for completing the exam is 4 hours0.

2. The data that are translated by the coder to be submitted to the payer are submitted on which form when billing for the physician?

Ans: C. CMS-1500 Feedback: The ability to interpret the different languages and correctly translate them into data for the CMS-1500 claim form, which becomes the source of the statistical medical data for the practice, payer, and governing bodies, is the foundation of the medical coder’s role.

3. The ―language‖ that is used by insurance carriers and includes terms such as noncovered services, unbundling, and duplicate claim is called: Ans: D. Payer language Feedback: Payer language comprises terms such as noncovered services, medical necessity, compliance language, and unbundling.

4. To achieve consistent and accurate communication, providers as well as coders must: Ans: D. All of these Feedback: To achieve consistent and accurate communication, providers as well as billing and coding personnel must fully understand coding guidelines and regulations. As guidelines and regulations are frequently updated and may change annually, coders must be diligent in maintaining and updating their knowledge of medical coding and billing policies, requirements, and procedures to be of value to the practices or organizations they work for and the health care field in general.

5. Certified coders, on average, earn ______________ more than noncertified coders.

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Ans: B. 20 percent Feedback: Certified coders, on average, earn 20 percent more than noncertified coders and often continue their education, becoming office managers, billing managers, consultants, auditors, and educators.

6. What is used by a coder as the basis for the information required to complete fields 21 and 24 on the CMS-1500?

Ans: D. Provider documentation, including either handwritten notes and dictated reports.

Feedback: ICD-10-CM codes are reported in field 21 of the CMS form, beginning with the firstlisted diagnosis followed by any secondary diagnoses that were treated or medically managed.

Patient record documentation must support the medical necessity reported.

7. A diagnosis may not receive direct treatment during an encounter but the physician still has to consider this diagnosis when determining treatment for other conditions. This is a definition of: Ans: B. Medically managed Feedback: Medically managed: A diagnosis which may not receive direct treatment during an encounter but which the provider has to consider when determining treatment for other conditions.

8. What is the name of the credentialing organization for the CPC exam?

Ans: D. AAPC Feedback: The American Academy of Professional Coders (AAPC) is a credentialing organization of more than 100,000 members, approximately 80 percent of whom are credentialed as Certified Professional Coders. The AAPC supports its members by providing coding education, identifying job opportunities, and offering networking opportunities.

9. Which books are required for the CPC exam?

Ans: D. All of these Feedback: The CPC exam is an ―open code-book‖ exam. This means approved current year coding manuals (CPT, HCPCS, and ICD) may be used during the exam.

10. Which of the following would not be a good test-taking tip?

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Feedback: Here are some tips that will help you improve your test-taking skills: Take a mock/practice test a few months before the actual test.

Use available resources to practice specific areas of weakness identified by the mock/practice test, such as ICD or compliance.

Form a study group among your peers.

Know the ICD, CPT, and HCPCS books, and know how to locate codes and use them.

Memorization of the guidelines is not required; however, the more you know without having to reference this information during the exam, the better for time management.

Practice exam time management.

Applying Your Knowledge 1. Explain how coding is like translating a language and how realizing this can help a coder pass the CPC exam.

Ans: Medical coding is a form of translating provider documentation and medical terminology into codes that illustrate the procedures and services performed by medical professionals. The Certified Professional Coder (CPC) exam is designed to test the coder’s skill in translating this information accurately and completely so that the provider is reimbursed correctly, fairly, and within compliance guidelines.

Feedback: Coding and billing language is used to assist physician offices, hospitals, patients, third-party administrators, and insurance companies in understanding why the patient was seen and what services, procedures, or supplies were provided for the patient and in identifying and submitting the claim as codes 2. List other career opportunities for a certified coder.

Ans: Office managers, billing managers, consultants, auditors, and educators. One additional reason for becoming credentialed is the increased opportunity for employment. According to the findings of the Bureau of Labor Statistics, employers prefer to hire credentialed medical coders over non-credentialed coders.

Feedback: One reason for becoming credentialed is the increased opportunity for employment.

According to findings of the Bureau of Labor Statistics, employers prefer to hire credentialed medical coders rather than noncredentialed coders, thereby increasing the chances of employment for CPCs.

3. Explain which test-taking tips you think will be most beneficial to you in preparing for the CPC exam.

Ans:  Take a mock/practice test a few months before the actual test.

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 Use resources available to practice specific areas of weakness as identified by the mock/practice test, such as ICD or compliance.  Form a study group among your peers.  Know the ICD, CPT, and HCPCS books and know how to locate and use them.  Take a second mock/practice test within a month before the CPC Exam.  Again using resources available, practice any areas of weakness identified by the second mock/practice test.  Go over the guidelines in both the ICD and CPT thoroughly the week of the exam.  Listen to the proctor carefully and follow all instructions.  Leave nothing blank.

Chapter 2 – Foundations of ICD-10-CM LESSON PLANS Class Preparation: Teaching Focus and Resources This chapter is designed to provide an understanding of the ICD-10-CM conventions and guidelines as needed for the proficiency exam and CPC exam after the final implementation of ICD-10-CM. Learning Outcomes After completing Chapter 2, students will be able to: LO 2.1 Understand the format of ICD-10-CM. LO 2.2 Explain the abbreviations, coding conventions, and punctuation marks used in ICD-10-CM. LO 2.3 Identify main terms, default codes, extenders, and placeholders and explain their importance in the use of the ICD-10-CM index.

LO 2.4 Apply ICD-10-CM chapter-specific guidelines.

LO 2.5 Explain ICD-10-CM diagnostic outpatient guidelines.

LO 2.6 Recognize the importance of translating provider terminology into accurate diagnostic codes.

Class Presentation LO 2.1 Understand the format of ICD-10-CM. Slides 2-1 through 2-3



Chapter introduction and Key Terms

Slide 2-4



Introduction to ICD-10-CM and ICD-10-PCS

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18 Slide 2-5



Format of ICD-10-CM

Slide 2-6



Format of ICD-10-CM -continued

LO 2.2 Explain the abbreviations, coding conventions, and punctuation marks used in ICD-10-CM. Slide 2-7



ICD-10-CM Abbreviations, Coding Conventions, Guidelines, and Instructional Notes, and Punctuation - NEC - NOS

Slide 2-8



ICD-10-CM Abbreviations, Coding Conventions, Guidelines, and Instructional Notes, and Punctuation

Slide 2-9



ICD-10-CM Abbreviations, Coding Conventions, Guidelines, and Instructional Notes, and Punctuation – continued - Acute and Chronic conditions

Slide 2-10



ICD-10-CM Abbreviations, Coding Conventions, Guidelines, and Instructional Notes, and Punctuation – continued - Acute and Chronic conditions – continued - And

Slide 2-11



ICD-10-CM Abbreviations, Coding Conventions, Guidelines, and Instructional Notes, and Punctuation – continued - With and Without

Slide 2-12



ICD-10-CM Abbreviations, Coding Conventions, Guidelines, and Instructional Notes, and Punctuation – continued - Excludes 1

Slide 2-13



ICD-10-CM Abbreviations, Coding Conventions, Guidelines, and Instructional Notes, and Punctuation – continued - Excludes 2

Slide 2-14



ICD-10-CM Abbreviations, Coding Conventions, Guidelines, and Instructional Notes, and Punctuation – continued - Symptoms and Signs

Slide 2-15



ICD-10-CM Abbreviations, Coding Conventions, Guidelines, and Instructional Notes, and Punctuation – continued - Code First - Use Additional Code

Slide 2-16



ICD-10-CM Abbreviations, Coding Conventions, Guidelines, and Instructional

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19 Notes, and Punctuation – continued - Punctuation - Parentheses LO 2.3 Identify main terms, default codes, extenders, and placeholders and explain their importance in the use of the ICD-10-CM index.

Slide 2-17



Main Terms, Default Coders, Extenders, Placeholders, and the ICD-10-CM Index - Main terms - Default Codes

Slide 2-18



Main Terms, Default Coders, Extenders, Placeholders, and the ICD-10-CM Index – continued - Seventh-Character Extenders

Slide 2-19



Main Terms, Default Coders, Extenders, Placeholders, and the ICD-10-CM Index – continued - Placeholder Characters Main Terms, Default Coders, Extenders, Placeholders, and the ICD-10-CM Index – continued - Sequela - Impending or threatened condition

 Slide 2-20

LO 2.4 Apply ICD-10-CM chapter-specific guidelines.

Slide 2-21



ICD-10-CM Chapter-Specific Guidelines - Introduction

Slide 2-22



ICD-10-CM Chapter-Specific Guidelines - Chapter 1 – Certain Infectious and Parasitic Diseases - Chapter 2 – Neoplasms - Chapter 3 – Diseases of the Blood and Blood-Forming Organs

Slide 2-23



ICD-10-CM Chapter-Specific Guidelines – continued - Chapter 4 – Endocrine, Nutritional, and Metabolic Diseases - Chapter 5 – Mental and Behavioral Disorders - Chapter 6 – diseases of the Nervous System

Slide 2-24



ICD-10-CM Chapter-Specific Guidelines - continued - Chapter 7 – Diseases of the Eye and Adnexa - Chapter 8 – Diseases of the Ear and Mastoid Process - Chapter 9 – Disease of the Circulatory System

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20 -

Chapter 10 – Diseases of the Respiratory System

Slide 2-25



ICD-10-CM Chapter-Specific Guidelines – continued - Chapter 11 – disease of the Digestive System - Chapter 12 – Diseases of the Skin and Subcutaneous Tissue - Chapter 13 – Diseases of the Musculoskeletal System and Connective Tissue - Chapter 14 – Diseases of the Genitourinary System - Chapter 15 – Pregnancy, Childbirth, and Puerperium

Slide 2-26



ICD-10-CM Chapter-Specific Guidelines – continued - Chapter 16 – Certain Conditions Originating in the Perinatal Period - Chapter 17 – Congenital Malformations, Deformations, and Chromosomal Abnormalities - Chapter 18 – Symptoms, Signs, and Abnormal Clinical and Laboratory Findings, Not Elsewhere Classified

Slide 2-27



ICD-10-CM Chapter-Specific Guidelines – continued - Chapter 19 – Injury, Poisoning, and Certain Other Consequences of External Causes - Chapter 20 – External Causes of Morbidity - Chapter 21 – Factors Influencing Health Status and Contact with Health Services

LO 2.5 Explain ICD-10-CM diagnostic outpatient guidelines.

Slide 2-28



Highlights of Diagnostic Outpatient Guidelines - First-listed Diagnosis versus Principal Diagnosis - Signs and Symptoms - Coding to the highest level of specificity

Slide 2-29



Highlights of Diagnostic Outpatient Guidelines – continued - Unconfirmed-diagnosis terms - Chronic disease

LO 2.6 Recognize the importance of translating provider terminology into accurate diagnostic codes.

Slide 2-30



Provider Documentation and Medical Necessity

Summary Slides Slides 2-31 through 2-35



Synopsis of the chapter

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21

Teaching Tips Using the ICD-10-CM manual, have the student locate each of the following. Review each of these topics in class discussion.

LO 2.1:  Volume 1: Tabular List  Volume 2: Alphabetic Index  ICD-10-PCS Coding Tips and Guidelines o When searching through the index, pay close attention to indentations as you move from one column to the next. o Coding students may find it very helpful to tab the ICD-10-CM manual. They use selfadhesive tabs or labels to mark the individual tables in the Alphabetic Index (hypertension, neoplasm, table of drugs and chemicals) and the individual chapters in the Tabular List to identify a range of codes. They may find that this saves them considerable time when they are taking the CPC exam since the tabs enable them to quickly locate the code indicated in the index.

LO 2.2:  Abbreviations o NEC o NOS  Coding conventions and Instructional notes o Acute o Chronic o Excludes 1 o Excludes 2  Punctuation o Brackets Coding Tips and Guidelines o Be sure to review both the acute and chronic subterms to identify available combination codes, since they are not always found under both terms. In the example above, the combination code is found only by reviewing the subterm of acute. o The ICD-10-CM conventions indicate that the default between with and without codes is always without. This means that if the documentation is unclear or does not state that the complication or comorbidity listed in the code description is present with the condition, the without code is to be listed. o Remember that the inclusion terms are not all-inclusive and other terms may be listed in the index and not included in the tabular list. When this occurs, be sure to double-check the term and code in the index to avoid transposition of code digits before selecting the code. o If the sign or symptom is inherent to (commonly a part of) the definitive diagnosis, the sign or symptom is not coded in addition to the diagnosis. o When searching for additional codes, be aware that unspecified codes may be used for the second-listed code when the provider’s documentation is less detailed than needed to select a more accurate code. For example: A41.9 Sepsis, unspecified.

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22 o

When the etiology/manifestation coding is identified in the index with the square bracket convention, the codes must be reported in the sequencing identified by the convention regardless of which condition, etiology or manifestation, is being treated by the provider.

LO 2.3:  Main terms: describes the patient illness or injury (the reason for the present encounter) documented by the provider  Steps in locating the appropriate ICD-10-CM code: 1. Identify the main term.

2. Locate the main term in the Alphabetic Index.

3. Identify appropriate subterms and default codes in the Alphabetic Index.

4. Read all instructional notes.

5. Verify the code in the Tabular List.

6. Code to the highest level of specificity.

Coding Tips and Guidelines o When unsure of the main term in a diagnostic statement, ask the question, ―What did the patient suffer from?‖ Non-main terms should sound out of place as answers to this question. o Be sure to review all indented subterms in the Alphabetic Index and the code nomenclature in the Tabular List before assigning a code, as a more specific ICD-10-CM code may be available. Also, although the ICD-10-CM index will indicate the need for additional fourth, fifth, and sixth characters by a dash (-) placed after the code, the need for seventh-character extenders is not identified in the Alphabetic Index. o Many coders have trouble with the late effect and sequela/residual condition concept. An easy way to distinguish between the two is to remember that sequel is a Latin term meaning ―sequel‖ and is used to describe the next step in a sequence. The sequela is the condition produced after the initial injury or condition has healed. The late effect code identifies the initial injury or condition. o Be sure to review the provider’s documentation thoroughly for the outcome of the patient’s condition as many providers use the term impending or threatened when others such as probable or possible would be more accurate coding terms for identifying the patient’s condition. o One of the tricks used by successful coding students when checking the tabular section or chapter of the ICD-10-CM is to look at the five codes above and five codes below the code identified in the index just to make sure they are not missing something.

LO 2.4:  The ICD-10-CM Chapter-specific guidelines Coding Tips and Guidelines o When preparing for the CPC exam, study the chapter-specific guidelines a few days before taking the exam. This is a good review, and it will remind you during the test that you just ―read something about this‖. This reminder during the exam often takes away the feeling of being overwhelmed.

LO 2.5:  First-listed diagnosis: This is the reason for visit and is used for provider/outpatient coding.

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23    

Signs and symptoms: These may be reported when a diagnosis has not been confirmed.

Code to highest level of specificity: Use fourth, fifth, sixth, and seventh characters, as appropriate.

Unconfirmed diagnoses: Do not use unconfirmed terms such as rule out.

Chronic conditions: A chronic condition may be coded if it affects the treatment or management of the presenting condition.

Coding Tips and Guidelines o According to ICD-10-CM, ―the coding conventions of ICD-10-CM as well as the general and disease specific guidelines take precedence over the outpatient guidelines.‖ When coding, remember that there is a hierarchy to the coding guidelines and conventions.

Guidelines or conventions listed at the code level in the Tabular List take precedence over those at the section level. Those listed at the section level take precedence over those at the chapter level. Basically, this means that the closer the guideline or convention is to the code in the Tabular List, the higher it is in the hierarchy of guidelines and thus it supersedes the other guidelines or conventions.

LO 2.6:  An important aspect is the ability to link the medical necessity of the documented encounter to the service provided. Provide specific examples of diagnoses that support medical necessity of a specific service as well as examples that do not.

Chapter 2 Answer Key Exercise 2.1 1. What is the function of a subterm?

Ans: Subterms follow the main term in a graduated indented format and allow for further clarification of the patient’s condition, thus allowing the coder to drill down to a more accurate code prior to looking up the code in the Tabular List.

2. Explain which providers and entities will use ICD-10-CM and/or ICD-10-PCS. Ans: Both providers and facilities will use ICD-10-CM codes to report diagnosis codes. Only facilities will use ICD-10-PCS to report procedures and services performed in the facility.

Feedback: Unlike the ICD-9-CM which is published in a 2 or 3 volume set, the ICD-10-CM is published in two main parts or sections and is used by both providers and facilities to identify why the service or procedure was provided. The ICD-10-CM includes only diagnostic codes.

Facilities will use ICD-10-PCS (Procedural Coding System) to code procedures performed in the facility after the final implementation date. The tabular list of the ICD-10-CM contains the codes and the full description (nomenclature) of each code and is divided into chapters based upon body systems or conditions. The index of the ICD-10-CM contains an alphabetic listing of main terms identifying the patient’s condition, injury, sign or symptom.

Exercise 2.2

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24

1. Explain with and without in ICD-10-CM. Ans: The distinction between these codes is identified by the statement of ―with‖ when the condition or complication is present and ―without‖ when the condition or complication is not present. The ICD-10-CM conventions indicate that the default between ―with‖ and ―without‖ codes is always ―without.‖ This means that if the documentation is unclear or does not state that the complication or comorbidity listed in the code description is present with the condition, the ―without‖ code is to be listed.

2. Explain Excludes 1 and Excludes 2 in ICD-10-CM. Ans: Excludes 1 indicates that the condition, disease, or injury being coded is located elsewhere in the ICD-10-CM manual and should never be coded with the code under which it is located.

Conditions identified by this note cannot be present together or are related and therefore are never coded during the same encounter.

However, should both conditions be present at separate anatomic sites, both conditions may be reported despite the Excludes 1 note.

Excludes 2 is used to alert the coder that the condition listed in the excludes list is distinct from the code’s condition and is coded elsewhere in the ICD-10-CM. The conditions excluded may occur with the condition represented by the code, and these two codes may be coded together during the same encounter.

Exercise 2.3 1. Explain default codes and their function in ICD-10-CM coding.

Ans: The ICD-10-CM identifies codes which are either unspecified or most often used with a condition as default codes. These codes are located directly after the bolded main term and should only be used if the provider’s documentation provides no additional detail regarding the patient’s condition or disease.

2. Explain extenders and their function in ICD-10-CM coding.

Ans: ICD-10-CM makes use of seventh character extenders to complete the description of many codes. This character is alphabetic and relays information related to the code selected such as episode of care, type of fracture, late effects, or trimester of pregnancy.

3. Explain placeholders and their function in ICD-10-CM coding.

Ans: The structure of ICD-10-CM codes is unique in requiring that the seventh character extender must always be in the seventh character place in the code. In ICD-10-CM, complete codes may be 3, 4 or 5 characters. ICD-10-CM uses placeholder character(s) to extend these codes through the sixth character. Using placeholder ―x‖ in the fourth, fifth, or sixth character place when needed allows the seventh character extender to remain in the seventh character placement.

Exercise 2.4

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1. Which guidelines are specific to Chapter 21 in ICD-10-CM? Ans: ICD-10-CM Chapter 21-specific guidelines cover coding for patient encounters for reasons other than illness or injury such as inoculations, vaccinations, contact or suspected exposure to disease, patient status, family or personal history of a medical condition, screening, observation, aftercare or follow up, and routine and administrative examinations.

2. Which guidelines are specific to Chapter 18 in ICD-10-CM? Ans: This section lists guidelines for use of symptom codes with and without definitive diagnosis codes, correct use of coma scale codes, rules for sequencing SIRS not due to infection, and a description of functional quadriplegia.

3. Which guidelines are specific to Chapter 10 in ICD-10-CM? Ans: Chronic Obstructive Pulmonary Disease (COPD), asthma, bronchitis, and respiratory failure instructions and code sequencing are included in these guidelines.

Exercise 2.5 1. Explain coding to the highest level of specificity in ICD-10-CM. Ans: Refers to the use of fourth, fifth, and sixth characters and seventh character extenders when required.

Feedback: Coding to the highest level of specificity in ICD-10-CM refers to the use of fourth, fifth, and sixth characters and seventh-character extenders when required.

2. What is the outpatient guideline concerning an unconfirmed diagnosis?

Ans: Unconfirmed diagnosis terms such as rule out, probable, access, and questionable MAY NOT be used in outpatient diagnostic coding. A sign or symptom must be used in place of an unconfirmed diagnosis.

Feedback: Refer to Official ICD-10-CM Guidelines for Coding and Reporting Guidelines, Section IV. 3. When may a chronic condition be coded?

Ans: Chronic conditions may be coded if the chronic condition affects the treatment or management of the presenting condition.

Exercise 2.6 1. Briefly discuss the importance of translating the medical record into accurate coding data, and explain why it is important to have a thorough knowledge of anatomy, medical terminology, and pathophysiology.

Ans: Answers will vary but should include medical necessity and linking the ICD-10-CM to the service or procedure provided to the patient.

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26

Feedback: The service or procedure provided to the patient should be documented to prove medical necessity.

Chapter Two Review Using Terminology 1. I

Acute

11. L Symptom

2 B

And

12. F Chronic

3. C

Main term

13. E Manifestation

4. M Square brackets (Tabular List)

14. H Parentheses

5. O

Square brackets (Alphabetic Index) 15. D NOS

6. G

Late effect

16. P Default code

7. N

Includes

17. Q Placeholder

8. J

Excludes 1

18. R Excludes 2

9. A

NEC

19. S Extender

10. K Sign

20. T Impending or threatened condition

Checking Your Understanding 1. This abbreviation is next to an ICD-10-CM code when a more appropriate code is not provided elsewhere in the manual.

Ans: B. NEC (Not Elsewhere Classified) Feedback: NOS is not otherwise specified and DEF is used to state a definition of the term or terms used.

2. Which chapter-specific guidelines include instructions for coding chronic kidney disease?

Ans: B. Chapter 14, Diseases of the Genitourinary System 3. Which of the following, when noted in the Alphabetic Index, instructs the coder on the mandatory sequencing of the etiology/manifestation?

Ans: D. Square brackets Feedback: ICD-10-CM does not use the slanted bracket. The square bracket instructs the coder of the mandatory sequencing of the etiology/manifestation.

4. Which is not an appropriate step in determining an ICD-10-CM code?

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27

Ans: C. Determine the code directly from the Alphabetic Index Feedback: The code should always be verified in the Tabular List and never coded directly from the Alphabetic Index.

5. According to the diagnostic outpatient guidelines, which of the following best fits the guidelines for the use of signs and symptoms?

Ans: B. They are reported only when a diagnosis has not been confirmed and reported by the provider.

Feedback: Per the diagnostic outpatient guidelines, they are reported only when a diagnosis has not been confirmed and reported by the provider. Refer to Official ICD-10-CM Guidelines for Coding and Reporting, Section IV. 6. Coding to the highest level of specificity means: Ans: C. Using a fourth, fifth, sixth, or seventh character when required Feedback: Coding to the highest level of specificity in ICD-10-CM refers to the use of fourth, fifth, and sixth characters and seventh-character extenders when required.

7. Which of the following are important aspects of a coder being able to translate provider documentation?

Ans: D. All of the choices are important aspects.

Feedback: Important aspects of a coder being able to translate provider documentation include ensuring the proper ICD-10-CM code is chosen, being able to stay within compliance guidelines, and linking the medical necessity of the encounter to the service provided.

8. According to the ICD-10-CM conventions, if the documentation is unclear or does not state that the complication or comorbidity listed in the code description is present with the condition, the default is: Ans: B. Without Feedback: In ICD-10-CM, without is the notation indicating that a separate associated complication or comorbidity is not present. This is the default in ICD-10-CM. 9. The way the condition due to the underlying disease or condition presents itself is: Ans: A. Manifestation Feedback: The way the condition due to the underlying disease or condition presents itself is the manifestation.

10. Which term is used to describe a residual condition that occurs after the initial illness or injury?

Ans: D. Sequela

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28

Feedback: The term sequela (late effect) is used to describe a residual condition that occurs after the initial illness or injury. It is a Latin term meaning ―sequel‖ and is used to describe the next step in a sequence.

Applying Your Knowledge 1. Discuss the main steps that a coder needs to follow when translating a provider’s documentation and determining the appropriate code using the ICD-10-CM manual.

Ans: After reading the provider documentation thoroughly, the coder should follow these steps: 1) Determine the main term(s) from the documentation.

2) Locate the main term(s) in the Alphabetic Index.

3) Identify and review any subterms listed below the main term in the Alphabetic Index.

Then identify in the provider’s documentation the subterm that further defines and supports the level of specificity of the condition as documented.

4) Review all notes listed in the Alphabetic Index and Tabular List.

5) Verify the code identified in the Alphabetic Index by checking it in the Tabular List.

6) Determine the code to the highest degree of specificity (use up to seven characters if required).

2. Explain the differences between acute and chronic, and list one of the guidelines pertaining to these terms.

Ans: Acute is a condition with sudden onset that often occurs without warning and is of brief duration. Chronic is a condition with slow onset and has a long duration.

Guidelines: When both the acute and chronic forms of a condition are documented, both conditions should be coded. When a combination code is not available and two distinct codes are needed to fully describe the patient’s condition or disease, the guidelines instruct the coder to list both the acute and chronic codes with the acute condition listed first followed by the chronic condition.

3. Explain the difference between includes and Excludes 1 and Excludes 2 and the importance each plays in determining the correct ICD-10-CM code.

Ans: Includes: Further clarifies the code or category by providing definitions or examples of conditions included in the code.

Excludes 1: Provides a list of conditions, diseases, or injuries which are not included in the code being considered in the Tabular List. This condition, disease, or injury is located elsewhere in the ICD-10-CM manual and the excludes note identifies this range of codes.

Excludes 2: Excludes 2 tells the coder that the excluded code is not part of the condition but there are times the patient may have both conditions and it would be appropriate to code both.

Feedback: The includes and excludes instructional notes help the coder to code accurately, efficiently, and within compliance guidelines.

4. List five mentor coding tips discussed in this chapter that you considered most helpful.

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29

Ans: The answers to this question will vary.

Feedback: Any of the mentor tips may be listed. Here are a few examples: 1) When searching through the index, pay close attention to indentations as you move from one column to the next.

2) Coding students have found it very helpful to tab the ICD-10-CM manual. They use selfadhesive tabs or labels to mark the individual tables in the Alphabetic Index (e.g., Hypertension, Neoplasm, and Table of Drugs and Chemicals) and the individual chapters in the Tabular List to identify a range of codes. They have found that this saves them considerable time when they are taking the CPC exam since the tabs enable them to more quickly locate the code indicated in the index.

3) Be sure to review both the acute and chronic subterms to identify available combination codes, since they are not always found under both terms.

4) When preparing for the CPC exam, study the chapter-specific guidelines a few days before taking the exam. This is a good review, and it will remind you during the test that you just ―read something about this.‖ This reminder during the exam often takes away the feeling of being overwhelmed.

5) According to ICD-10-CM, ―The coding conventions of ICD-10-CM as well as the general and disease-specific guidelines take precedence over the outpatient guidelines.‖ When coding, remember that there is a hierarchy to the coding guidelines and conventions.

Chapter 3 – ICD-10-CM Chapter-Specific Guidelines LESSON PLANS Class Preparation: Teaching Focus and Resources This chapter explains the more difficult coding concepts of ICD and is to be used in addition to the chapter-specific guidelines in the ICD Manual to provide instruction and interpretation for the student.

Guidelines covered in this chapter include:  HIV  Septicemia, SIRS, Sepsis, Severe sepsis and septic shock  Neoplasms  Diabetes Mellitus

Learning Outcomes After completing Chapter 3, students will be able to: LO 3.1 Review ICD chapter-specific general guidelines.

LO 3.2 Understand the chapter-specific guidelines on human immunodeficiency virus (HIV) infections.

LO 3.3 Apply the chapter-specific guidelines for septicemia, systemic inflammatory response syndrome (SIRS), sepsis, severe sepsis, and septic shock.

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30

LO 3.4 Recognize the chapter-specific guidelines for coding neoplasms.

LO 3.5 Identify the chapter-specific guidelines for diabetes mellitus.

Class Presentation LO 3.1 Reviewing ICD chapter-specific general guidelines.

Slides 3-1 through 3-4



Chapter Introduction and Key Terms

Slide 3-5



Chapter specific General Guidlines

LO 3.2 Understand the chapter-specific guidelines on human immunodeficiency virus (HIV) infections.

-

Slide 3-6

Slide 3-7



Human Immunodeficiency Virus Infections – continued - Sequencing of conditions presenting with HIV/AIDS

Slide 3-8



Human Immunodeficiency Virus Infections – continued - Sequencing of conditions presenting with HIV/AIDS - continued

Slide 3-9



Human Immunodeficiency Virus Infections – continued - HIV testing

Slide 3-10



Human Immunodeficiency Virus Infections – continued - HIV testing – continued - Sequencing of other conditions when HIV/AIDS is present

LO 3.3 Apply the chapter-specific guidelines for septicemia, systemic inflammatory response syndrome (SIRS), sepsis, severe sepsis, and septic shock.

Slide 3-11



Septicemia, Systemic Inflammatory Response Syndrome, Sepsis, Severe Sepsis, and Septic Shock - Differentiation of guideline terms for each condition

Slide 3-12



Septicemia, Systemic Inflammatory Response Syndrome, Sepsis, Severe Sepsis, and Septic Shock – continued - Identifying the variations of codes related to the underlying cause of each condition

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31 Slide 3-13



Septicemia, Systemic Inflammatory Response Syndrome, Sepsis, Severe Sepsis, and Septic Shock – continued - Coding SIRS Sepsis verses severe sepsis

Slide 3-14



Septicemia, Systemic Inflammatory Response Syndrome, Sepsis, Severe Sepsis, and Septic Shock – continued - Additional sequencing directions for various conditions

LO 3.4 Recognize the chapter-specific guidelines for coding neoplasms.

Slide 3-15



Neoplasms - Indexing steps for locating neoplasm codes

Slide 3-16



Neoplasms – continued - Sequencing of primary and secondary sites

Slide 3-17



Neoplasms – continued - Sequencing encounters for treatment of cancer or complications related to treatment

Slide 3-18



Neoplasms – continued - Sequencing of malignant neoplasm in transplant organ Sequencing encounters for testing - Sequencing of malignant neoplasm in transplant organ

LO 3.5 Identify the chapter-specific guidelines for diabetes mellitus.

Slide 3-19



Diabetes Mellitus - Intro to Type 1, Type 2, and secondary diabetes mellitus

Slide 3-20



Diabetes Mellitus – continued - Type 1 - Type 2 - Coding for long-term insulin use with DM - Using DM combination codes and associated conditions

Slide 3-21



Diabetes Mellitus – continued - Coding for insulin pump malfunction

Slide 3-22



Diabetes Mellitus – continued - Coding for secondary DM

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32 -

Secondary DM due to removal of the pancreas

Summary Slides Slides 3-23 through 3-25



Synopsis of Chapter

Teaching Tips LO 3.1:  Review each of the chapter-specific guidelines of ICD included in this chapter.  Remind students that the chapter-specific guidelines are more specific and detailed than the general coding guidelines.  Identify, using examples, how the guidelines and directions provided in the Tabular List at the chapter, section, and code levels supersede the chapter-specific guidelines.

Coding Tips and Guidelines o Although coding guidelines listed at the code level (in the tabular list) supersede those listed in the chapter-specific guidelines, many times the tabular guidelines mimic the chapter-specific guidelines by providing a step-by-step process to correct coding, as demonstrated when coding for severe sepsis.

LO 3.2:  When coding for HIV and HIV-related conditions, the coder must understand the current state of the patient in relation to the condition of HIV. o A patient who was exposed to HIV may be seeking testing or counseling. o A patient who has been diagnosed as HIV-positive may have HIV-related conditions o When HIV-related illnesses, or opportunistic infections (OIs), are documented in conjunction with HIV-positive status, convert the patient’s diagnosis from HIV-positive status Z21 to (AIDS) B20.

Coding Tips and Guidelines o HIV-related illnesses, or opportunistic infections (OIs ), when documented in conjunction with HIV-positive status, convert the patient’s diagnosis from HIV positive status Z21 to AIDS (B20). o More than two codes are needed to code for an encounter unrelated to HIV when the appropriate HIV code is B20. Additional codes identifying the OIs are needed to report all HIV-related conditions. o When coding encounters related to HIV, always list the most specific condition or reason for the encounter as the first code. For example, encounters for patients with symptoms presenting for HIV testing would be coded on the symptoms. Encounters for patients presenting for follow-up test results when the test is positive would be coded with the appropriate HIV code (either Z21 or B202).

LO 3.3:  Septicemia is a progressive condition that may or may not begin with an infectious process but may result in organ failure and loss of life.  Several terms are used to describe this condition, and many coders find them confusing: o Septicemia: the presence of toxins or disease in the blood, such as bacteria or a fungus o Systemic inflammatory response syndrome (SIRS): the body’s response to septicemia, trauma, or, in some cases, cancer

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33 o Sepsis: a response specifically to infection o Severe sepsis: sepsis with organ failure o Septic shock: a form of organ failure of the vascular system Coding of this condition requires a minimum of two ICD codes.

Coding Tips and Guidelines o As septic shock is organ failure due to sepsis, documentation of septic shock alone indicates the presence of severe sepsis, this condition is reported with two codes. o In coding this condition, the only difference between sepsis and severe sepsis is the presence of organ dysfunction or failure due to the infection, as documented by the physician. Identifying this detail, in review of the documentation, helps to simplify coding this condition. o To code severe sepsis or SIRS due to a noninfectious process with organ failure, the documentation must clearly reflect that the organ dysfunction/failure is due to sepsis or SIRS in the presence of other comorbidities. o ICD provides the sequencing directions code first and use additional code at the code level for each step needed to correctly code this condition and its progression. Using this directional information will guide the coder in coding this condition correctly and completely.

LO 3.4:  The neoplasm chapter contains most, but not all, codes for benign and malignant neoplasms.

Some neoplasm codes are located in the chapters that are specific to neoplasms’ anatomical sites.  Remind students to that selection of neoplasms always begins by indexing the histologic term, then review the subterms for the condition documented before accessing the neoplasm table if directed by the index.

Coding Tips and Guidelines o Many coders begin searching for a neoplasm code in the Table of Neoplasms. This is incorrect and typically takes more time or leads to inaccurate coding. o A clear understanding of primary and secondary cancer sites is important when selecting the code for these conditions. As physicians typically do not document using the terms primary and secondary, the coder must be able to translate terms such as malignant (the primary site) and metastatic (the secondary site) and phrases such as with metastases to the or metastatic from. o To help determine sequencing of the codes for a patient with both cancer and a complication of the condition or treatment, ask yourself, ―What is the reason for the encounter?‖ and then, ―Why is this complication present?‖ LO 3.5:  ICD divides diabetes mellitus into multiple categories: diabetes mellitus due to an underlying cause (E08), drug or chemical induced diabetes (E09), type 1 and diabetes mellitus (E10), Type 2 diabetes mellitus (E11) and other specified diabetes (E13).  Most of the codes listed in each of these categories are combination codes that identify the type of diabetes and an associated manifestation or complication.

Coding Tips and Guidelines o Consider the description of code Z79.4 as meaning that the patient uses insulin in the patient’s daily management of diabetes mellitus.

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Chapter 3 Answer Key Exercise 3.1 1. What supersedes the chapter-specific guidelines?

Ans: Guidelines and direction provided in the Tabular List at the chapter, section, and code level supersede chapter-specific guidelines.

Feedback: A complete listing of the chapter-specific coding guidelines is located in the ICD-10CM Official Guidelines for Coding and Reporting, Section I, C, Chapter-Specific Guidelines.

The chapter-specific guidelines are more specific and detailed than the general coding guidelines. However, the guidelines and directions provided in the Tabular List at the chapter, section, and code levels supersede the chapter-specific guidelines.

Exercise 3.2 Code the following diagnostic statements: 1. An HIV-positive patient presents to the orthopedist for distal shaft fracture of the left radius.

Ans: S52.502A, Z21 Feedback: HIV patient presents with unrelated condition, radial fracture. Guidelines instruct the coder to code the unrelated condition (such as a traumatic injury) first followed by the HIV code.

2. The patient presents for severe fever, abdominal pain, and diarrhea; lab test confirmed shigellosis dysenteriae in this HIV-positive patient.

Ans: B20, A03.0 Feedback: Shigellosis dysenteriae is an example of an OI (opportunistic infection). Reference Chapter 1 specific guidelines in the ICD-10-CM manuals for the appropriate sequencing.

3. Nurse Jaci is seen by the occupational health provider for testing after exposure to an HIV-positive patient by accidental needle stick.

Ans: Z20.6, W46.1XXA Feedback: Z20.6 describes that HIV was the disease she came in contact with and W46.1XXA describes how she contacted the disease (contact with a hypodermic needle).

Exercise 3.3 Code the following: 1. Sepsis with acute renal failure due to E. coli following gastric bypass.

Ans: K95.81 (Complication>bariatric procedure>specified procedure>infection)); A41.51 (sepsis due to E. coli); R65.20 (severe sepsis without septic shock); N17.9 (acute kidney failure)

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Feedback: Reference Chapter 1 specific guidelines in the ICD-10-CM manuals for the appropriate sequencing of sepsis due to postprocedural infection.

2. A 20-day-old infant is admitted in respiratory failure due to sepsis; labs are pending.

Ans: P36.9 (bacterial sepsis of newborn, unspecified); R65.20 (Severe sepsis without septic shock); J96.00 (Acute respiratory failure, unspecified whether with hypoxia or hypercapnia) 3. The patient was admitted to the hospital for streptococcal pneumoniae. On day 2 of admission, patient symptoms include tachycardia and labs confirm leukocytosis. Physician is queried and confirms sepsis.

Ans: A40.3 (sepsis due to streptococcus pneumoniae) Feedback: delete Exercise 3.4 Code the following: 1. Biopsy of a suspicious mass of the lower outer quadrant of the right breast in a 42-yearold female with a maternal history of malignant breast cancer.

Ans: N63.13 (unspecified lump in right breast, lower outer quadrant); Z80.3 Feedback: The term mass, unless otherwise stated, is not to be regarded as a neoplastic growth.

N63.xx can be further specified as to the laterality (right) and location (lower outer guardant) of the lump. The appropriate history of neoplasm code, family versus personal, should be reported for this scenario.

2. The patient presents to the operating suite for removal of a malignant neoplasm of the thyroid, metastatic from a previously removed squamous cell carcinoma of the right forearm.

Ans: C79.89; Z85.828 Feedback: The malignant neoplasm currently being treated is the metastases to the thyroid.

3. Radiation therapy for an occipital lobe lesion is provided for astrocytic glioma of unknown origin.

Ans: Z51.0; C79.31; C80.1 Feedback: Reference chapter specific guidelines for sequencing when the encounter is for radiation therapy.

Exercise 3.5 1. A poorly controlled type I DM patient is seen and has elevated ketone levels. The physician query confirms a diagnosis of ketoacidosis.

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Ans: E10.10 Feedback: E10.10 describes Type I diabetes mellitus with ketoacidosis without coma and the ketoacidosis defines the diabetes as poorly controlled

2. The patient is admitted for diabetic gastroparesis. The patient history notes total pancreatectomy 6 years ago.

Ans: E11.43; K31.84; Z90.410 Feedback: Note the instructional note with K31.84 (gastroparesis) guiding the coder to first code any underlying disease, if known, such as diabetes mellitus E.11.43.

3. The endocrinologist provides a 3-month recheck for a DM patient. The patient had managed DM with diet; however, for the past 4 months the patient has required insulin for adequate control.

Ans: E11.9; Z79.4 Chapter Three Review Using Terminology Answers: 1. B

MRSA

6. F

Septicemia

2. E

Opportunistic Infection (OI) 7. H

Sepsis

3. I

Metastases

8. J

Systemic inflammatory response syndrome (SIRS)

4. G

Primary neoplasm

9. C

Severe sepsis

5. A

Secondary diabetes mellitus 10. D Septic shock

Checking Your Understanding 1. The medical record states diabetic proliferate retinopathy of the right eye in a patient with controlled type 1 diabetes. This is coded as: Ans: B. E10.3591 (Type 1 diabetes mellitus with proliferative retinopathy without macular edema , right eye Feedback: E10.3591 describes the type 1 DM with proliferative retinopathy and further specifies with macular edema and laterality (right eye).

2. A 49-year-old female patient has been diagnosed with invasive lobular breast cancer in the right breast at 8:00 with spread to the axillary sentinel lymph node. The codes for this are:

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Ans: A. C50.511 (Malignant neoplasm of lower outer quadrant of right female breast); C77.3 (secondary and unspecified malignant neoplasm of axilla and upper limb nodes) Feedback: The primary cancer is of the breast and C50.511 shows the specificity of lower outer quadrant (8 o’clock position), laterality (right), and gender (female).

3. A patient who is 32 weeks pregnant is admitted because of an HIV related illness. The patient spent 3 days in the hospital and was sent home in stable condition. The baby was not delivered during this hospital stay. The codes for this are: Ans: D. 098.713 ((Human immunodeficiency virus (HIV) disease complicating pregnancy, third trimester; B20.

Feedback: Refer to chapter-specific guidelines for sequencing instructions for pregnancy and HIV. 4. A 53-year-old obese female was diagnosed with chronic kidney disease, stage III, resulting from malignant hypertension and type 2 diabetes mellitus. Which codes would be reported in this case?

Ans: C. E11.22; I12.9; N18.30 Feedback: E11.22 is assigned to indicate Type 2 DM with CKD; I12.9 indicates hypertensive CKD stage 1 through 4; and N18.30 describes the stage 3 CKD. 5. A 70-year-old male is brought to the operating room for a biopsy of the pancreas. A wedge biopsy is performed and the specimen sent to pathology. The report comes back immediately indicating that malignant cells are present in the specimen. The code for this case is: Ans: C. C25.2 Feedback:: C25.2 is specific to malignant neoplasm of the tail of the pancreas.

6. A 16-year-old patient who is suffering from osteosarcoma located above the right knee begins chemotherapy treatments. Which codes should be reported?

Ans: D. Z51.11; C40.21 Feedback: Per the chapter-specific guidelines for neoplasms, Z51.11 would be coded as the primary diagnosis since the encounter is for the chemotherapy, and the malignancy code C40.21 would be used as an additional code to identify osteosarcoma of the knee. Osteosarcoma in the index instructs the coder to see neoplasm, bone, malignant, knee.

7. Which of the following is not considered a type of diabetes?

Ans: C. Hypertensive diabetes Feedback: Type I diabetes mellitus sometimes is called insulin-dependent diabetes or juvenile diabetes. Non-insulin dependent diabetes mellitus is the same as Type II diabetes mellitus.

Gestational diabetes is only present when a female is pregnant. With gestational diabetes, after

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delivery the blood sugars stabilize again. If they don’t, then the patient is diagnosed with either Type I or Type II diabetes.

8. You cannot code HIV if: Ans: B. There are positive test results but no physician documentation.

Feedback: To code HIV there must be physician documentation; coders cannot interpret lab findings.

9. The patient is being admitted for a sprained coccyx due to a fall off a roof. The patient also has been diagnosed with AIDS. This is coded as: Ans: A. S33.8XXA; B20 Feedback: The encounter was for a condition not related to HIV; the reason for the encounter is coded first and the HIV positive second. This is per the chapter-specific guidelines for HIV. 10. Septicemia due to pseudomonas with septic shock is coded as: Ans: D. A41.52, R65.21, N17.9 Feedback: Even though septic shock may be the most important, it is not coded first. The chapter-specific guidelines for septicemia should be referred to for guidance in coding this scenario.

Applying Your Knowledge CASE STUDY Clinical information Patient has a history of breast cancer with left lumpectomy and radiation 4 years ago. Chest CT shows multiple pulmonary nodules.

Specimen submitted Left lower-lobe lung mass.

Gross description Received, labeled with the patient’s name and ―lung Bx,‖ are seven white to gray needle biopsy cylinders measuring 1.5 x 1.0 x 0.1 cm in aggregate.

Microscopic and final diagnosis Lung, left lower lobe, needle biopsy: Adenocarcinoma, consistent with breast primary.

1. Which is (are) the correct code(s) for this case?

Ans: C C78.02, Z85.3 Feedback: The reason for the biopsy was to determine the disease related to the lung mass, so the primary diagnosis is the carcinoma of the lung which is metastatic with the breast cancer being the primary site. The metastatic lung cancer is coded first. Z85.3 personal history of malignant

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neoplasm of the breast would be coded since lumpectomy and radiation were 4 years ago and there is no mention of current disease of the breast.

Chapter 4 – Foundations of CPT LESSON PLANS Class Preparation: Teaching Focus and Resources The focus of this chapter is to build upon the students understanding of the format and guidelines of the CPT manual which will lead to accurate utilization and application of the CPT codes while completing a certification exam or reporting of services in the field.

Learning Outcomes After completing Chapter 4, students will be able to: LO 4.1 Recognize the importance of linking the CPT and ICD codes.

LO 4.2 Understand the format of CPT. LO 4.3 Apply the coding conventions, instructional notes, guidelines, and symbols used in CPT. LO 4.4 Identify main terms and use the CPT index.

LO 4.5 Apply HCPCS Level I CPT modifiers.

LO 4.6 Evaluate the process of accurately translating provider documentation into accurate codes.

Class Presentation LO 4.1 Recognize the importance of linking the CPT and ICD codes.

Slides 4-1 through 4-4



Chapter introduction and Key Terms

Slide 4-5



Linking medical necessity to service/procedure

LO 4.2 Understand the format of CPT. Slide 4-6



HCPCS level I sections, categories and code structure

Slide 4-7



CPT Sections

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40 LO 4.3 Apply the coding conventions, instructional notes, guidelines, and symbols used in CPT. Slide 4-8



CPT Coding conventions, Guidelines, Instructional notes and symbols - Guidelines - Parenthetical Notes

Slide 4-9



CPT Coding conventions, Guidelines, Instructional notes and symbols – continued - Symbols

Slide 4-10



CPT Coding conventions, Guidelines, Instructional notes and symbols – continued - Semicolon

Slide 4-11



CPT Coding conventions, Guidelines, Instructional notes and symbols – continued - Separate procedure

LO 4.4 Identify main terms and use the CPT index.

Slide 4-12



CPT Main Terms and the Index - Determining the CPT main term

Slide 4-13



CPT Main Terms and the Index – continued - Steps in locating the appropriate CPT code

LO 4.5 Apply HCPCS Level I CPT modifiers.

Slide 4-14



Introduction to CPT Modifiers

LO 4.6 Evaluate the process of accurately translating provider documentation into accurate codes.

Slide 4-15



Translating Provider documentation to ensure accurate and complete CPT code selection

Summary Slides Slides 4-16 through 4-19



Synopsis of Chapter

Teaching Tips Using the CPT manual, have the student locate each of the following. Review each of these topics in class discussion.

LO 4.1:

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41   

Review medical necessity in relation to the diagnosis, or the why, supporting the service or procedure provided, or the what.

Discuss linkage is a term used to show this support on the claim form submitted to the payer.

Provide specific examples of diagnosis/service linkage which do and do not support medical necessity.

LO 4.2:  Using the CPT review the • Six main sections: 1. Evaluation and Management 2. Anesthesia 3. Surgery 4. Radiology 5. Pathology and Laboratory 6. Medicine • Category II and III codes • Appendices Coding Tips and Guidelines o Healthcare Common Procedure Coding System (HCPCS) Level I—CPT codes: five numeric digits except for category II and category III codes.

Level II—national codes: five alphabetic and numeric characters. Codes within this level are not included in Level I. o It is imperative that a coder use the current CPT manual both for the exam and in the workplace. o Being familiar with the sections and their code ranges contributes to success on the CPC exam. For example: A CPC exam scenario may depict a surgical procedure with description of the work provided by both the anesthesiologist and the surgeon. The question instructs the coder to code for the surgeon only. One or more of the multiplechoice answers contains a code that begins with 00xxx. By knowing the CPT code ranges, the coder can identify 00xxx codes as anesthesiologist services and thus not a correct answer for this scenario. Therefore, the coder could eliminate one or more choices of the available answers very quickly. Since the CPC exam is a timed test, this type of elimination is important to the coder’s timely completion of the exam.

LO 4.3:  Review the CPT coding conventions and symbols  Semicolon: A stand-alone code shares the first portion of the verbiage to the left of the semicolon with all dependent codes that follow it.  Separate procedure: This is a procedure that may be performed alone, but when it is performed with a more extensive procedure at the same site, it is considered a part of the more extensive procedure .  Bullet: designates a new CPT code  Triangle: designates a CPT code that has been revised  Facing triangles: designate the portion of the guideline or note that has been revised  Null Zero: designates that modifier 51 is not to be used with the code  Plus sign: designates that the code is an add-on code to be used with the primary procedure

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Coding Tips and Guidelines o As mentioned in earlier chapters, it is a good idea to identify where the guidelines are located and to understand and review their implementation shortly before taking the CPC exam. As with the ICD manuals, students have found it beneficial to tab the different sections and guidelines of the CPT manual. o Coders have found it helpful to highlight certain ―trigger‖ words within parenthetical notes. In the example above, a coder might highlight in the CPT book the terms single, multiple, 3 or more, and imaging guidance. This helps during the timed CPC exam to remind the coder that there are several important notes to this code. Highlighting is a really good approach for sections in which a coder is having particular difficulty determining the right code. o Knowing the meaning of each of the symbols at a glance increases the speed at which accurate codes are selected. o The function of the semicolon is a critical concept for coders to understand. This understanding of the full definition of the indented code is often troublesome for coders and leads to the assignment of the wrong CPT code. To overcome this difficulty, some coders highlight in the CPT the part of the code located before the semicolon and then the indented definition. The highlighting acts as a ―trigger‖ for them to remember this particular coding convention. o Separate procedures performed in addition to other procedures not of the same anatomical or surgical site are reportable in addition to a more extensive procedure.

When considering a code designated as a separate procedure, review the documentation to determine the anatomical site or surgical site of the more extensive procedure or procedures.

LO 4.4:  Using specific examples walk through the steps below to identify main terms and locate CPT codes  Main terms are identified in CPT by service, procedure, condition, eponym, or anatomical site.

Steps in locating the appropriate CPT code After reading the documentation thoroughly: 1. Determine the main term(s) and subterm(s) from the documentation.

2. Locate the main term and subterm in the alphabetic index.

3. Determine any modifying circumstances from the documentation that require the use of a modifier.

4. Verify the code identified in the alphabetic index by checking it in the appropriate section of the CPT manual.

5. Review all section-specific guidelines and instructional notes.

6. Select the appropriate CPT code, along with appropriate modifiers.

Coding Tips and Guidelines o

CPT coding is not memorizing all the terms, guidelines, and so on. Coding is being able to use the CPT manual to translate the medical story in an accurate and compliant manner by utilizing the information that is located throughout the manual. When coding, students are often asked, ―Why did you choose that code?‖ and the response is ―because the documentation led me to that code.‖

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As with ICD, one of the tricks used by successful coding students when checking the main sections or subsections of CPT is to look at the five codes above and five codes below the code identified in the index just to make sure that there is not a more accurate code and that they are not missing subsection guidelines or information found in parenthetical notes.

LO 4.5:  The purpose of a modifier is to show that the service or procedure was altered in some way. The CPT code does not change; only the telling of the patient’s story changes.

LO 4.6:  Several codes in CPT need very specific information from the medical record in order to tell the most specific and accurate story of the service or procedure provided.

Chapter 4 Answer Key Exercise 4.1 1. Identify the importance of linkage in reference to CPT and ICD coding.

Ans: Supporting the medical necessity of the CPT code with the ICD code(s) is also referred to as linkage on the claim form submitted to payers.

For example, consider a visit for management of benign hypertension and removal of six skin tags. To support medical necessity for each of these services, a different distinct diagnosis code would need to be linked to each.

Feedback: The CPT manual is used to complete the story of the patient’s encounter or visit.

While the ICD manual tells why the visit occurred, the CPT manual tells what was provided to the patient during the encounter. Medical necessity requires that the diagnosis, or the why, support the service or procedure provided, or the what.

2. Explain medical necessity and its importance to CPT coding.

Ans: Medical necessity requires that the diagnosis (or ―why‖) supports the service or procedure provided (or ―what‖).

Feedback: Backing up the necessity of the CPT code with the condition documented as the medical reason for the service or procedure is known as supporting medical necessity of the service.

Exercise 4.2 1. List the six main sections of the CPT manual.

Answer:

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1. Evaluation and Management 2. Anesthesia 3. Surgery 4. Radiology 5. Pathology/Laboratory 6. Medicine Feedback: The six main sections of the CPT manual are Evaluation and Management, Anesthesia, Surgery, Radiology, Pathology/Laboratory, and General Medicine.

2. Explain the two levels of HCPCS. Ans: Level I—CPT codes: 5 numeric digits except for category II and category III codes.

Level II—national codes: 5 alpha and numeric characters. Codes in Level II are codes that are not included in Level I. Feedback: HCPCS is the Healthcare Common Procedure Coding System. The two levels are: Level I– CPT codes and Level II– National codes 3. Who is responsible for the annual CPT updates?

Ans: The American Medical Association (AMA) is responsible for the annual updates of the CPT manual.

Feedback: Each update occurs in the third quarter of each year for use beginning January 1 of the year immediately following the update.

Exercise 4.3 1. Explain the concept of separate procedure.

Ans: CPT includes a number of codes for services or procedures which, though they may be performed alone, when performed with a more extensive procedure or service of the same site are considered a part of the more extensive procedure or service and are therefore not separately reportable.

Feedback: These codes are designated as Separate Procedures and are identified by the term (separate procedure) within the description of the code.

2. Explain the function of the semicolon in CPT coding.

Ans: For its full description, the dependent code must refer to the stand-alone code for a portion of its description. CPT identifies the dependent code by indenting the description of the code. To determine the full description of the dependent code, the coder must first locate the stand-alone or parent code located above the dependent code. Stand-alone or parent codes are not indented and the first word of the description begins with an upper case or capital letter. The stand-alone code shares the first portion of the verbiage to the left of the semicolon with all dependent codes which follow it, and in this way a full description of the service or procedure is completed for each dependent code.

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Feedback: As a means of saving space within the manual, CPT uses an indented dependent format in the nomenclature or description of many codes. In CPT, a semicolon indicates that the verbiage preceding it in a stand-alone code is shared with all dependent codes that follow it, thus providing a full description for each dependent code.

3. Explain the function of a parenthetical note in CPT coding.

Ans: Parenthetical notes provide additional information regarding the code being reviewed by the coder. These notes may inform the coder that the service or procedure described by the code or codes being reviewed are a part of or included in the work of the code for the service or procedure code listed in the parenthetical note. These notes also indicate when an additional code or codes may be needed to capture additional work not included in the code being reviewed.

Feedback: Parenthetical notes (coding notes enclosed in parentheses) are located directly below the code or code range to which the note applies.

Exercise 4.4 1. List the major steps in locating an appropriate CPT code.

Answer: 1. Determine the main term(s) and subterm(s) from the documentation.

2. Locate the main term and subterm in the alphabetic index.

3. Determine any modifying circumstances that require the use of a modifier.

4. Verify the code identified in the alphabetic index by checking it in the appropriate section of CPT. 5. Review all section-specific instructional notes and guidelines.

6. Determine the CPT code that represents the service or procedure provided to the patient, along with appropriate modifiers.

Be sure to read all of the instructional notes that exist for the main sections and subsections of CPT. Feedback: The coder should begin by reading the provider documentation thoroughly to determine the service or procedure provided to the patient. Then the coder should follow the steps as outlined in the answer above.

2. How are main terms indexed in the CPT manual?

Ans: Main terms are referenced in the index by a service, procedure, condition, anatomic site, or eponym.

Feedback: Unlike main terms in the ICD manual index—which may be a condition, disease, or injury—main terms in the index of CPT may be a service, procedure, condition, anatomical site, or eponym.

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Exercise 4.5 1. Explain the purpose of a modifier.

Ans: The purpose of a modifier is to continue to tell the patient’s story by showing that the service or procedure performed was altered in some way. The CPT code does not change, just the telling of the story.

Feedback: There are several types of modifiers that need to be used in order to translate completely the service or procedure provided to the patient.

2. A screening mammogram is performed on the left breast. CPT code 77067 is reported.

Does a modifier need to be attached to this code? If so, which one and why?

Ans: Yes, the code description for code 77067 is screening mammography, bilateral of each breast. If a screening mammogram was performed on only one breast, modifier 52 (reduced service) would be appended to 77067.

Feedback: The purpose of a modifier is to continue to tell the patient’s story by showing that the service or procedure performed was altered in some way. Since the code description for code 77067 is screening mammography, bilateral of each breast, and this screening mammogram was performed on only one breast, modifier 52 (reduced service) is needed.

3. A 54-year-old patient presents to the office for their annual visit. The patient has no complaints. During the exam, the physician determines that the patient’s blood pressure has continued to remain elevated over the past three months and the provider prescribes medication. The coder reports 99396 for the preventive medicine visit. Is it appropriate to also code for the office visit? If so, is a modifier needed, and which one would be appropriate?

Ans: Yes, modifier 25 would be appended to the evaluation and management (office visit) code.

Feedback: The guidelines in the CPT manual before codes 99381-99397 instruct the coder in the use of modifier 25 with a preventive medicine visit.

Exercise 4.6 1. Why is accurate translation of the patient encounter important to both the provider and the patient?

Ans: Accurate translation of the medical record into codes is important to the provider as well as the patient. This story decides reimbursement, creates an insurance profile for the patient, and gathers statistical and research data.

Feedback: It is important to the patient because it creates an insurance profile for the patient.

2. Give some examples of situations in which the documentation determines the accurate code selection for radiology.

Ans: Answers will vary.

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Feedback: Some radiology codes are specific as to the number of views or whether contrast was administered. The reimbursement for a code with a definition of one view versus one with three views is different, but if the radiologist is not specific in his documentation that a three view xray was taken, the code defined as a one view must be used.

Chapter Four Review Using Terminology Answers: 1. D

Bullet

8. C

2. H

Pound sign

3. A

Eponym

10. B Plus sign

4. K

Facing triangle

11. I

5. F

Parenthetical notes

12. M Separate procedure

6. E

Linkage

13. L Triangle

7. G

Moderate sedation

9. J

Modifier

Null zero

Semicolon

Checking Your Understanding Identify the main term in each diagnostic statement and the main section and subsection of the CPT in which the code would appear.

1. CT scan of the abdomen Ans: Main term = CT scan; Section = Radiology; Subsection = Diagnostic Radiology 2. Basic metabolic panel Ans: Main term = Panel (coder is directed in the Alphabetic Index to see Organ or Disease Oriented Panels); Section = Pathology and Laboratory; Subsection = Organ or Disease-Oriented Panels 3. Excision of tendon sheath of the palm Ans: Main term = Excision; Section = Surgery; Subsection = Musculoskeletal 4. Destruction by laser surgery of a malignant lesion of the arm Ans: Main term = Destruction; Section = Surgery; Subsection = Integumentary 5. Patient is seen in the office for a 2-week follow-up visit for hypertension Ans: Main term = Office visit; Section = Evaluation and Management; Subsection = Office or Other Outpatient Services

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Choose the most appropriate answer for each of the following questions.

6. A patient presented to the ED with a possible fractured femur. A two-view x-ray of the femur was performed, and the radiologist confirmed a fracture of the femur. The patient was sent to the orthopedic department, and the fracture was treated. A few hours later the patient was sent back to radiology for a one-view x-ray of the femur.

Attach the appropriate modifier to the second x-ray of the femur. The modifier is: Ans: B. No modifier is needed.

Feedback: There are now two codes for x-ray of the femur. 73551 reflects one view and 73552 reflects a minimum of two views. Modifier 76 would not be appropriate since these are not the same procedure (or CPT code).

7. A patient is sent to the radiology department with an indication of abdominal pain. A KUB is ordered. The coder inputs data that is then transferred to line 21 of the CMS-1500 form, showing ICD-10-CM R10.11 (abdominal pain RUQ), and line 24 field C, showing CPT 74018. The coder has demonstrated which of the following: Ans: C. Linkage and medical necessity Feedback: The diagnosis code for abdominal pain shows the medical necessity for the KUB, and correctly identifying this on lines 21 and 24 shows the linkage between the diagnosis and procedure code.

8. When a code has a bullet symbol,  before it in the current edition of the CPT, this indicates to the coder that the code is: Ans: A. New to this edition Feedback: The bullet symbol indicates the code is new to this edition.

10. A patient underwent an emergency cholecystectomy 6 days after having a lung biopsy.

The same surgeon performed both procedures. Assign the correct CPT modifier to tell this patient’s story.

Ans: C. Modifier 79 Feedback: Modifier 79 is the appropriate code since this modifier tells the payer an unrelated procedure or service was performed by the same physician during the postoperative period.

11. Which statement is not true about HCPCS Level II codes?

Ans: B. Level II HCPCS codes are 5-digit numeric codes.

Feedback: Level I HCPCS codes are 5-digit numeric codes; Level II are alpha and numeric.

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12. Which entity is responsible for updating CPT, and in which month is the update implemented?

Ans: D AMA, January Feedback: The AMA (American Medical Association) through the CPT Editorial panel updates the CPT manual. It is implemented every January 1.

13. Determine the full description of code CPT 33244.

Ans: B. Removal of single or dual chamber implantable defibrillator electrode(s) by transvenous extraction Feedback: Removal of single or dual chamber implantable defibrillator electrode(s) is the description of the code above, 33243, to the left of the semi-colon. This part of the description becomes part of the description of code 33244 with the phrase ―by transvenous extraction‖ completing the description.

14. CPT code 45398 has a symbol and coding conventions attached to the code. Identify them from the list below.

Ans: D. All of these Feedback: All of the coding conventions listed pertain to CPT code 45398.

15. In which section of the CPT manual would code 0210T, speech auditory threshold,automated , be located?

Ans: D. Category III Feedback: Category III codes are T codes.

Applying Your Knowledge 1. The patient had a pacemaker inserted with atrial and ventricular lead placements. This procedure was coded as 33249 and 33217. Determine whether the codes are correct. If they are incorrect, what code or codes should have been reported and what translation errors were made?

Ans: The correct code would be 33208. Code 33249 is for an implantable cardioverter defibrillator and the record clearly stated a pacemaker was inserted. There would be only one code, 33208, since this code includes the placement of the generator and the electrodes (leads) so a separate code for lead placement would not be reported.

Feedback: The pacemaker placed is a dual chamber since the record stated there were both atrial and ventricular leads placed.

2. In the following scenario, locate the main term and subterms that need to be identified to accurately code for the radiologist. Then choose the appropriate CPT code. The code chosen needs to be supported by a medically necessary diagnosis code.

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50

A 10-year-old male was seen in the office today, complaining of pain in the right ankle. He had been playing soccer after school and received an injury to the ankle.

Mild abrasions and contusions were noticed on the ankle; slight swelling was noted.

There was some discomfort when he walked. A two-view x-ray of the ankle was ordered. The x-ray confirmed a mild sprain of the ankle.

Ans: Diagnoses code(s): main term would be sprain of the ankle; ICD-10-CM code S93.401A, Sprain of unspecified ligament of right ankle, initial encounter

Mentoring TIP: Remember that with ICD-10-CM, it will also be important to pull out of the report that it was the right ankle, since laterality becomes important in ICD-10-CM. Procedure codes: CPT—main term would be x-ray with subterms being ankle and 2 views; code 73600.

Feedback: ICD: Once the sprain is a confirmed diagnosis, the signs and symptoms are no longer reported. CPT: The ―2 views‖ is important since there is a code for complete, minimum of 3 views.

Unit 1 Exam Answer Key 1. The language that is built on medical terminology, anatomy, and pathophysiology and describes services, procedures, and the medical necessity of those services and procedures is referred to as: Ans: A Feedback: Provider language is built on medical terminology, anatomy, and pathophysiology and describes services, procedures, and the medical necessity of those services and procedures. Payer language comprises terms such as noncovered services, medical necessity, compliance language, and unbundling. Billing language includes terms such as accounts receivable (A/R), clean claims, denials, modifiers, and advanced beneficiary notices (ABNs). Compliance language brings terms such as unbundling, fraud, false claims, and abuse into the translation.

2. The flow of a practice’s revenue, which begins when charges for services, procedures, or supplies are incurred and continues until those charges are paid in full or adjusted off the account, is known as the: Ans: C Feedback: The revenue cycle is the flow of a practice’s revenue, which begins when charges for services, procedures, or supplies are incurred and continues until those charges are paid in full or adjusted off the account.

3. The diagnostic statement ―goiter, nodular nontoxic‖ would be coded as an unspecified nontoxic goiter, ICD-10-CM code E04.9 since the diagnosis does not describe the condition as uninodular or multinodular. This is an example of which abbreviation used in ICD?

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51 Ans: B Feedback: The NOS abbreviation is used when there is not enough information in the documentation to provide a more specific code. NEC stands for Not Elsewhere Classified. MUE is the abbreviation for Medically Unlikely Edits, and CCI is Correct Coding Initiative.

4. Which of the following are true statements concerning acute and chronic conditions and their coding guidelines?

Ans: D Feedback: The guidelines instruct that when both the acute and chronic forms of a condition are documented, both conditions should be coded. Based on the guidelines, there are two ways these conditions may be coded: together, with a combination code that identifies both the chronic and acute forms of the condition in one code, or separately, with one code for the acute condition and another for the chronic condition. Both combination codes and distinct codes are recognizable in the Alphabetic Index. After locating the main term of the condition (acute and chronic forms of the same condition are located under the same main term), review both subterms, acute and chronic. If the subterms acute and chronic are connected by a with statement, ICD provides a combination code, or one code to indicate both conditions.

5. Identify the true statement concerning signs and symptoms: Ans: D Feedback: A sign is a condition that can be measured and recorded. Sign is an objective term. A symptom is a condition that is relayed to the provider by the patient. Symptom is a subjective term. A symptom is actually defined as related to the provider by the patient, such as stating they were presenting to the office with a cough, pain, etc.

6. When a condition is produced as a manifestation of another condition or a complication of a treatment, disease, or condition, more than one code is needed to clearly define the condition, injury, or disease. This is noted by which instructional note or notes in the ICD manual?

Ans: B Feedback: ICD provides the instructional notes ―code first‖ and ―use additional code‖ in the tabular section when additional information is needed to further define the patient’s diagnosis.

7. A patient who is suffering from osteosarcoma located above the right knee begins chemotherapy treatment at today’s encounter. Select the appropriate ICD-10-CM codes to be reported for this encounter: Ans: C Feedback: Z51.11, encounter for antineoplastic chemotherapy; C40.21, malignant neoplasm of long bones of right lower limb . Sequencing of admission or encounters for chemotherapy requires the reason for the encounter be the first listed code.

8. The patient is admitted to the ER for excessive weight loss and dehydration. The patient has a history of HIV-2 and has been taking nucleoside reverse transcriptase (RT) inhibitors. Assign the appropriate ICD-10-CM codes: Ans: B

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52 Feedback: B20 should be used for the HIV, T37.5X5A reports the adverse effect of antiviral drugs, R63.4 is for the weight loss, and E86.0 is for the dehydration.

9. A 67-year-old female patient with stage 5 chronic kidney disease presents today for ongoing dialysis. Choose the appropriate ICD-10-CM codes: Ans: D Feedback: Code N18.6 is assigned for chronic kidney disease, stage 5 requiring ongoing dialysis per an

instructional note with N18.5 and N18.6. There is also an instructional note with N18.6 telling the coder to use additional code to identify dialysis status Z99.2.

10. A 32-year-old female was diagnosed with premature menopause that is symptomatic of ovarian failure and is experiencing headaches, flushing, and night sweats. Select the correct ICD-10- CM code(s): Ans: C Feedback: Index menopause, premature, symptomatic to located the code E28.310 describes symptomatic premature menopause.

11. Many conditions and diseases have sequelae (late effects) such as a CVA. How much time must elapse between the incident and the acute symptoms for a residual condition to be coded as a sequela (late effect)?

Ans: C Feedback: There is no set time because the cause of a sequela (late effect) can occur years ago and a person can have side effects from an injury that occurred two to three years ago. This specific guideline is located in the general coding guidelines of the ICD manual.

12. A patient is diagnosed with sickle cell crisis and acute chest syndrome with respiratory failure.

Select the correct ICD codes: Ans: D Feedback: Code D57.01 describes sickle cell disease with crisis with acute chest syndrome. J96.90 describes the respiratory failure, unspecified whether with hypoxia or hypercapnia.

13. Where will a coder locate all the instructions necessary to properly code a procedure in the CPT manual?

Ans: C Feedback: Specific guidelines are found at the beginning of each of the sections of the CPT manual.

These guidelines are necessary to appropriately assign services and procedures that are assigned to the section.

14. A physician performed a simple mastectomy on both the left and right breasts—19303 mastectomy, simple, complete. Assign the appropriate modifier to be added to 19303 to indicate that both breasts were removed in the same operative session: Ans: A

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53 Feedback: The modifier -50, bilateral procedure, should be assigned to code 19303, indicating both breasts were removed at the same operative session.

15. Why is it necessary for a medical coder to use a current edition of the AMA CPT manual?

Ans: C Feedback: Use of an updated CPT manual is critical to ensure accurate assignment of codes.

16. What is a two-digit modifier used for in CPT coding?

Ans: D Feedback: Per CPT guidelines, a modifier provides the means by which a service or procedure that has been performed has been altered by some specific circumstance but not changed in its definition or code.

17. CPT code range 90281–99607 is located in which section of the CPT manual?

Ans: D Feedback: This code range is located in the Medicine section of the CPT manual.

18. A nonhealing burn should be coded as which type of burn?

Ans: B Feedback: Per ICD chapter-specific guidelines for burns, all nonhealing burns are coded as acute burns, and necrosis of burned skin should be coded as a nonhealing burn.

19. The patient has type 2 diabetes mellitus that is controlled with insulin and complicated by proliferative retinopathy, gangrene, and ketonuria. Identify the correct ICD-10-CM codes: Ans: C E11.52, E11.3599, R82.4, Z79.4 Feedback: E11.52 describes type 2 diabetes mellitus with diabetic peripheral angiopathy with

gangrene (type 2 DM with diabetic gangrene); E11.3599 describes type 2 diabetes mellitus with proliferative diabetic retinopathy without macular edema; R82.4 describes ketonuria (no mention of ketoacidosis); and Z79.4 describes long term (current) use of insulin.

20. Four people were seen in the ED. Which one will receive a diagnosis of poisoning?

Patient A: digitalis toxicity Patient B: allergic reaction to contrast dye used for a CT exam Patient C: syncope after taking antihistamine with alcohol Patient D: reaction between two properly administered prescription drugs Ans: C Feedback: The other answers are examples of adverse effects to properly administered medication.

21. Which is an example of a pathologic fracture?

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54 Ans: D Feedback: Pathologic fractures are defined as caused by disease which leads to weakness of a bone, thereby causing a fracture of the bone. Pathologic fractures are defined in the Chapter 13 specific guidelines in the ICD manual.

22. The patient is in the intensive care unit with fluid overload with acute renal failure. He has type 2 DM and sepsis. The patient is sedated and on a ventilator because of respiratory failure. Code the diagnoses only: Ans: A Feedback: This diagnosis follows the chapter-specific guidelines for sepsis with organ failure.

23. The patient is admitted for severe anemia due to chemotherapy treatments for metastatic bone cancer. The primary site is the prostate. What are the correct ICD-10-CM codes?

Ans: B Feedback: When coding and sequencing complications due to cancer or the treatment of cancer, such as anemia, dehydration, vomiting, or surgical complications, and the patient is being seen and/or treated for the complication, the code for the complication is listed first followed by the code for the site(s) of the cancer. The metastatic cancer is being treated, so it would be sequenced after the anemia code, followed by the code for the prostate cancer and the adverse effect code.

24. An elderly patient was admitted with malnutrition. He had suffered a stroke two years previously that left him with dysphagia. He was treated for the malnutrition with hyperalimentation. He was also diagnosed with hypokalemia. What are the correct codes?

Ans: D Feedback: The malnutrition code (E46) is coded first, then the hypokalemia E87.6 (This is what the patient is being treated for this encounter). ICD I69.391 identifies dysphagia following cerebral infarction (there is an instructional note with this code telling the coder to use additional code to identify the type of dysphagia, if known, R13.10).

25. A patient returns to the physician’s office with flulike symptoms during the postoperative period for an appendectomy performed 1 month ago. Which modifier would need to be appended to today’s office visit?

Ans: A Feedback: Unrelated evaluation and management service by the same physician during a postoperative period is the definition for modifier 24. By appending this modifier to the office visit for the flu symptoms, this lets the payer know the visit was not a follow-up visit for the appendectomy during the postoperative period.

Chapter 5 – Evaluation and Management

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55

LESSON PLANS Class Preparation: Teaching Focus and Resources Chapter 5 reviews the E/M section of CPT. This range of codes is used to tell the story of the services provided to the patient in an examination rather than procedures.

Categories included in this chapter are:  Office visits  Hospital encounters  Nursing home service  Emergency services  Critical Care  Case management services 

Preventive medicine visits

Learning Outcomes After completing Chapter 5, students will be able to: LO 5.1 Understand the format and guidelines of the Evaluation and Management (E/M) section of the CPT manual.

LO 5.2 Determine the range of E/M codes required for the service provided.

LO 5.3 Define the components of an E/M code.

LO 5.4 Apply the guidelines for determining the level of service of an E/M code.

LO 5.5 Review the modifiers commonly used with E/M codes.

Class Presentation LO 5. 1 Understand the format and guidelines of the Evaluation and Management (E/M) section of the CPT manual Slides 5-1 through 5-4



Chapter introduction and Key terms

Slide 5-5



Format and Guidelines of the E/M section of the C P T Mnual

Slide 5-6



Format and Guidelines of the E/M section of the C P T Mnual continued - Office or Other Outpatient Services (99201-99215) - New patients (99202-99205) - Established patients (99211-99215)

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56 Slide 5-7



Format and Guidelines of the E/M section of the C P T Mnual – continued - Hospital Observation Services Observation care discharge services (99217) Initial observation care (99218-99220)

Slide 5-8



Format and Guidelines of the E/M section of the C P T Mnual – continued - Hospital observation services – continued Subsequent observation care (99224-99226) Observation or Inpatient care services (99234-99236) Hospital discharge services (99238-99239)

Slide 5-9



Format and Guidelines of the E/M section of the C P T Mnual – continued - Hospital inpatient services Initial hospital care (99221-99223) Subsequent hospital care (99231-99233)

Slide 5-10



Format and Guidelines of the E/M section of the C P T Mnual – continued - Consultations (99241-99245, 99251-99255)

Slide 5-11



Format and Guidelines of the E/M section of the C P T Mnual – continued - Consultations – continued Office or other outpatient consultation (99241-99245) Inpatient consultation (99251-99255)

Slide 5-12



Format and Guidelines of the E/M section of the C P T Mnual – continued - Emergency department services (99281-99285)

Slide 5-13



Format and Guidelines of the E/M section of the C P T Mnual – continued - Critical care services (99291-99292)

Slide 5-14



Format and Guidelines of the E/M section of the C P T Mnual – continued - Nursing facility services (99304-99318)

Slide 5-15



Format and Guidelines of the E/M section of the C P T Mnual – continued - Home services New patient (99341-99345)

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57 Established patient (99347-99350) Slide 5-16



Format and Guidelines of the E/M section of the C P T Mnual – continued - Prolonged services With and without direct patient contact

Slide 5-17



Format and Guidelines of the E/M section of the C P T Mnual – continued - Prolonged services – continued With direct patient contact (99354-99357) Without direct patient contact (99358-99359)

Slide 5-18



Format and Guidelines of the E/M section of the C P T Mnual – continued - Care Plan Oversight Services (99374-99380):

Slide 5-19



Format and Guidelines of the E/M section of the C P T Mnual – continued - Preventive Services (99381–99397)

Slide 5-20



Format and Guidelines of the E/M section of the C P T Mnual – continued - Counseling Risk Factor Reduction and Behavior Change Intervention (99401-99412)

Slide 5-21



Format and Guidelines of the E/M section of the C P T Mnual – continued - Basic life and/or disability evaluation services (99450) - Work-related or medical disability evaluation services (9935599356)

Slide 5-22



Format and Guidelines of the E/M section of the C P T Mnual – continued - Newborn Services

Slide 5-23



Format and Guidelines of the E/M section of the C P T Mnual – continued - Delivery/birthing room attendance and resuscitation services (99464-99465) - Inpatient neonatal intensive care services and pediatric and neonatal critical care services (99466-99486)

Slide 5-24



Format and Guidelines of the E/M section of the C P T Mnual – continued - Pediatric critical care patient transport (99466-99467, 99485-

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58 99486) Slide 5-25



Slide 5-26





Slide 5-27

Format and Guidelines of the E/M section of the C P T Mnual – continued - Inpatient neonatal and pediatric critical care (99468-99476) Format and Guidelines of the E/M section of the C P T Mnual – continued - Inpatient neonatal and pediatric critical care – continued Format and Guidelines of the E/M section of the C P T Mnual – continued - Initial and Continuing Intensive Care Services (99477–99480)

LO 5.2 Determine the range of non-office or outpatient E/M codes required for the service provided.

Slide 5-28



Steps in determining the E/M code range - Chief complaint - Place of service - Type of service

Slide 5-29



Steps in determining the E/M code range – continued - Identify patient status Inpatient Outpatient New patient Established patient

Slide 5-30



Steps in determining the E/M code range – continued - Significance of forth digit

LO 5.3 Define the components of a non-office or outpatient E/M code.

Slide 5-31



The components of an E/M service - Seven components of an E/M service

Slide 5-32



The components of an E/M service – continued - Intro to key components - Time

LO 5.4 Apply the guidelines for determining the level of service of a non-office or outpatient E/M code.

Slide 5-33



Determining the level of a non-office or outpatient E/M code - Key components sub-elements

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59 Slide 5-34



Determining the level of a non-office or outpatient E/M code – continued - Sub-elements of key component - History (table 5.4)

Slide 5-35



Determining the level of a non-office or outpatient E/M code – continued - Sub-elements of key component – Exam (table 5.5)

Slide 5-36



Determining the level of a non-office or outpatient E/M code – continued - Sub-elements of key component – MDM (table 5.6)

LO 5.5 Review the modifiers commonly used with E/M codes.

Slide 5-37



Modifiers Commonly Used with E/M Codes

Summary Slides Slides 5-38 through 5-39



Synopsis of Chapter

Teaching Tips Using the CPT Manual, review the follow areas and concepts LO 5.1:  The Evaluation and Management section of the CPT manual contains ranges of codes that require the coder to abstract information from the provider documentation to determine the appropriate code(s) from this section.  The coder must have a full understanding of the distinct requirements for each of the code ranges within this section.

Coding Tips and Guidelines o Face-to-face time is the time actually spent by the physician in direct contact with the patient and/or family in the office or outpatient setting. In the hospital the time spent by the provider on the floor or unit that is related to the care given to the patient for that day’s encounter is the provider time. o Code 99211 may not require the presence of a physician. Often this code is referred to as a nurse visit. Note that this code has no key-component requirements. o Note that there are only three codes to choose from in this range. To obtain a level 99222 or 99223 code, a comprehensive exam must have been performed and documented. When determining the appropriate level for this code range, coders find it helpful to determine the level of exam first. If a comprehensive exam was not performed and documented, the code choice becomes 99221. Delete this bullet point Now N/A o Consultation codes are used when the three R’s rule can be applied: request, render, and report. The three R’s can be summarized as follows: The service must be in the form of a written request to the consulting physician asking that physician to render an opinion and supply a written report to the requesting physician. o Some payers, such as Medicare, do not recognize consultation code ranges 99242–99245 and 99252–99255. o A provider may not report both an outpatient consult and an inpatient consult for services related to the patient’s same hospital stay.

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60 o

o

o o o

o

CPT defines a critical illness or critical injury as one that acutely impairs one or more vital organ systems and presents a high probability of life-threatening deterioration. A patient can be in a critical care unit (CCU), such as an intensive care unit (ICU), and not be designated as critically ill. A patient can also be in a setting other than a critical care unit and be designated as critically ill. It is not the setting but the condition that defines critical care.

Remember that 99292 is an add-on code to be used for each additional 30 minutes. Use the grid supplied in some CPT manuals to determine how many times 99292 should be used for the encounter. If less than 30 minutes is documented as the time spent with the critically ill patient, code 99291 may not be reported and an appropriate E/M code should be chosen.

Be aware that code 99359 has a plus sign (_) in front of it and therefore can never be used alone or as the first code.

The documentation often will not state that the visit is a preventive medicine visit. The coder should look for terms such as annual visit, yearly checkup, and well-woman check.

The patient will present with no signs or symptoms.

If less than 30 minutes of time is recorded, these codes may not be used; instead, an appropriate E/M service code is used. The time reported for these codes is for the physician contact time only; any services provided by others during the transport are not included in the physician time.

Read the guidelines included in the CPT manual for more specific instruction as to the use of these codes. These are new codes ranges and have very specific guidelines.

LO 5.2:  Determine the E/M code range for the service provided following these steps: 1. Determine the chief complaint.

2. Identify the place of service or setting of the encounter.

3. Identify the kind of service provided.

4. Identify the status of the patient.

Coding Tips and Guidelines o ―Patient seen today for follow-up‖ is not an appropriate chief complaint. A reason for the visit has not been given. ―Follow-up for asthma‖ would be an appropriate chief complaint. o The words exact and subspecialty were added to the wording of the definition of new patient and established patient in the 2012 edition of the CPT manual. There is a decision tree in the evaluation and management guidelines that can help with deciding whether a patient is new or established. o The concept of same practice, as described in the E/M section guideline defining a new versus established patient, is considered by payers to be all providers providing services under the same tax ID. This means that two providers seeing patients at different physical locations are considered in the same practice if the services are billed under the same tax ID. o In the E/M section, the fourth digit identifies the place of service and patient status, as shown in the list below. Knowing this relationship between the fourth digit and the code description helps coders during the CPC exam to quickly eliminate some of the answers included in the E/M section.  

LO 5.3: Delete the current LO5.3 and replace with the following Discuss the components of Evaluation and Management codes

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61  



Medically appropriate history and exam Medical Decision Making o Straightforward o Low o Moderate o High Time o Total time for E/M services performed on the date of the encounter.

LO 5.4:  Review the guidelines for selection of the appropriate level of medical decision making and locate this information in the provider documentation to determine and support the level of nonoffice or outpatient service reported for the patient encounter.

Coding Tips and Guidelines delete the following coding tips and guidelines, n/a o The 1995 documentation guidelines are followed for the CPC exam, and the determination of the three key components is based on these guidelines in this textbook. o Problem-focused, expanded focused, and detailed exams can use documentation supporting examination of a combination of body areas and organ systems. To qualify as a comprehensive exam, the documentation must support a minimum of 8 organ systems examined. o One way that providers dictate is based on the SOAP format. This format correlates with how coders abstract the documentation to support the level of service reported.

SOAP Notes Component Subjective HPI and ROS Objective Exam Assessment Medical decision making Plan Medical decision making LO 5.5:  Using specific examples discuss modifiers 24, 25, 32, and 57 as they are used with codes reported from the E/M section of the CPT manual.

Coding Tips and Guidelines o Being familiar with these modifiers and their appropriate use can help when coders are taking the CPC exam. Often, two answer choices can be eliminated by the absence or presence of the correct modifier.

Chapter 5 Answer Key Exercise 5.1 1. Explain the three R’s needed to support a consultation code.

Ans: The service must be in the form of a written request to the consulting physician asking them to render an opinion and supply a written report to the requesting physician.

Feedback: The three R’s can be summarized as follows: The service must be in the form of a written request to the consulting physician asking that physician to render an opinion and supply a written report to the requesting physician.

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62 2. Define face-to-face time.

Ans: Face-to-face time is defined as the time actually spent face-to-face with the patient and/or family.

Feedback: Face-to-face time is the time the physician actually spends face-to-face with the patient and/or family in the office or outpatient setting. In the hospital, the time the physician spends on the floor or unit that is related to the care given to the patient for that day’s encounter is the physician time.

3. Explain CPT’s definition of a critical illness or injury.

Ans: CPT defines a critical illness or injury as one that acutely impairs one or more vital organ systems and with which there is a high probability of life-threatening deterioration.

Feedback: The patient can be in a critical care unit, such as ICU or CCU, and not be designated as critically ill. A patient can also be in a setting other than a critical care unit and be designated as critically ill. It is not the setting but the condition that defines critical care.

Exercise 5.2 1. Define new patient and established patient.

Ans: New patient: One who has not received face-to-face services from the physician/qualified healthcare professional or another physician/qualified healthcare professional of the exact same specialty and subspecialty in the same group within the past 3 years. Established patient: One who has received face-to-face services from the physician/qualified healthcare professional or another physician/qualified healthcare professional of the exact same specialty and subspecialty in the same group within the past 3 years.

2. Define inpatient and outpatient.

Ans: Inpatient: One who has been formally admitted to inpatient status at a health care facility.

Outpatient: One who has not been formally admitted to inpatient status in a health care facility 3. List the four steps that can lead the coder to the appropriate range of E/M codes for the patient encounter.

Ans: 1) Determine the patient’s chief complaint.

2) Identify the place of service or setting of the encounter.

3) Identify the kind of service.

4) Identify the status of the patient.

Exercise 5.3 1. When is time a factor?

Ans: Delete the current answer and replace with the following :The appropriate level of E/M services is now based on either the level of MDM supported by the provider documentation or the total time spent on the date of the encounter which includes face to face time, reviewing test results and provider notes, and completion of the medical record.

Feedback: The documentation must state the total time of the visit and record this was performed on the date of the encounter.

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63 2. List the seven components of a non-office or outpatient E/M service.

Ans: History, examination, medical decision making, counseling, coordination of care, nature of presenting problem, and time 3. List the components of an E/M service.

Ans: Medically appropriate history and exam and medical decision making Feedback: N/A Exercise 5.4 1. What year’s E/M documentation guidelines are followed for the CPC exam for non-office or outpatient services?

Ans: Neither the 1995 nor 1997 guidelines are used. The new guidelines for 2024 and 2025 are now used.

Feedback: delete the feedback.

2. Define the required elements for determining the level of medical decision making Ans: Delete the current bullet points and replace with the highlighted bullet points  Location: Anatomical location of present signs/symptoms.  Duration: How long have the signs and/or symptoms of the present illness or injury been present?  Quality: Description of present illness, such as sharp, throbbing, persistent.  Severity: Descriptors such as mild, moderate, and severe or the use of the pain scale (pain is 5/10).  Timing: When do the signs and or symptoms occur?  Context: What is happening or happened when the present illness or injury occurred?  Modifying factors: What makes the present illness or injury worse or better?  Associated signs/symptoms: Other factors occurring which are related to or affect the present illness or injury.  Medically Appropriate history and/or examination  Medical Decision Making Level  Total Time (on date of the encounter)  3. What are the elements that determine the appropriate level of medical decision making Ans.: Number and Complexity of Problems Addressed at the Encounter; Amount and/or Complexity of Data to be Reviewed and Analyzed, and Risk of Complications and/or Morbidity or Mortality of Patient Management Delete and replace with aboveAns: In this element, the highest level in any one subelement (presenting problem, diagnostic procedure, or management option) determines the overall risk.

Exercise 5.5 1. Which modifier informs the payer that an unrelated E/M service was provided by the same physician during a postoperative period?

Ans: Modifier 24

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64 Feedback: Modifier 24 – Unrelated E/M service by the same physician during a postoperative period 2. A patient presents to the office asking for a second opinion about an upcoming surgery. The patient wants reassurance that the surgery is necessary. Would modifier 32 be appropriate in this case?

Ans: No Feedback: Modifier 32 is to be used if a second opinion is mandated by someone other than the patient such as the payer, worker’s compensation etc.

3. Which modifier allows for a preoperative visit to be reported separately from the global surgical package?

Ans: Modifier 57 Feedback: If the decision for surgery was made during the visit the same day as the surgery or the day before the surgery.

Chapter Five Review Using Terminology Ans: 1. B

Chief complaint

8. D

Inpatient

2. C

Consultation

9. E

Medical decision making (MDM)

3. G

Critical Care

10. H

New patient

4. J

Emergency Department

11. A

Outpatient

5. K

Established patient

12. L

Past, family, and social history (PFSH)

6. F

Face-face-time

13. N

Preventive care

7. M

History of present illness (HPI) 14. I

Review of systems (ROS)

Checking Your Understanding Complete each sentence with the most appropriate term or terms.

1. It is not the setting but the _____________________that defines critical care.

Ans: Condition Feedback: It is not the setting but the condition that defines critical care.

2. LTCF is an abbreviation for _______________________.

Ans: Long-term care facility Feedback: LTCF is an abbreviation for long-term care facility.

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65 3. CPT code 99221 is found under the subheading __________________in the E/M section of the CPT manual.

Ans: Inpatient Care Services Feedback: CPT code 99221 is found in the subheading inpatient care services in the E/M section of the CPT manual.

4. The words ______________ and _____________ were added to the definition of new and established patient in the 2013 edition of the CPT manual.

Ans: Exact; subspecialty Feedback: The words exact and subspecialty were added to the definition of new and established patient in the 2013 edition of the CPT manual.

5. A patient presents to the office for an annual visit and has no signs or symptoms. An appropriate code would be chosen from the _________________ section.

Ans: Preventive Medicine Feedback: A patient presents to the office for their annual visit and has no signs or symptoms. An appropriate code would be chosen from the Preventive Medicine section.

Choose the most appropriate answer for each of the following questions.

6. The patient states to the physician that her throat is sore. Which element of Medical Decision Making this an example of?

Ans: A. Number and Complexity of Problems Addressed at the Encounter Feedback: Delete feed back. N/A The patient stated that her throat was sore; it was not stated that the physician examined the throat. History of present illness is a key component, not an element.

7. Delete question 7 n/a The physician observes that the patient’s throat is red and swollen. Which element within the physical exam component is this an example of?

Ans: B. Ears, nose, mouth, and throat organ system Feedback: In this statement, the physician examined (observed) the patient’s throat, which would make it an organ system within the physical exam component.

7. The number 5 in the CPT code 99252 indicates that the type of service provided to the patient was: Ans: A. Inpatient consultation Feedback: The number 5 in the CPT code 99252 indicates that the type of service provided to the patient was inpatient consultation.

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66 8. A provider documents spending 35 minutes in the morning and 65 minutes in the afternoon providing critical care for a patient. CPT code(s) ________ would be reported.

Ans: B. 99291, 99292 Feedback: Total time spent is 100 minutes. Time spent with a critically ill patient does not have to be continuous. 99291 is for the first 30-74 minutes; 99292 reports each additional 30 minutes. The grid in the CPT manual shows 75-104 minutes would be coded 99291 and 99292.

9. What are the three R’s needed to support the choice of a code from the consultation code ranges 99241-99246 and 99251-99255?

Ans: A. Request, render, report Feedback: There must be a written request from the requesting provider, and the consulting provider must render an opinion and submit a written report to the requesting provider.

10. The patient calls the office and asks the cardiologist for a ―consultation‖ regarding his chest pain. The patient is seen, and the physician determines that his chest pain is due to heartburn and sends a report to the patient’s family physician. The cardiologist’s office reports this visit as a consultation, using codes from range 99241-99245. One of the three ―Rs‖ is missing and therefore the appropriate code range 99202-99205 should be reported. Which ―R‖ is missing?

Ans: A. Request Feedback: The request must come from a provider; this request was from the patient.

11 . Delete this question N/AThe provider documentation states that no abnormal bowel sounds were heard. What element of which one of the key components is this an example of?

Ans: B. Organ system; exam Feedback: Organ system is the element of the exam key component.

12. delete this question N/A The patient states that her pain occurs upon exertion. Which subelement of the history of present illness (HPI) is this an example of?

Ans: B. Context (What is happening or happened when the present illness or injury occurred?)

Feedback: Timing is defined as when the signs and or symptoms occur. Associated signs and symptoms is defined as other factors occurring which are related to or affect the present illness or injury. Severity is defined as descriptors such as mild, moderate, and severe or the use of the pain scale.

11. A 45-year-old female patient presents to the office today for her annual visit. During the visit it is discovered that her hypertension needs managing, and the physician changes her medication and orders some lab work. Which modifier needs to be appended to the office visit code for both the preventive medicine visit (annual visit) and the office visit (managing the hypertension) to be reimbursed?

Ans: B. Modifier 25

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67 12 . A 30-year-old male patient is seen in the office. He is a returning patient who has not been seen for 4 years by the physician. The patient states that he has been having chronic back pain for several months. The physician performs a medically appropriate history and exam. The physician prescribes medication and asks to see the patient in 3 weeks. The medical decision making is low.

What is the appropriate CPT code?

Ans: C.. 99203 Feedback: This is a new patient in the office, so 99212 and 99242 are eliminated right away since they are codes for established patient and office consultation. Although the condition is identified as chronic in the medical record, the CPT defines a chronic condition as one with expected duration of at least one year or the life of the patient. As the documentation does not indicate this condition is expected to be of long duration, the problem addressed is categorized as an acute, uncomplicated illness or injury.

Applying Your Knowledge 1. Using the techniques described in this chapter, work through the following case study to determine the appropriate E/M code.

A 17-year-old year old high school student presents with his mother, complaining of a sore throat which began three days ago. He denies any fever or chills but does state that he feels tired and weak. The patient has been seen for frequent bouts of sore throat in the last year.

Physical Exam: Neck: supple General appearance- no acute distress Vitals: 98.6, 80, 120/75 HEENT: pharynx is clear; throat is mildly red and swollen Lungs: normal respiratory effort Impression: viral URI Plan: drink plenty of fluids, Tylenol as needed. rest, and return in a week if no improvement Ans: Chief Complaint = sore throat Place of Service = office Type of Service = office or other outpatient Status = established Medical Decision-Making Component = Straightforward Number and complexity of problems addressed = –Acute, uncomplicated illness or injury Data reviewed and analyzed = None Risk of patient management options = Low - over the counter drugs Final CPT Code = 99213 ICD Code = J31.2 (sore throat, chronic) Write a scenario for a new patient seen in the office with a diagnosis of DM and hypertension. The documentation should support a 99203 CPT code. Show the ICD codes.

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68 Ans: The documentation should clearly show this visit was an initial visit and occurred in an office setting. There needs to be a clear chief complaint.

Delete this paragraph n/aThe expected key components (CPT defined) for a 99203 are History: Detailed; Exam: Detailed; and Medical Decision Making: Low. The given components (provider documentation) must support the expected key components.

The documentation should support a detailed history by including the following: Chief Complaint Medically appropriate history and exam The body areas or organs should be relevant to the patient’s condition (e.g., cardiovascular, endocrine) The documentation should support low medical decision making by including the following: Number and complexity of problems addressed=as there are two chronic illnesses addressed, the moderate level of complexity met.

Low amount of data to be reviewed or analyzed Risk of patient management must not exceed the low level of complexity for this category.

Feedback: The documentation should clearly show this visit was an initial visit and occurred in an office setting. There needs to be a clear chief complaint.

The expected key components (CPT defined) for a 99203 are Medical Decision Making: Low.

Chapter 6 – Anesthesia LESSON PLANS Class Preparation: Teaching Focus and Resources This chapter discusses the various types of anesthesia used, the role of the anesthesiologist and other providers of anesthesia, and the anesthesia formula.

The code sets used to report anesthesia services and the modifiers needed to further clarify the service are reviewed in depth and applied to case studies.

Learning Outcomes After completing Chapter 6, students will be able to: LO 6.1 Recognize the anesthesia reimbursement formula.

LO 6.2 Apply physical-status and qualifying circumstance modifiers.

LO 6.3 Define HCPCS Level II modifiers and explain their function in anesthesia billing.

LO 6.4 Identify medical terminology specific to anesthesia billing.

LO 6.5 Examine the types of anesthesia used for specific procedures.

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69 LO 6.6 Explain other procedures or services provided during anesthesia and locate anesthesia terms in the CPT manual index.

Class Presentation LO 6.1 Recognize the anesthesia reimbursement formula.   

Slide 6-1 through 6-4 Slide 6-5 Slide 6-6

Chapter introduction and Key Terms The anesthesia reimbursement formula components Applying the anesthesia reimbursement formula

LO 6.2 Apply physical-status and qualifying circumstance modifiers.

Slide 6-7 Slide 6-8

 

Physical – Status Modifiers and Qualifing Circumstances Physical – Status Modifiers and Qualifing Circumstances– continued

LO 6.3 Define HCPCS Level II modifiers and explain their function in anesthesia billing.

Slide 6-9



Modifiers Specific to Anesthesia - Certified Registered Nurse Anesthetist

LO 6.4 Identify medical terminology specific to anesthesia billing.

Slide 6-10



Slide 6-11



Medical Terminology Specific to Anesthesia - Medical direction - Airway management Intubation Extubation Medical Terminology Specific to Anesthesia– continued - Post-anesthesia care unit (PACU)

LO 6.5 Examine the types of anesthesia used for specific procedures.

Slide 6-12



Slide 6-13



Procedures and the Type of Anesthesia Used for Specific Procedures - General anesthesia - Monitored anesthesia care (MAC) Procedures and the Type of Anesthesia Used for Specific Procedures– continued - Moderate (conscious) sedation

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70 LO 6.6 Explain other procedures or services provided during anesthesia and locate anesthesia terms in the CPT manual index.

Slide 6-14



Slide 6-15



Slide 6-16



Procedures and Services provided during anesthesia - Services included in anesthesia package Procedures and Services provided during anesthesia - continued - Services not included in anesthesia package Locating terms in CPT - Indexing anesthesia

Summary Slides Slide 6-17 through 6-21



Synopsis of Chapter

Teaching Tips LO 6.1:  The reimbursement formula of time-based general anesthesia services consists of three components: base units (B), total time of anesthesia care (T), and modifying factors (M).

Therefore, the formula is B + T+ M LO 6.2:  Physical-status modifiers: used with all anesthesia procedure codes to rank the physical condition of the patient and the level of anesthesia complexity inherent to each ranking.  Qualifying-circumstances modifiers: used when anesthesia is provided under circumstances such as extreme patient age, medical condition of patient or surgical procedure, or emergency situations.

Coding Tips and Guidelines o Use as many qualifying-circumstance modifiers as needed to completely identify the patient and/or procedure conditions.

LO 6.3:  Anesthesia-specific modifiers: Anesthesia services may be provided by an anesthesiologist or by a Certified Registered Nurse Anesthetist acting under the direction of an anesthesiologist or acting without medical direction. As these providers and the level of service being provided are reimbursed at different rates, the anesthesia-specific modifiers are used to identify these circumstances.

Coding Tips and Guidelines o When coding for anesthesia services both during the CPC exam and in the field, coders must first identify the provider of service (MD or CRNA), the level of service provided, and which provider’s service is being coded in order to be able to apply the correct anesthesia billing modifier.

LO 6.4:  Medical direction: As it applies to anesthesia services, this term refers to physician involvement with and direction of anesthesia that is carried out by a qualified provider.

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71  

Airway management: The documentation reports that the patient was intubated or extubated, the patient’s airway was then managed by endotracheal means, and the type of anesthesia is general.

Post-anesthesia care unit (PACU): This is where the patient is monitored by a nurse specializing in post-sedation care.

Coding Tips and Guidelines o Requirements of Medical Direction The anesthesiologist must: • Complete preanesthetic examination and evaluation.

• Set the anesthesia plan.

• Attend to patients during the most demanding procedures of the anesthesia plan.

• Ensure that any procedures that are not personally performed are performed by individuals qualified to do so.

• Monitor the course of anesthesia in frequent intervals.

• Remain physically present and available for emergencies.

• Provide indicated postoperative care.

LO 6.5:  The only two types of anesthesia sedation services reported with an Anesthesia section code (CPT codes beginning with 0) are general anesthesia and monitored anesthesia care.

Coding Tips and Guidelines o All forms of sedation—conscious, general, and monitored anesthesia— will have documentation of the patient’s O2 stats during anesthesia. It is important to recognize that this documentation indicates that the patient’s respiration was monitored during the sedation and does not indicate that the patient’s airway was managed by the provider. o If the anesthesia service begins as a MAC and changes to general anesthesia due to the patient’s inability to control his or her own airway, the service should be reported as general anesthesia, not MAC. LO 6.6:  Some services are considered part of the work of the anesthesia service and as such are not coded separately. These services include: • Preoperative and postoperative visits • General or regional anesthesia and patient care • Administration of fluids and/or blood • Usual monitoring services (e.g., ECG, temperature, blood pressure, capnography, and mass spectrometry)  Several procedures and services often provided and documented by the anesthesia provider are not considered part of the anesthesia service and should be billed and coded in addition to the anesthesia service when documented: • Insertion of central venous catheter (36555–36558, 36568–36569) • Insertion of an intra-arterial catheter (36620–36625) • Insertion of Swan-Ganz (93503) • Transesophageal echocardiography (93312–93318) • Procedures performed for postoperative pain management



The main term indexed for anesthesia services is always anesthesia. The terms listed after the Anesthesia headers are listed by surgical procedure and/or the anatomical site being operated on.

Chapter 6 Answer Key

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72 Exercise 6.1 1. Define the term anesthesia.

Ans: Anesthesia means without sensation.

Feedback: This loss of sensation can be partial or complete and can be achieved by different types of anesthesia.

2. Define time in the context of anesthesia coding.

Ans: Time begins when the patient is being prepared for anesthesia by the anesthesiologist and ends when the patient is no longer being attended to by the anesthesiologist.

Feedback: Total time is converted into units (typically 15 minutes equals 1 unit per ASA recommendation) and added to the base units allotted for the surgical procedure.

3. What is the anesthesia reimbursement formula?

Ans: B + T + M (basic unit + time + modifying factor [physical status modifier and qualifying circumstance]) Exercise 6.2 1. What is the function of a qualifying-circumstance modifier?

Ans: At times anesthesia may be provided under more challenging circumstances such as extreme patient age, condition of patient or surgical procedure, or emergency situations when the patient’s medical history or history of previous anesthesia response is not available prior to initiation of anesthesia. Qualifying circumstance modifiers are used to indicate this type of information.

Feedback: Qualifying-circumstance modifiers are used to indicate information regarding challenging circumstances such as extreme patient age, condition of patient or surgical procedure, or emergency situations when the patient’s medical history or history of previous anesthesia response is not available prior to initiation of anesthesia.

2. What is the function of a physical-status modifier?

Ans: Physical-status modifiers are used with all anesthesia procedure codes to rank the physical condition of the patient and the level of anesthesia complexity inherent to each ranking.

Feedback: Physical-status modifiers rank the physical condition of the patient and the level of anesthesia complexity inherent to each ranking.

3. A 72-year-old patient is taken to the operating room for emergency surgery. The patient is known to be diabetic. What physical-status modifier and qualifying-circumstance modifiers, if any, would be appended to this patient’s anesthesia code?

Ans: P2, 99100, 99140 Feedback: P2 for mild systemic disease; 99100 for age, since the patient is 72; and 99140 since this was an emergency situation.

Exercise 6.3

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73 1. What is the purpose of the anesthesia-specific modifiers?

Ans: Anesthesia-specific modifiers are used to identify circumstances regarding providers and the level of service being provided, since they are reimbursed at different rates.

Feedback: At times anesthesia services may be provided by different levels of providers performing different levels of service, for example, an anesthesiologist providing the services or a Certified Registered Nurse Anesthetist (CRNA) acting under the direction of an anesthesiologist or providing the service without medical direction. As providers and the level of service being provided are reimbursed at different rates, these modifiers are used to identify these circumstances.

2. To select the appropriate anesthesia-specific modifier, what must a coder be able to identify from the documentation?

Ans: The provider of service, level of service provided, and whose services the coder is being asked to code.

Feedback: In order to be able to apply the correct anesthesia billing modifier, it is necessary to first identify the provider of service (M.D. or CRNA), level of service provided, and whose services the coder is being asked to code.

3. Which anesthesia-specific modifier identifies that the service was performed by the CRNA with no medical direction or supervision?

Ans: QZ Feedback: Use of modifier QZ identifies that the service was performed by the CRNA with no medical direction or supervision.

Exercise 6.4 1. Define intubation.

Ans: Intubation is the placement of a flexible tube into the trachea to maintain an open airway or allow for ventilation of the lungs during anesthesia.

2. Define extubation.

Ans: Extubation is the removal of a flexible tube previously placed in the trachea for airway management.

3. List the requirements of medical direction.

Ans:

 Complete pre-anesthetic examination and evaluation.  Set the anesthesia plan.  Attend to patients during the most demanding procedures of the anesthesia plan.

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74  Ensure any procedures that are not personally performed are performed by individuals qualified to do so.  Monitor the course of anesthesia in frequent intervals.  Remain physically present and available for emergencies.  Provide indicated postoperative care.

Exercise 6.5 1. The only two types of anesthesia sedation services reported with an Anesthesia section code (CPT codes beginning with 0) are general anesthesia and monitored anesthesia care. What is the key to understanding when to report general anesthesia and when to report MAC? Ans: Knowing whether or not the patient’s airway was managed during the anesthesia service Feedback: If the airway was managed by the anesthesiologist, the service is reported as general anesthesia.

2. The documentation of the anesthesia service states that the patient managed his airway on his own, and there was no documentation indicating that the patient’s airway was managed. Which type of anesthesia care is this an example of?

Ans: MAC - Monitored anesthesia care Feedback: When the documentation of the anesthesia service states that the patient managed his airway on his own or when no information is documented indicating that the patient’s airway was managed, the anesthesia was monitored anesthesia care.

3. List some of the methods of airway management.

Ans: Endotracheal, through existing tracheostomy, or via a mask or nasal cannula.

Feedback: Methods of airway management include endotracheal, through existing tracheostomy, or via a mask or nasal cannula.

Exercise 6.6 1. List services that are considered part of the work of the anesthesia service and as such are not coded separately.

Ans:

   

Preoperative and postoperative visit General or regional anesthesia and patient care Administration of fluids and/or blood Usual monitoring services (e.g., ECG, temperature, blood pressure, oximetry, capnography, and mass spectrometry) Feedback: There are several procedures or services that might be performed and documented by the provider of anesthesia services that, although they may have a distinct CPT code to identify them, are considered part of the work of the anesthesia service and as such are not coded separately. (These include the list above.)

2. Several procedures or services that are often provided and documented by the anesthesia provider are not considered part of the anesthesia service and thus should be billed and coded in addition to the anesthesia service when documented. List these services.

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75 Ans:

   

Insertion of central venous catheter (36555-36558, 36568-36569) Insertion of an intra-arterial catheter (36620-36625) Insertion of Swan-Ganz (93503) Transesophageal echocardiography (TEE) (93312-93318)

Feedback: Several procedures or services often provided and documented by the anesthesia provider are not considered part of the anesthesia service. They should be billed and coded in addition to the anesthesia service when documented.

Chapter Six Review Using Terminology 1. L

Airway management

9. I

MAC

2. C

Anesthesia

10. G

Medical direction

3. B

Base unit

11. M Moderate/conscious sedation

4. F

CRNA

12. K

PACU

5. J

Emergency condition

13. E

Physical-status modifiers

6. A

Extubation

14. H

Qualifying-circumstance modifiers

7. N

General anesthesia

15. D

Time

8. O

Intubation

Checking Your Understanding 1. As it applies to anesthesia services, which of the following terms describes physician involvement with and direction of anesthesia that is carried out by a qualified physician?

Ans: C. Medical direction Feedback: Medical direction is the physician involvement with and direction of anesthesia that is carried out by a qualified provider.

2. The correct modifier to report for monitored anesthesia care (MAC) for a patient who has a history of severe cardiopulmonary condition is: Ans: D. G9 Feedback: G9 identifies MAC for a patient who has a history of a severe cardiopulmonary condition.

G8 identifies MAC for a deep complex, complicated, or markedly invasive surgical procedure.

QS identifies a MAC service.

QZ identifies that the service was performed by the CRNA with no medical direction or supervision.

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76 3. A 72-year-old normal, healthy patient presents to the operating room for a corneal transplant.

The anesthesiologist administers general anesthesia. Choose the appropriate codes the anesthesiologist would report: Ans: C. 00144, P1, 99100 Feedback: 00144—Anesthesia for procedures on eye: corneal transplant; P1—normal healthy patient; and 99100— qualifying circumstance modifier for age older than 70.

00140, P3, 99100 is incorrect since it is specified as a corneal transplant, and P3 is for a patient with severe systemic disease.

65710, 00144, P1, 99100 is incorrect because it includes 65710, which is the code the surgeon would report.

00144, P1 is incorrect since it does not include the qualifying circumstance modifier.

4. An 8-month-old boy was transported to the ED after being involved in an automobile accident.

He required emergency surgery for an injury to the larynx and trachea. The general anesthesia was administered by the anesthesiologist. Choose the appropriate codes: Ans: A. 00326, P1, 99140 Feedback: 00326—Anesthesia for all procedures on the larynx and trachea in children younger than 1 year of age; P1—normal healthy patient; 99140—qualifying circumstance modifier to show this was an emergency condition 00350, P1, 99140 is incorrect since code 00350 is for anesthesia for procedures of major vessels.

00326, P1, 99100, 99140 is incorrect since 00326 has an instructional note directing the coder to not use 99100 with this code since the code description includes ―children younger than 1 year of age.‖ 00326 is incorrect since it does not include the appropriate physical status and qualifying circumstance modifiers.

5. Choose the appropriate description of when time begins and ends for anesthesia procedures: Ans: B. Time begins when the anesthesiologist begins to prepare the patient for the induction of anesthesia, and it ends when the anesthesiologist is no longer in personal attendance.

Feedback: This total time is then converted into units (typically 15 minutes equals 1 unit per ASA recommendation) and added to the base units allotted for the surgical procedure.

Applying Your Knowledge Case 1 The patient presents for anesthesia for open appendectomy needed for acute appendicitis (Base Units 6).

The patient is 19 and otherwise in good health. Under medical direction of Dr. Thames, the anesthesiologist, the CRNA begins to prepare the patient for induction of endotracheal anesthesia at 7:45 a.m. The procedure is performed without incident, and patient is released to PACU at 9:05 a.m.

Answer the following questions.

CPT Coding for Anesthesia Services Only

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77 1. What type of sedation is provided for this service?

Ans: Endotracheal, general 2. What is the main term for this service?

Ans: Anesthesia 3. What is the surgical procedure and/or anatomic site of the procedure (subterm)?

Ans: Abdomen, intraperitoneal 4. What is the correct CPT code for this anesthesia service?

Ans: B. 00840 ICD-10-CM Coding 1. What is the main diagnostic term for this patient’s condition?

Ans: Appendicitis 2. What subterm(s) is(are) indicated in the documentation that would further specify the ICD-10CM code? What other question(s) might you ask to specify the code even further?

Ans: The subterm is acute. The coder should consider if there are any complications such as peritonitis or rupture. If so, the coder will need to know if the peritonitis is localized or general, chronic or recurrent.

3. Are any additional signs, symptoms, or conditions needed to complete this diagnosis?

Ans: No Feedback: Appendicitis is the confirmed diagnosis, and the signs and symptoms would be inherent to the condition.

4. What is the correct ICD-10-CM code for this anesthesia service?

Ans: A. K35.80 Feedback: The ICD-10-CM code would be K35.80 unspecified acute appendicitis since the documentation did not specify with generalized or localized peritonitis.

Modifiers 1. What level of provider performed the service?

Ans: CRNA 2. Under what level of service did the provider perform?

Ans: Medical direction 3. What is the correct modifier to identify the provider and level of supervision for this service?

Ans: QX

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78 4. What is the physical status of this patient?

Ans: Normal healthy patient 5. What is the correct physical-status modifier for this service?

Ans: P1 6. Where there any unusual circumstances for this patient or procedure?

Ans: No 7. What is the qualifying-circumstance modifier for this service?

Ans: There is none.

Units of Service 1. What is the number of base units assigned to this service?

Ans: 6 2. Using the ASA standard of 15 minutes per unit, how many time units are assigned?

Ans: 5 3. What is the total number of units listed on the claim for this anesthesia service?

Ans: 11

Case 2 Following Dr. Thames’ anesthesiologist prescribed plan for a patient with type 2 diabetes mellitus not well controlled, the CRNA intubates the patient at 8:58 a.m. The surgeon performs an excision of a benign tumor on the olecranon process (Base Units 4). At 10:18 a.m. the patient is extubated and sent to the PACU. CPT Coding for Anesthesia Services Only 1. What type of sedation is provided for this service?

Ans: Endotracheal, general 2. What is the main term for this service?

Ans: Anesthesia 3. What is the surgical procedure and/or anatomical site of the procedure (subterm)?

Ans: Elbow 4. What is the correct CPT code for this anesthesia service?

Ans: C. 01740 ICD-10-CM coding

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79 1. What is the main diagnostic term for this patient’s condition?

Ans: Tumor 2. What subterm(s) is(are) indicated in the documentation that would further specify the ICD-10CM code? What other question(s) might you ask to specify the code even further?

Ans: Benign, location (olecranon process); for ICD-10-CM, you will need to know laterality (left or right) 3. Are any additional signs, symptoms, or conditions needed to complete this diagnosis?

Ans: Yes, type II diabetes mellitus, not well controlled. This is a chronic condition that will affect the treatment and management of this patient.

4. What are the correct ICD-10-CM codes for this anesthesia service?

Ans: D D16.02; E11.65 Feedback: ICD-10-CM codes D16.02 shows specificity of left upper limb; E11.65, type 2 diabetes with hyperglycemia. ICD-10-CM index under diabetes, type 2, uncontrolled refers the coder to diabetes with hyperglycemia.

Modifiers 1. What level of provider performed the service?

Ans: CRNA 2. Under what level of service did the provider perform?

Ans: Medical direction 3. What is the correct modifier to identify the provider and level of supervision for this service?

Ans: QX 4. What is the physical status of this patient?

Ans: Severe systemic disease 5. What is the correct physical-status modifier for this service?

Ans: P3 6. Were there any unusual circumstances for this patient or procedure?

Ans: No 7. What is the qualifying-circumstance modifier for this service?

Ans: There is none.

Units of Service

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80 1. What is the number of base units assigned to this service?

Ans: 4 2. Using the ASA standard of 15 minutes per unit, how many time units are assigned?

Ans: 5 3. What is the total number of units listed on the claim for this anesthesia service?

Ans: 9

Case 3 Using the information from Cases 1 and 2 above, provide the coding information needed to bill for Dr. Thames’ services.

For Case 1: CPT Ans: 00840 ICD-10-CM Ans: K35.80 Provider-of-service modifier Ans: QK Feedback: Refer back to the note at the beginning of the case studies: All anesthesia services in the following cases are performed on the same day by Thames Anesthesiology Group, which provides services at General Medical Hospital.

Physical-status modifier Ans: P1 Qualifying-circumstances modifier Ans: None Total number of units Ans: 11 For Case 2: CPT Ans: 01740 ICD-10-CM

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81 Ans: D16.02; E11.65 Provider-of-service modifier Ans: QK Feedback: Refer back to the note at the beginning of the case studies: All anesthesia services in the following cases are performed on the same day by Thames Anesthesiology Group, which provides services at General Medical Hospital.

Physical-status modifier Ans: P3 Qualifying-circumstances modifier Ans: None Total number of units Ans: Nine

Case 4 Arthroplasty right hip DJD of right hip After satisfactory anesthesia by Dr. Thames, the surgeon completed the arthroplasty of the right hip of this 72-year-old male. Patient comorbidities include well-controlled type 2 DM and benign hypertension.

Both the head of the femur at the greater trochanter and the acetabulum were replaced during this procedure (Base Units 8). Induction of the patient began at 11:02 a.m., and the patient was extubated and sent to postanesthesia recovery at 1:48 p.m.

CPT Coding for Anesthesia Services Only 1. What type of sedation is provided for this service?

Ans: Endotracheal, general 2. What is the main term for this service?

Ans: Anesthesia 3. What is the surgical procedure and/or anatomical site of the procedure (subterm)?

Ans: Arthroplasty, Hip 4. What is (are) the correct CPT code(s) for this anesthesia service?

Ans: B. 01214 ICD-10-CM Coding 1. What is the main diagnostic term for this patient’s condition?

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82 Ans: Degenerative Feedback: Index then tells the coder to see osteoarthritis.

2. What subterm(s) is (are) indicated in the documentation which would further specify the ICD10-CM code? What other question(s) might you ask to even further specify the code?

Ans: Joint, hip. Is it documented as unilateral (laterality) or bilateral, primary or secondary, resulting from hip dysplasia or post-traumatic?

Feedback: (For ICD-10-CM code selection, the coder will need to know if this is a post-traumatic condition, primary, secondary, results from dysphasia, and laterality.)

3. Are any additional signs, symptoms, or conditions needed to complete this diagnosis?

Ans: Yes, type II diabetes mellitus, controlled and benign hypertension Feedback: These are chronic conditions that will affect the treatment and management of this patient.

4. What is (are) the correct ICD-10-CM code(s) for this anesthesia service?

Ans: C. M16.11; E11.9; I10 Modifiers 1. What level of provider performed the service?

Ans: Anesthesiologist 2. Under what level of service did the provider perform?

Ans: No direction needed 3. What is the correct modifier to identify the provider and level of supervision for this service?

Ans: AA 4. What is the physical status of this patient?

Ans: Mild systemic disease 5. What is the correct physical-status modifier for this service?

Ans: P2 6. Were there any unusual circumstances for this patient or procedure?

Ans: Yes, extreme age 7. What is the qualifying-circumstance modifier for this service?

Ans: 99100 Units of Service 1. What is the number of base units assigned to this service?

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83 Ans: 8 2. Using the ASA standard of 15 minutes per unit, how many time units are assigned?

Ans: 11 3. What is the total number of units listed on the claim for this anesthesia service?

Ans: 19

Case 5 A 6-year-old boy presents to the OR for closed reduction of a distal ulnar fracture at 3:45. Dr. Thames monitors the patient’s vital signs and respirations while on room air. The total time of the procedure is 48 minutes. (Base Units 3) CPT Coding for Anesthesia Services Only 1. What type of sedation is provided for this service?

Ans: Monitored Anesthesia Care or MAC 2. What is the main term for this service?

Ans: Anesthesia 3. What is the surgical procedure and/or anatomical site of the procedure (subterm)?

Ans: Arm, lower 4. What is the correct CPT code for this anesthesia service?

Ans: A. 01820 ICD-10-CM Coding 1. What is the main diagnostic term for this patient’s condition?

Ans: Fracture 2. What subterm(s) is (are) indicated in the documentation which would further specify the ICD10-CM code?

Ans: Subterms are ulna, distal, closed. Laterality should be considered; for ICD-10-CM, you will need to know left or right.

3. Are any additional signs, symptoms, or conditions needed to complete this diagnosis?

Ans: No 4. What is the correct ICD-10-CM code for this anesthesia service?

Ans: B. S52.241A Modifiers

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84 1. What level of provider performed the service?

Ans: Anesthesiologist 2. Under what level of service did the provider perform?

Ans: No medical direction 3. What is the correct modifier to identify the provider and level of supervision for this service?

Ans: QS 4. What is the physical status of this patient?

Ans: Normal healthy 5. What is the correct physical-status modifier for this service?

Ans: P1 6. Were there any unusual circumstances for this patient or procedure?

Ans: No 7. What is the qualifying-circumstance modifier for this service?

Ans: There is none.

Units of Service 1. What is the number of base units assigned to this service?

Ans: 3 2. Using the ASA standard of 15 minutes per unit, how many time units are assigned?

Ans: 3 3. What is the total number of units listed on the claim for this anesthesia service?

Ans: 6

Chapter 7 – Surgery Section LESSON PLANS Class Preparation: Teaching Focus and Resources Chapter 7 discusses the format and general guidelines of the surgery section as well as terms and modifiers commonly used with this section of CPT.

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85 Additionally, examinees will be introduced to methods of breaking down each piece of the operative report through a series of questions which will assist the coder in targeting in on main terms for each of the coding systems; CPT and modifiers, ICD, and HCPCs. Learning Outcomes After completing Chapter 7, students will be able to: LO 7.1 Recognize and understand the general guidelines and format of the Surgery section of the CPT manual.

LO 7.2. Define global surgical package.

LO 7.3 Identify the modifiers most commonly used with codes in the Surgery section.

LO 7.4 Examine the common medical and procedural terms used in operative reports.

LO 7.5 Practice using the index to locate codes for surgical procedures.

Class Presentation LO 7.1: Recognize and understand the general guidelines and format of the Surgery section of the CPT manual.

Slides 7-1 through 7-4



Chapter introduction and key terms

Slide 7-5



CPT surgery section guidelines and format

Slide 7-6



CPT surgery section guidelines and format – continued - Surgery section subsections and code ranges

Slide 7-7



CPT surgery section guidelines and format – continued - Separate procedures

Slide 7-8



CPT surgery section guidelines and format – continued - Category I - Category III - Unlisted procedure codes

Slide 7-9



CPT surgery section guidelines and format – continued - Approaches

Slide 7-10



CPT surgery section guidelines and format – continued - Approaches – continued (table 7.2) Open Closed Percutaneous

Slide 7-11



CPT surgery section guidelines and format – continued

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86 

Slide 7-12

Surgical verses diagnostic scope procedures

CPT surgery section guidelines and format – continued - Scope verses open procedures

LO 7.2. Define global surgical package.

Slide 7-13



The global surgical period and global surgical package - Postoperative periods

Slide 7-14



The global surgical period and global surgical package– continued - Bundled services

Slide 7-15



The global surgical period and global surgical package– continued - Bundled services - continued

LO 7.3 Identify the modifiers most commonly used with codes in the Surgery section.

Slide 7-16



Common surgery section modifiers

Slide 7-17



Common surgery section modifiers – continued - modifier examples

LO 7.4 Examine the common medical and procedural terms used in operative reports.

Slide 7-18



Medical and procedural terms used in operative reports

LO 7.5 Practice using the index to locate codes for surgical procedures.

Slide 7-19



Indexing surgical procedures - Introduction to targeting main terms

Slide 7-20



Indexing surgical procedures - continued - Targeting steps

Slide 7-21



Indexing surgical procedures – continued - Process 1 – Procedure coding

Slide 7-22



Slide 7-23



Slide 7-24



Indexing surgical procedures – continued - Process 2 – Diagnosis coding Indexing surgical procedures – continued - Process 2 – Diagnosis coding continutProcess 3 – Modifiers Indexing surgical procedures – continued - Process 3 – Add modifiers

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87 Summary Slides Slides 7-25 through 7-28



Synopsis of chapter

Teaching Tips LO 7.1:  Using the CPT manual as a reference tool, review the following concepts and processes. o The guidelines at the beginning of the Surgery section as well as the beginning of each subsection provide the framework for the use of the codes located in this section. o The Surgery section is divided into six subsections that are based on organ systems or body areas. o Codes designated as separate procedures are procedures that, when performed with another procedure at the same anatomical site at the same time, are bundled into the other procedure and not coded and reported separately. CPT provides two means of coding for services or procedures when this occurs: category III codes and unlisted codes.

Coding Tips and Guidelines o When deciding on a code, be sure to look at the bottom of each CPT page for the tips that appear there relating to the codes above. o When available, category III codes must be used instead of an unlisted code because category III codes provide more information regarding the service or procedure performed than do the unlisted codes. Unlisted procedure codes are considered the codes of last resort and are used only when the service or procedure provided is not identified by a distinct CPT or category III code. o With only a few exceptions, unlisted service or procedure codes end in 99. A complete list for each section of the CPT is located in the section guidelines. Category III codes are five-character alphanumeric codes that always end in a ―T,‖ which indicates emerging technology. o In reporting a diagnostic scope with an open procedure, a modifier is needed to explain the change. Append modifier 59, distinct procedural service, to the diagnostic scope procedure to identify it as a separate procedure performed during the same operative session.

LO 7.2:  This package specifies what services are bundled with, or a part of, the surgical service. While these services, when not provided during the surgical period, may be coded and reported separately, they are not reportable with the surgical procedure. These services include: • The anesthesia needed to perform the procedure, such as topical, local, and digital blocks. Forms of anesthesia not included are general, MAC, and moderate sedation when not indicated as included in the procedure.

• Postoperative care including documenting operative notes, writing orders, and providing typical follow-up care. Not included in postoperative care are complications related to the surgery (e.g., infection, post-op bleeding) that require a return to the operating room (OR). (See modifiers 76, 77, and 78 in Section 7.3.) Also not included in the postoperative package are E/M or surgical services for a condition unrelated to the surgery. (See modifier 79 in Section 7.3.)

• History and physical exam on the day of or day prior to the procedure. However, the E/M service on which the need for surgery was determined, regardless of the date on which it was completed, is not included in the global package.

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88

Coding Tips and Guidelines o The global surgical period for major surgical procedures includes the day prior to surgery. Thus, if the E/M service that resulted in the decision for surgery was completed the day before or the day of surgery, it must be identified to the payer by appending modifier 57 to the E/M code.

LO 7.3:  Modifiers relay information such as laterality, services provided that significantly increase or decrease the code description, multiple procedures, discontinued procedures, staged procedures, and reasons for additional services provided during the global surgical period.

Coding Tips and Guidelines o If the code describes a bilateral procedure and the procedure is completed unilaterally, append modifier 52 as well as the correct site modifier (RT or LT). o Before appending modifier 50, verify that a bilateral code is not available for the procedure performed.

LO 7.4:  Biopsy: removal of all or part of a lesion for pathologic examination  Destruction: destroying of tissue by means of heat, cold, or chemicals. (Note: There is no tissue to send for pathology.)  Excision: removal by cutting all or part (suffix: -ectomy)  Harvest: removal of a donor organ, tissue, or bone for implantation to another anatomical site or patient (e.g., harvesting of a vein or artery for CABG)  Incision: creation of an opening by surgically cutting into the skin or other tissue (suffix: -otomy)  Repair: restoration of diseased or damaged tissue, organ, bone, etc.

Coding Tips and Guidelines o A clear understanding of medical terminology, pathophysiology, and anatomy pertaining to the body system affected by the present encounter is critical to accurate coding within the Surgery section.

LO 7.5:  The language and format of surgical documentation may vary, but the information needed to code the case is still contained within the document.  This information is the primary procedure and the condition for which the procedure was performed, as well as any additional services or conditions that were provided and documented during the operative session.

Coding Tips and Guidelines o Keep a medical dictionary handy when coding, as many terms used in the documentation of surgical cases may be new and easily misunderstood. o Although the primary procedure is typically documented in the header of the operative report, it is imperative that the coder briefly review the documentation to make sure the procedure listed was actually performed. o Many coders find it helpful to highlight or circle the answer to each question used in targeting before coding the report. Care should be taken not to highlight the entire report, as this makes it impossible to pick out the target information. To avoid the

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89

o

o

o

coloring-book effect, highlight only after all necessary questions have been developed.

Post-op diagnoses often differ from pre-op findings as more definitive information regarding the patient’s condition can be determined once the surgeon has direct visualization of the condition, organ, or site. For this reason, many coders begin the diagnosis coding process with the post-op diagnosis.

The ICD can be helpful when translating documented diagnostic information or terms unfamiliar to you. For example, in Case Study 7.1 the coder notes that the post-op diagnosis is DJD; however, the body of the document states severe osteoarthritis. By locating and reviewing the main term for DJD (degenerative joint disease) in the ICD manual, the coder finds the instruction ―see also Osteoarthrosis‖ and it list the same ICD-10-CM code as it did for DJD, making these two terms synonymous.

As you read through the op report, circle or highlight any additional conditions; these conditions are considered working diagnoses. Many of the working diagnoses will become nonessential once you have applied the ICD-10-CM coding guidelines regarding additional diagnosis codes.

Chapter 7 Answer Key Exercise 7.1 1. Explain the format of the Surgery section.

Ans: The surgery section is broken into six subsections which are based on organ systems or body areas: e.g., integumentary, musculoskeletal.

Feedback: The Surgery section guidelines contain information and rules that pertain only to the Surgery section, and, as with all other sections, knowing these guidelines and how to use them is one of the keys to correct coding in the Surgery section.

2. List some of the approach methods described in the Surgery section.

Ans: Endoscopic, open, closed, percutaneous Feedback: Some of the approach methods described in the Surgery section are endoscopic, open, closed, and percutaneous.

3. Explain a laparoscopic procedure.

Ans: A scope is inserted into the abdominal cavity via an incision in the abdominal wall.

Feedback: Procedures or inspection of the outside of the organs contained within the abdominal cavity such as colon, intestines, ovaries, fallopian tubes, and uterus may be completed via this approach.

4. Explain the guideline regarding diagnostic and surgical scope procedures performed at the same operative session.

Ans: CPT clarifies that when this occurs, only the surgical scope procedure is reportable. As a diagnostic scope procedure is part of all surgical scope procedures, it is bundled into the surgical scope procedure when performed on the same anatomic site during the same operative session.

Feedback: One guideline that applies throughout the Surgery section pertains to surgical and diagnostic scope procedures that are performed at the same operative session and same anatomical site. CPT clarifies that when this occurs, only the surgical scope procedure is reportable. Since a diagnostic scope procedure

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90 is part of all surgical scope procedures, it is bundled into the surgical scope procedure when performed on the same anatomical site during the same operative session.

Exercise 7.2 1. Explain the use of modifier 57 in regard to the global surgical package.

Ans: As the global surgical period for major surgical procedures includes the day prior to surgery, the E/M service which resulted in the decision for surgery completed the day before or the day of surgery must be identified to the payer by appending the modifier -57 to the E/M code.

2. List some services that are included in the global surgical package and not reported separately.

Ans: Preoperative care, the procedure, postoperative care, and anesthesia needed to perform the procedure, such as topical, local, and digital blocks Feedback: Services included in the global surgical package which are not reported separately per CPT guidelines include preoperative care, the procedure itself, postoperative care, and anesthesia needed to perform the procedure, such as topical, local, and digital blocks.

3. How many postoperative days are typically allocated for minor and major procedures?

Ans: Minor procedure: 10 days Major procedure: 90 days Feedback: Minor procedures typically have a 0- to 10-day post-op period, and major procedures typically have post-op periods of 90 days or more. Additionally, major procedures have a 1 day pre-op included in the surgery days.

Exercise 7.3 1. What questions must a coder answer when determining whether the procedure was performed as described by the nomenclature of the code or requires a modifier to define the variance from the description?

Ans: Was the procedure more difficult or time consuming or did it require extra work on the part of the surgeon such as unusual anatomy? If yes, append modifier 22.

Was the procedure performed less than the procedure described by the code? If yes, verify that the code is correct, and if so, append modifier 52.

Was the procedure discontinued after anesthesia but prior to completion? If yes, append modifier 53.

2. What questions must a coder answer when determining whether the procedure was performed in the global period of another procedure and requires a modifier to report why this procedure should be reported separately?

Ans: Was the procedure the same (same CPT code) as the previous procedure? If yes, consider the following questions: • Was the procedure performed by the same surgeon? If yes, append modifier 76.

• Was the procedure performed by a different surgeon? If yes, append modifier 77.

• Was the procedure performed as the result of a complication of the previous procedure? If yes, append modifier 78. If not, append modifier 79.

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91 • Was the procedure planned or expected, or more extensive than the original procedure? If yes, append modifier 58.

3. What questions must a coder answer from the documentation to determine the appropriate use of modifier 62, 80, or 81?

Ans: Did the surgeon have help from another surgeon or other appropriate person?

Did each surgeon perform integral parts of the same procedure (i.e. approach and definitive procedure)? If yes, append modifier 62.

Did the assist at surgery remain and assist during the entire procedure? If yes, append modifier 80.

Did the assist at surgery attend and assist for only a portion of the procedure? If yes, append modifier 81.

Exercise 7.4 1. Explain the difference between the suffixes -ectomy, -otomy, and -ostomy.

Ans: -ectomy = surgical removal by cutting -otomy = cutting into or incising -ostomy = surgically creating an artificial opening Feedback: The suffixes -ectomy, -otomy, and –ostomy are different. -ectomy is defined as surgical removal by cutting. -otomy is defined as cutting into or incising. -ostomy is defined as surgically creating an artificial opening.

2. CPT code 69300, which involves surgical repair of protruding ears, can be indexed in the CPT manual by adding which suffix to the word root oto?

Ans: -plasty, which forms the word otoplasty, meaning surgical repair or revision of the ear Feedback: Oto, meaning ear, and plasty, meaning reshaping or replacing by surgical means, combine to form otoplasty, meaning surgical repair or revision of the ear.

3. Identify another way that ‖harvesting‖ of a vein or artery for CABG could be dictated in an operative report.

Ans: ―Harvesting‖ could also be dictated as ―procurement‖ of vein or artery for CABG. Feedback: Another way ―harvesting‖ of a vein or artery for CABG could be dictated in an operative report would be ―procurement‖ of a vein or artery for CABG. Exercise 7.5a CPT Coding 1. How much of the hip was replaced?

Ans: Total hip replacement Feedback: The hip has two components, the femoral head and the acetabulum or hip socket. From the note, we can identify replacement of both of these components, confirming a total hip replacement: ―the acetabular component was done…‖ and ― head component was tapped onto the femoral stem.‖ 2. Was this a revision of a previous arthroplasty?

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92 Ans: No Feedback: Review of the documentation reveals no previous arthroplasty at this site. If this had been a revision, the documentation would have included removal of the previous prosthesis.

3. If this was a partial replacement or partial revision, what portion was replaced?

Ans: This is not relevant as it has been established that this was a total initial replacement of the left hip.

4. Based upon the answers found in the documentation for this case, identify the correct CPT code for this case.

Ans: 27130 5. Based on your review of the documentation, were any other procedures performed that should be coded in addition to the primary procedure?

Ans: If yes, follow steps 1 through 5 for each additional procedure.

Exercise 7.5b ICD-10 Coding 1. Based on the operative report header, what is the preoperative diagnosis?

Ans: Degenerative joint disease 2. Is the postoperative diagnosis the same as or different from the preoperative diagnosis? If the post-op diagnosis is different, review the documentation and verify that the post-op diagnosis is supported by the documentation Ans: In Case 7.1, the post-op diagnosis was the same as the pre-op diagnosis: degenerative joint disease.

3. Review the documentation, and determine whether the post-op diagnosis is supported in the body of the report. Was the post-op diagnosis supported?

Ans: Yes. The documentation states, ―severe osteoarthritis was noted‖.

4. Locate the main term in the alphabetic index and following the direction of see osteoarthritis, develop the next question or set of questions for reviewing the documentation on the basis of the subterms listed below the main term.

What was the anatomical site for the condition?

Ans: Hip (a.k.a. pelvic region and thigh) Was the condition primary, secondary, or post-traumatic?

Ans: Not documented Was the condition unilateral or bilateral?

Ans: Unilateral 5. Locate the code in the Tabular List and determine whether additional questions are needed to further specify the diagnosis. Based on the information in the Tabular List, is additional information needed to determine the appropriate diagnosis code?

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93 Ans: No 6. Based on the answers from the documentation, what is the primary ICD-10-CM code for the procedure in Case 8.1?

Ans: M16.9 7. Determine whether additional conditions are documented and should or should not be coded by comparing each working diagnosis to the questions below, which are based on the ICD-10-CM coding guidelines: Is the condition, sign, or symptom an integral part of the primary (or other) condition coded?

Ans: No, neither are.

Does the condition require or affect patient care treatment or management?

Ans: Diabetes Mellitus – Yes, as this condition will need to be monitored during the healing as well as impacts the patient’s ability to heal and increases the risk of infection as well as healing time.

Feedback: This condition should be coded: E11.9 Hyperlipidemia – No, the presence of this condition does not affect management of this patient for this procedure.

Exercise 7.5 c Modifiers 1. Was the procedure performed different from that described by the nomenclature of the code?

Ans: No 2. Was the procedure performed on an anatomical site that has laterality?

Answer: Yes, left side 3. Was the procedure performed in the global period of another procedure?

Ans: No 4. Were additional procedures performed during the operative session, and does the documentation support them?

Ans: No 5. Did the surgeon have help from another surgeon or another appropriate person?

Ans: No

6. Did a physician different from the surgeon provide the preoperative or postoperative part of the procedure?

Ans: No

Chapter Seven Review

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94

Using Terminology 1. C

Approach

9. M

Laparoscopy

2. A

Biopsy

10. O

Open procedure

3. E

Closed procedures

11. P

Percutaneous

4. I

Destruction

12. J

Repair

5. K

Endoscopy

13. D

Separate procedures

6. B

Excision

14. N

-oscopy

7. H

Global surgical package

15. L

-ostomy

8. F

Incision

16. G

-plasty

Checking Your Understanding 1. The Surgery section of CPT is divided into __________subsections based on _______________.

Ans: B. six; organ systems or body areas Feedback: The Surgery section of CPT is divided into six subsections based on organ systems or body areas.

2. When a provider documents a service or procedure for which there is no specific HCPCS Level I code, the following (if a code exists) should be used first to report the service or procedure: Ans: A. A category III code Feedback: When available, category III codes must be used instead of an unlisted code as category III codes provide more information regarding the service or procedure performed than unlisted codes. unlisted procedures codes are considered the code of last resort and are used when the service or procedure provided is not identified by a distinct CPT or category III code.

3. Which of the following modifiers would be appropriate to use if each surgeon performed integral parts of the same procedure?

Ans: C. 62 Feedback: Each surgeon performed integral parts of the same procedure (i.e. approach and definitive procedure).

Modifier 80: The surgeon assisted at the surgery and remained and assisted during the entire procedure.

Modifier 81: The surgeon assisted at surgery and attended and assisted for only a portion of the procedure.

4. CPT coding for breast procedures is categorized in which section of the CPT manual?

Ans: B. Integumentary

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95 Feedback: When a breast procedure such as a mastectomy or lumpectomy is located in the CPT manual index, the coder is referenced to the Integumentary section of the CPT manual.

5. The process of using a scope inserted through a natural opening or stoma to examine the inside of an organ or system (e.g., respiratory or gastrointestinal) is referred to as: Ans: B. endoscopy Feedback: The process of using a scope inserted through a natural opening or stoma to examine the inside of an organ or system (e.g., respiratory or gastrointestinal) is referred to as endoscopy.

Applying Your Knowledge Process 1: Procedural Coding (CPT) 1. What is the primary procedure?

Ans: Surgical arthroscopy Feedback: The initial intent of the procedure was diagnostic to look for a tear. Once the tear was found and repaired the procedure became a surgical arthroscopy. The coder needs to know that when a procedure starts out as a diagnostic procedure and then becomes a surgical procedure only the surgical procedure is reported.

2. Locate the main term in the index. What additional questions or set of questions can be determined based upon any terms or subterms as listed under the main term?

Ans: Diagnostic or Surgical are the main terms in the index. Additional questions or sets of questions can be determined based upon the terms or subterms under the main term, such as ―anatomic site‖ and ―type of procedure.‖ 3. Upon review of the all code choices identified in the index, what additional questions can be determined?

Ans: Were autografts or transplantations completed? Was there infection present? Lateral release, foreign bodies, synovectomy, shaving or debridement, arthroplasty, or meniscectomy? And which compartments?

4. Based on the documentation, what is (are) the correct code(s) for this case?

Ans: B. 29881 Process 2: Diagnostic Coding ICD-10-CM Coding 1. Based on the operative report header, what is the preoperative diagnosis?

Ans: Possible torn medial meniscus 2. Is the postoperative diagnosis the same as or different from the preoperative diagnosis?

Ans: Same , Post operative diagnosis identifies a bucket-handle tear of medial meniscus. The post operative diagnosis confirms the tear as well as giving more specificity to the diagnosis.3. Is the post-op diagnosis supported?

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96 Ans: Yes Feedback: Documentation states, ― A bucket-handle medial meniscus tear was noted‖4. What is the main term for this condition?

Ans: Tear 5. Based on the subterm choices, what question can be developed for this condition?

Ans: Anatomic location, old or current and type of tear, laterality 6. Based on the information in the Tabular List, is additional information needed to determine the appropriate diagnosis code?

Ans: Yes, episode of care 7. Is any sign, symptom, or additional condition documented?

Ans: Yes, minimal erosion of the medial femoral condyle, and medial plateau 8. Is the additional condition, sign, or symptom an integral part of the primary (or other) condition coded?

Ans: No 9. Does the additional condition require or affect patient care, treatment, or management?

Ans: No 10. Based on the documentation, what is the correct ICD-10-CM code for this case?

Ans: C. S83.212A Process 3: Adding Modifiers 1. Was the procedure performed different from that described by the nomenclature of the code?

Ans: No 2. Was the procedure performed on an anatomic site that has laterality?

Ans: Yes, LT 3. Was the procedure performed in the global period of another procedure?

Ans: No 4. Were additional procedures performed during the operative session, and does the documentation support them?

Ans: No

5. Did the surgeon have help from another surgeon or another appropriate person?

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97 Ans: No 6. Did a physician different from the surgeon perform the preoperative or postoperative part of the procedure?

Ans: No 7. Which modifier should be appended to the CPT code for this case?

Ans: B. LT

Unit 2 Exam Answer Key 1. A physician who is part of a medical group practice sees a patient today who has not been treated by the practice for 7 years. The patient presented with a persistent cough and some congestion. The physician performed a medically appropriate history and/or exam The patient is diabetic, which is controlled with diet and medication. The physician ordered lab work and a CXR. The physician prescribed medication for the cough and congestion and gave the patient a new prescription for his diabetic medication. The patient was asked to return in 1 week. Choose the appropriate evaluation and management code for today’s encounter.r Ans: C. 99203 Feedback: The E/M code for the encounter is 99203. The patient is a new patient since he has not been seen by the practice for seven years. A medically appropriate history and/or exam was noted in the documentation but does not enter into the decision of the level reported. The medical decision making component is low based on 1 acute or uncomplicated illness (cough and congestion) amount of data to be reviewed is limited (labs and radiology); and risk of complications is moderate (prescription drug management). Answers 99214 and 99213 should have been eliminated once the patient status was identified as new since the fourth digit ―1‖ identifies an established patient.

2. A patient was admitted into the observation unit of the hospital at 8:00 a.m. after presenting with pain in the lower back. After reviewing the test results of the lab work and discussing the ultrasound results with the radiologist, the physician diagnosed kidney stones. The physician performed a medically appropriate history and/or exam. The physician approved a plan of treatment and discharged the patient at 1:30 p.m. the same day. Choose the appropriate CPT code(s).

Ans: B. 99235 Feedback: The CPT code is 99235. The patient was in the observation area of the hospital and was admitted and discharged on the same day; therefore, the correct code range would be 99234-99236. A medically appropriate history and/or exam was documented. . A moderate decision making is documented by the new problem of kidney stones; amount of data is moderate (labs and radiology, ultrasound ordered and reviewed, and the ultrasound results discussed with the radiologist); and the risk of complication is moderate.

3. A 92-year-old woman is confined to a wheelchair and cannot live by herself. She resides in a residential facility for the elderly. Once every month, the facility has a physician come to the

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98 facility to examine and monitor the health of the residents. The physician makes recommendations to the facility and/or family members as to the course of care to be given to the woman each month in order to maintain her health. At today’s encounter the physician performs a medically appropriate history and exam . The decision making is straightforward. Choose the appropriate CPT code.

Ans: D. 99334 Feedback: The CPT code is 99334. The physician comes to the facility on a regular basis so the patient is not a new patient; therefore, answers 99324 and 99328 do not apply. The patient is established and the physician performs a medically appropriate history and exam. The decision making is straightforward.

4. Choose the appropriate CPT code for a care-plan oversight service performed by a physician for 45 minutes.

Ans: C. 99375 Feedback: The CPT code is 99375. Care Plan Oversight Services codes include time elements of 30 minutes or more. Care Plan Oversight Services are reported separately from codes for office/outpatient, hospital, home, nursing facility, or domiciliary services or non-face-to-face services. When using these codes, the physician is acting in a predominantly supervisory role, or indirect care, during a 30-day period with the patient.

5. Which of the following is a true statement?

Ans: A. Medically appropriate history and/or exam is required but not used when determine the level of E/M service provided.

Feedback: Though necessary, a medically appropriate history and/or exam is not used when determing the level of E/M service. The level of E/M service is determined based on complexity of the MDM or time..

6. Mary was admitted to the hospital with congestive heart failure by her primary care physician, and cardiology was consulted on the day of admission. On the second day, the cardiologist made hospital rounds and stopped by to see Mary. A medically appropriate history and/or exam was performed. Mary is showing some improvement with IV therapy. Select the appropriate code for Mary’s encounter with the cardiologist today.

Ans: A. 99232 Feedback: The CPT code 99232 indicates a subsequent hospital visit and moderate level of medical decision making . 99253 indicates an inpatient consultation. 99213 indicates an office visit. 99233 indicates a subsequent hospital visit requiring a high level of medical decision making 7. Jonathan is a 12-year-old male whose mother took him to his pediatrician for his annual exam.

While examining him, his pediatrician discovered that he had an inguinal hernia and performed a medically appropriate history and exam and straightforward medical decision making. The pediatrician is referring Jonathan to a surgeon for the hernia repair, and Jonathan is to return to his pediatrician in 1 year. Choose the appropriate code(s) for Jonathan’s visit: Ans: C. 99394, 99212-25 Feedback: The CPT codes are 99394 and 99212-25. 99394 indicates an established patient between the ages of 12 and 17 was seen for a preventive service. While there, an abnormality (the hernia), which was significant enough to require additional documentation to support medical decision making of an

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99 office/outpatient E/M service, was encountered. Per the CPT guidelines, modifier 25 should be appended to the office/outpatient code.

8. The patient presented today with swelling and pain in the right knee. The patient suffers from primary osteoarthritis. Following a medically appropriate history and/or exam the physician aspirated the joint followed by an injection of steroid medication. Select the appropriate codes for today’s visit: Ans: B. 99213-25, 20610, M17.11 Feedback: The CPT codes are 99213-25, 20610, and M17.11 The office visit 99213 needs modifier 25 appended to show a separate E/M service was provided on the same day as a procedure.

9. A 19-year-old male was jumping off the roof of his home onto a trampoline. After several successful jumps, he was careless and miss judged the distance on his next jump. He missed the trampoline and landed on the ground, injuring his right foot. The next day the teen was taken to his physician’s office. The physician ordered a three-view x-ray of the right foot. The physician performed a medically appropriate history and/or exam and the medical decision making was of a moderate complexity. After determining the teen has suffered a displaced fracture of a metatarsal bone of thes right foot, the physician refers the teen to an orthopedic surgeon. Select the appropriate code(s) for the family physician: Ans: A. 99214, S92.311A Feedback: The CPT code is 99214 and ICD-10 code is S92.311A. Answers ―99204 and ―99205‖ can be eliminated since they are for new patients and this is an established patient.

10. For which of the E/M service categories is time not a descriptive component?Ans: C. Emergency department E/M services Feedback: Only the MDM components are allowed when determining the complexity of emergency department E/M services.

11. What anesthesia codes would be assigned for harvesting organ(s) from a brain-dead person?

Ans: C. 01990, P6 Feedback: The anesthesia code is 01990. This code is indicated for the harvesting of organ(s) from a brain-dead person along with the physical status modifier P6.

12. Peter Dixon was found to have an esophageal stricture, so he consented to esophageal dilation under general anesthesia to reduce this stricture. Select the appropriate anesthesia code(s): Ans: C. 00500, P1 Feedback: The anesthesia codes are 00500 and P1. In the scenario, there is no mention of an emergency situation so 99140 would not be appropriate, and there is no mention of a severe systemic disease so P4 would not be appropriate.

13. Code the appropriate anesthesia service for Fowler-Stephens orchiopexy. The patient is a normal, healthy, 30-year-old male.

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100 Ans: B. 00930, P1 Feedback: The CPT code for the anesthesia service is 00930, P1.

00926 would be for anesthesia for a radical inguinal orchiectomy.

00924 is for undescended testis.

00928 is for a radical abdominal orchiectomy.

14. P1 and P6 are examples of which of the following?

Ans: C. Anesthesia physical-status modifiers Feedback: P1 and P6 are examples of anesthesia physical-status modifiers.

15. A donor was brought to the operating room and placed under general anesthesia for harvesting of bone marrow. Select the correct code(s) to report the anesthesia services: Ans: D. 01112, P1, Z52.3 Feedback: CPT code 01112 is specific for anesthesia for bone marrow aspiration, and ICD-10-CM code Z52.3 indicates bone marrow donor.

16. The patient is a weight lifter who was training with heavy weights. While doing bicep curls, the patient experienced pain in the left forearm. A hematoma occurred, and he sought immediate medical treatment. He was diagnosed with a ruptured vein in his forearm. General anesthesia was administered in order to suture the vein. Which of the following codes is the appropriate code for reporting this service?

Ans: B. 01852 Feedback: The CPT code is 01852. Under the Anesthesia CPT codes, there is a specific code for anesthesia delivered for procedures on veins of the forearm, wrist, and hand specifically for phleborrhaphy, which is 01852.

17. Which of the following is a type of medication used solely to relieve pain?

Ans: C. Analgesic Feedback: The type of medication used to relieve pain is an analgesic. Corticosteroids are used to relieve inflammation. Muscle relaxants are used to relieve stiffness. NSAIDs are used to reduce inflammation.

18. Which of the following is the type of anesthesia that makes a large portion of body numb?

Ans: D. Regional anesthesia Feedback: Regional anesthesia is administered to make a large portion of the body numb, such as that which occurs in an epidural, which renders the lower half of the body numb during child birth. Local anesthesia only numbs a small portion of the body receiving care. General anesthesia renders the patient unconscious, and moderate sedation involves leaving the patient awake but sedated.

19. Which modifier would be assigned to an anterior packing of both nares for a nose bleed?

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101 Ans: C. Modifier 50 Feedback: There is an instructional note below CPT 30901 (control nasal hemorrhage, anterior) instructing the use of modifier 50 to report bilateral procedure. Modifier 22 is for increased procedural services, modifier 51 indicates multiple procedures, and modifier 59 is for a separate and distinct procedure.

20. An examination of joints using a scope is an: Ans: B. Arthroscopy Feedback: Arthrography is the examination of a joint using radiography, arthroplasty is the surgical repair of a joint, and arthrodesis is the surgical fixation of a joint.

21. CPT codes that contain a set of temporary codes used for emerging technology, services, and procedures can be found in which of the following sections of the CPT manual?

Ans: C. Category III Feedback: Category III codes are found in the CPT manual. Category III codes contain a set of temporary codes used for emerging technology. Category II refers to tracking codes that are used for performance measurement. Appendix B lists a summary of code additions, deletions, and revisions. Appendix D is a summary of CPT add-on codes.

22. Which one of the following procedures is completed without incision and is considered noninvasive in nature?

Answer: D. Closed procedure Feedback: Closed procedure: Completed without incision and is considered noninvasive in nature.

Open procedure: Through an incision in the skin or other membranes the provider has full view of the organs or structures as needed for the procedure, for example, a laparotomy.

Percutaneous procedure: Procedures completed through the skin; however, the surgical site is not opened to view as in a laparotomy.

Endoscopic procedure: An optic instrument (scope) is inserted into the body for visualization within the body cavity or organ. Typically introduced via a natural opening, the scope may also be inserted through an incision.

23. Dr. G was asked to provide a cardiology consultation in the emergency department for a patient who was experiencing atrial fibrillation. Dr. G determined the patient needed to have a dualchamber pacemaker inserted, and he scheduled the patient to have this procedure on the following morning. To correctly code the outpatient consultation visit in the ED, which of the following modifiers needs to be appended?

Ans: B. Modifier 57 Feedback: Since the pacemaker insertion is part of a global surgical package and has a 90-day global period attached, modifier 57, decision for surgery, needs to be appended to the consultation code. This tells the payer this visit was not a routine preoperative visit but the visit where the determination for surgery was made. This visit must be the same day as the surgery or the next day to appropriately use modifier 57.

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102 24. A screening mammogram is performed unilaterally. Choose the appropriate code for this service: Ans: C. 77067-52 Feedback: The description for CPT code 77067 is screening mammography, bilateral. If the code describes a bilateral procedure and the procedure is completed unilaterally, append modifier 52. CPT code 77065 is a unilateral diagnostic mammogram, not a screening.

25. A perineoplasty, nonobstetrical, was performed on a 37-year-old female patient. Which range of CPT codes is appropriate for this procedure?

Ans: D. 56405-58999 Feedback: 56405-58999 Female genitalia: The procedure is nonobstetrical and would not be coded in the maternity care and delivery range of codes (59000-59899).

Chapter 8 – Surgery Section: Integumentary System LESSON PLANS Class Preparation: Teaching Focus and Resources The focus of this chapter is the understanding of the anatomy of the integumentary system, the importance of translating this knowledge from the provider documentation into the coding language, and then applying the coding guidelines in selection of the most appropriate codes.

Learning Outcomes After completing Chapter 8, students will be able to: LO 8.1 Recognize the anatomy of the integumentary system.

LO 8.2 Review ICD-10-CM guidelines for diseases of the skin and subcutaneous tissue.

LO 8.3. Understand the general guidelines and format of the Integumentary System subsection of the CPT Surgery section.

LO 8.4 Apply the CPT subheading guidelines for the Integumentary System subsection.

LO 8.5 Identify the modifiers most commonly used with codes in the Integumentary System subsection.

LO 8.6 Examine the common medical and procedural terms used in operative reports

Class Presentation LO 8.1: Recognize the anatomy of the integumentary system.

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103 Slides 8-1 through 8-4



Chapter introduction and key terms

Slide 8-5



Anatomy of the integumentary system

Slide 8-6



Skin layers - Epidermis

Slide 8-7



Skin layers – continued - Dermis - Subcutaneous

Slide 8-8



Skin layers – continued - Glands

Slide 8-9



Integumentary anatomy – continued - Nails

Slide 8-10



Integumentary anatomy – continued - Parts of the nail

LO 8.2: Review ICD-10-CM guidelines for diseases of the skin and subcutaneous tissue.

Slide 8-11



Guidelines and format for Diseases of the Skin and Subcutaneous Tissue – Introduction - Common conditions of the integumentary system

Slide 8-12



Infections of the skin and subcutaneous tissue - Carbuncles and furuncles - Cellulitis and abscess - Pilonidal cyst

Slide 8-13



Other inflammatory conditions of the skin and subcutaneous tissue - Pemphigus and pemphigoid - Contact dermatitis - urticaria

Slide 8-14



Other diseases of the skin and subcutaneous tissue - nail disorders - corns and callosities - skin tags - Pressure ulcer

LO 8.3: Understand the general guidelines and format of the Integumentary System subsection of the CPT Surgery section.

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104

Slide 8-15 through 8-16



General guidelines and format of the Integumentary subsection of CPT - Integumentary system subsections - Table 8.4

LO 8.4: Apply the CPT subheading guidelines for the Integumentary System subsection.

Slide 8-17



CPT Subheading guidelines for the Integumentary system subsection - Incision and Drainage (10030-10180)

Slide -818



CPT Subheading guidelines for the Integumentary system subsection -cont - Debridement (11000-11047)

Slide 8-19



CPT Subheading guidelines for the Integumentary system subsection -cont - Paring or Cutting (11055-11057)

Slide 8-20



CPT Subheading guidelines for the Integumentary system subsection -cont - Biopsy (11100-11101) change these codes to 11101-11107

Slide 8-21



CPT Subheading guidelines for the Integumentary system subsection -cont - Removal of skin tags (11200-11201)

Slide 8-22



CPT Subheading guidelines for the Integumentary system subsection -cont - Shaving of epidermal or dermal lesions (11300-11313)

Slide 8-23



CPT Subheading guidelines for the Integumentary system subsection -cont - Excision of benign and malignant lesions (11400-11646)

Slide 8-24



CPT Subheading guidelines for the Integumentary system subsection -cont - Excision of benign and malignant lesions (11400-11646)– continued

Slide 8-25



CPT Subheading guidelines for the Integumentary system subsection -cont - Nails (11719-11765) - Pilonidal cyst (11770-11772)

Slide 8-26



CPT Subheading guidelines for the Integumentary system subsection -cont - Repair (closure) (12001-16036)

Slide 8-27



CPT Subheading guidelines for the Integumentary system subsection - cont - Repair (closure) (12001-16036) – continued

Slide 8-28



CPT Subheading guidelines for the Integumentary system subsection - cont - Adjacent tissue transfers and flaps (14000-14350, 15570-15738)

Slide 8-29



CPT Subheading guidelines for the Integumentary system subsection -cont - Adjacent tissue transfers and flaps (14000-14350, 15570-15738) - cont

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105 Slide 8-30



CPT Subheading guidelines for the Integumentary system subsection -cont - Grafts and skin replacement procedures (15002-15278)

Slide 8-31



CPT Subheading guidelines for the Integumentary system subsection -cont - Grafts and skin replacement procedures (15002-15278) – continued

Slide 8-32



CPT Subheading guidelines for the Integumentary system subsection -cont - Burns, local treatment (16000-16036)

Slide 8-33



CPT Subheading guidelines for the Integumentary system subsection -cont - Burns, local treatment (16000-16036) – continued

Slide 8-34



CPT Subheading guidelines for the Integumentary system subsection -cont - Destruction of benign, premalignant, and malignant lesions (1700017999)

Slide 8-35



CPT Subheading guidelines for the Integumentary system subsection -cont - Destruction of benign, premalignant, and malignant lesions (1700017999) - continued

Slide 8-36



CPT Subheading guidelines for the Integumentary system subsection -cont - Breast (19000-19499)

LO 8.5: Identify the modifiers most commonly used with codes in the Integumentary System subsection.

Slide 8-37



Modifiers commonly used with the integumentary system codes - 51 Multiple procedures - 58 Staged or related procedure or service - 59 Distinct procedural service

LO 8.6: Examine the common medical and procedural terms used in operative reports Slide 8-38 through 8-40



Common medical and Procedural terms used in operative report - Table 8.7 and 8.8

Summary Slides Slides 8-39 through 8-43



Synopsis of chapter

Teaching Tips LO 8.1:  The anatomy of the integumentary system includes:

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106 o o o o

Epidermis: the outer layer of the skin, which forms a protective covering for the other layers of the integumentary system.

Dermis: the middle layer of the skin, directly below the epidermis. It is made up of elastin and collagen fibers and contains arteries and veins, which supply nutrients and remove waste.

Subcutaneous: the deepest layer of the integumentary system, located below and attached to the dermis but not extending beyond the fascia, which covers the muscle.

Sweat glands, or sudoriferous glands: glands that produce sweat, which travels to the surface of the body and exits through pores located in the epidermis.

Coding Tips and Guidelines o Many coders find it helpful to refer to the diagrams supplied in the CPT manual to help identify the layers of the skin when coding for integumentary procedures.

LO 8.2:  Some of the more common conditions of the skin and subcutaneous tissue include cellulitis, pilonidal cyst, dermatitis, psoriasis, corns and callosities, dermatoses such as seborrheic keratosis, and pressure ulcers.  When coding these conditions, coders must thoroughly review the provider documentation as well as the guidelines and instructional notes.  ICD-10-CM: Diseases of the Skin and Subcutaneous Tissue is Chapter 12 in the ICD-10-CM manual, with the code range L00–L99.

LO 8.3:  The Integumentary subsection contains the code range 10040–19499. This subsection has several specific guidelines and trouble areas for coders.  Translating inches to centimeters is just one of these trouble areas. Coders must know that 1 inch equals 2.54 centimeters to be able to convert inches to centimeters, as needed for CPT codes.

When calculating square centimeters, as needed for many grafting procedures, coders must know that the equation to do so is length times width, or L x W Coding Tips and Guidelines o Many coders find it helpful to write these two equations in the guidelines of the Integumentary subsection: 1 inch = 2.54 cm and L x W = sq cm.

LO 8.4:  Before selecting the appropriate codes for specific procedures, coders need to find answers in the medical record to questions on the following: • I&D procedures: site, condition, and complexity.

• Excision procedures: pathology, site, size, and type of closure.

• Repairs: type of closure, anatomical site, wound size, and multiple wounds of same anatomical grouping.

• Adjacent tissue transfers and flaps: tissue location, anatomical site of the defect, and total size of the defect.

• Destruction procedures: nature, number, size, and anatomical site of the lesion(s).

Coding Tips and Guidelines

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107 o o o o o o o o

o o o

o o o

o o

o

Providers may not specifically identify an abscess and cyst when documenting. For abscess, look for words like pus, infection, and so on. For cyst, look for words like sac and pouch.

Debridement may also be described as excisional, which involves surgical removal or cutting away of tissue, or nonexcisional, which involves nonsurgical brushing, irrigating, scrubbing, or washing of tissue.

The index of the ICD includes a text box below the main term ―Wound, Open‖ that identifies complicated wounds as those with delayed healing, delayed treatment, a foreign body, or infection.

When the entire lesion is removed, the procedure is considered an excision and should be reported as such using excision codes 11400–11646.

New coders find it helpful to highlight the body areas and lesion size and bracket each division of these codes. Providing this visual key enables them to quickly and accurately locate the correct code choice.

Lesion excision codes are selected by the diameter of the actual lesion prior to removal, not the specimen sent to the lab, as the specimen tends to shrink due to the required method of preserving it.

Do not add together lesions of the same anatomical grouping. Code each excised lesion separately, appending the 51 or 59 modifier as needed.

Do not use uncertain behavior and unspecified neoplasm codes interchangeably.

Neoplasms classified as uncertain behavior pathologically show cells of both benign and malignant behavior, whereas unspecified neoplasms are coded when the nature of the lesion is undocumented.

Closures using only adhesive strips or butterflies are not coded as repairs. Such work is captured in the E/M code reported for the encounter.

Don’t confuse the type of repair with the type of wound.

Determining the correct codes for multiple repairs of different anatomical sites and complexities can become confusing. Many coders find it helpful to bracket and number each category and anatomical grouping. For example bracket 1 would be code range 12001 through 12007; bracket 2, code range 12011 through 12018; bracket 3, code range 12031 through 12037; and so forth. Once all categories and groupings are bracketed, it is now helpful to highlight the wound lengths of each code.

When coding for cellulitis, rely on the physician documentation. When the condition is documented with an injury or burn, report one code for injury and one code for cellulitis.

Sequencing depends on circumstances of admission.

The surgeon’s work to remove a lesion or otherwise prepare the primary defect site is included in the code with the adjacent tissue transfer and is not separately reported.

Read the descriptions of each add-on code carefully. Most are reported for any additional size or percentage beyond that included in the initial code. However, some do not, follow this convention, for example 15156 and 15157. Lack of attention to the information contained in these codes can lead to incorrect code reporting.

The rule of nines is located in the guidelines and in the Tabular List of burn codes in many editions of the ICD manual.

The rule of nines is a general guideline of body surface area. As patients are proportioned differently based on body type or condition, the percentage of any given body area may differ from that assigned by the rule. For example, the anterior portion of a morbidly obese patient’s trunk may be considered 20 percent of TBSA versus the 18 percent assigned by the rule. Provider’s documentation of TBSA will dictate the percentage of TBSA in these cases.

Nonhealing burns are acute burns. Necrosis is a nonhealing burn and, therefore, an acute burn.

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108 o

o

o

o o o o

Many resources are available to the coder to determine the nature of the lesion and therefore the correct destruction category. During the CPC exam, you may refer to your ICD-10-CM manual for this information, and the category of the condition many times includes the nature of the lesion as benign or malignant or of uncertain behavior (premalignant).

Although Mohs terminology seems complex, it can easily be applied to an everyday item.

Using a loaf of bread slices stacked vertically to represent the tumor, remove the top slice from the loaf, cut it into five pieces, and place it in a bowl. The contents of this bowl, the slice with its pieces, represent your first stage and blocks (up to five) or CPT codes 17311 or 17313. Now remove the next slice and cut it into seven pieces. Place five of these pieces into the next bowl. The contents of this bowl, the five pieces of the second slice, represent your second stage and up to five blocks, codes 17312 or 17314. The remaining pieces represent additional blocks after the first five (any stage) and are coded as 17315 for each block.

As procedures performed involve the breast structure and not the skin, it is appropriate and correct to append laterality modifiers to services performed on the breast (50, LT, or RT). CPT provides guidance throughout regarding additional services that are separately reportable when provided by the same physician as the one providing the primary procedure or service. Many coders find it helpful to highlight these parenthetical notes.

Radical procedures, such as described in CPT codes 19305 and 19306, are more invasive and include the excision of the tumor, tissue surrounding the tumor, and all lymph nodes in the area of the excised tumor.

The surgical approaches and descriptions of both of these procedures are the same, with the exception of the amount of tissue removed. Correct coding requires that the coder understand the surgeon’s intent.

Another clue that helps the coder distinguish between these codes is the incision site of the flap. The incision site of the latissimus dorsi flap is on the back, and for the TRAM the incision site is the low abdomen.

For all breast reconstruction procedures, it is important that the coder identify the timing of the procedures to properly append modifiers

LO 8.5:  Modifiers 51, 58, and 59 are the most commonly used modifiers for this section.

Coding Tips and Guidelines o

As the integumentary system, or skin, is considered one organ, there are no bilateral sites.

Therefore, if procedures are performed on the skin at separate sites, such as right arm and left arm, it would be incorrect to use the bilateral modifier, 50. Instead, use the 59 or 51 modifier, as appropriate.

LO 8.6:  Many of the common medical terms have other terms that can be used in provider documentation to describe a condition or procedure.

Chapter 8 Answer Key Exercise 8.1 1. In which layer of the skin are the sweat pores located?

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109

Ans: The sweat pores are located in the epidermis.

Feedback: Sweat glands produce sweat, which travels to the surface of the body and exits through pores located in the epidermis.

2. Describe the two layers of the epidermis.

Ans: Outermost layer (stratum corneum) and basal layer (stratum basale) Feedback: The two layers of the epidermis are the outermost layer (stratum corneum) and the basal layer (stratum basale). The outermost layer is comprised of cells devoid of nuclei and filled with hard fibrous protein, keratin. The basal layer is the deepest layer of the epidermis and is made up of living cells which continue to divide and work their way to the surface, becoming keratin during the process.

3. What is the function of melanocytes, and in which layer are they located?

Ans: Melanocytes are found in the epidermis of the skin. They protect the skin as well as give the skin its pigment. It is in the melanocytes that melanoma, a malignant neoplasm of the skin, begins its formation.

Feedback: It is in the melanocytes that melanoma, a malignant neoplasm of the skin, begins its formation.

Exercise 8.2 1. Explain the difference between inflammation and infection.

Ans: Infection is defined as an invasion of the body by a pathogenic organism while inflammation is defined as a localized response to an injury or destruction of tissues.

Feedback: Invasion of the body by a pathogenic organism is defined as an infection. A localized response to an injury or destruction of tissues is defined as an inflammation.

2. Explain the possible causes of contact dermatitis, and identify the factors a coder must know before assigning the appropriate ICD-10-CM code.

Ans: Contact dermatitis may be due to ingestion of or direct contact by the skin to detergents, solvents, food, medicine, or other chemicals resulting in a rash. Contact dermatitis is coded to category L23- through L26-, ICD-10-CM and further defined as allergic contact dermatitis or irritant contact dermatitis and the agent causing the dermatitis.

Feedback: Direct contact to the skin by solvents, food, medicine, or other chemicals are some of the causes of contact dermatitis 3. Discuss the guidelines concerning the coding of pressure ulcers.

Ans:  Assign as many codes from category L89 as needed to identify all the pressure ulcers the patient has.

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   

Pressure ulcers whose stage cannot be clinically determined should be coded as unstageable pressure ulcer (example: ulcer is covered by an eschar). This should not be confused with unspecified stage.

No code is assigned if the documentation states the pressure ulcer is completely healed.

Pressure ulcers described as healing should be assigned the appropriate pressure ulcer stage code.

If a patient is admitted with a pressure ulcer at one stage and it progresses to a higher stage, two separate codes should be assigned: one code for the site and stage of the ulcer on admission and a second code for the same ulcer site and the highest stage reported during the stay.

Feedback: The specific guidelines for coding pressure ulcers and their stages are located in the ICD-10-CM manual.

Exercise 8.3 1. The physician dictates the size of the lesion as 2 inches x 3 inches. Convert the inches to centimeters.

Ans: Two inches = 2 x 2.54 = 5.08 centimeters. Three inches = 3 x 2.54 = 7.62 centimeters.

Feedback: Coders must know that 1 inch (in.) equals 2.54 centimeters (cm).

2. The physician dictates the size of a malignant lesion as 3 cm x 5 cm. Calculate the square centimeters.

Ans: 3 cm x 5 cm = 15 square centimeters Feedback: When calculating square centimeters (sq cm), as needed for many grafting procedures, coders must know that the equation to do so is length times width, or L × W. 3. For coding a Z-plasty, which is an adjacent tissue transfer procedure, what is the appropriate range of codes?

Ans: 14000-14350 Feedback: CPT code range 14000-14350 is used to report adjacent tissue transfer procedures such as Z-plasty.

Exercise 8.4 1. Explain the difference between a simple incision and drainage and a complex I&D. Ans: A simple I&D involves opening and draining the pus or cyst and leaving the site open to heal on its own. Complex procedures require additional work, such as placement of drains and packing, in addition to the work done in simple I&Ds. Feedback: A simple I&D leaves the site open to heal on its own. A complex I&D involves placement of drains and packing.

2. List the different ways that debridement can be accomplished.

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Ans: Surgically, chemically, and mechanically Feedback: Debridement can be accomplished surgically using sharp instruments; chemically using topical drugs; or mechanically using wet to dry dressing.

3. Describe the difference between excisional and nonexcisional debridement.

Ans: Excisional debridement is surgical removal or cutting away of tissue. Nonexcisional debridement is brushing, irrigating, scrubbing, or washing of tissue.

Feedback: Surgical removal or cutting away of tissue is an excisional debridement while a nonexcisional debridement involves brushing, scrubbing or washing of tissue.

4. Define simple, intermediate, and complex repair.

Ans/feedback: A simple repair is a single layer closure which involves closing the wound in one layer regardless of wound depth.

An intermediate repair is a layered closure, such as suturing the subcutaneous in one layer followed by the dermis in a second layer. They may also include repairs for wounds which are contaminated to the point that they require extensive cleaning to prepare for closure even if the closure is completed in a single layer.

A complex repair requires additional work beyond that of an intermediate repair, such as extensive undermining, exposure of bone, cartilage, tendon, named neurovascular structure, involvement of freemargins of helical rim, vermilion border, or nostril rim, retention sutures, or wound edge debridement.

5. List and define the six degrees of burns.

Ans: First-degree burns are limited to the epidermis and top layer of the dermis.

Second-degree burns extend beyond the epidermis and deeper into the dermis, which results in blistering and pain.

Third-degree burns involve all layers of the skin and the subcutaneous tissue and results in destruction of the nerves.

Fourth-degree burns extend beyond the subcutaneous tissue involving the underlying structures of muscle, tendon, and ligament but not through the bone.

Fifth- and sixth-degree burns extend into the bone and beyond to the underlying organs, typically resulting in the demise of the patient.

Feedback: Although clinically there are six degrees of burns, for ICD-10 coding purposes there are only three categories of burns: First degree, erythema; second degree, blistering or epidermal loss; and third degree, full thickness skin loss and beyond.

Exercise 8.5

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1. Explain the function of a modifier in coding a procedure involving the integumentary system.

Ans: Modifiers used with the integumentary system function to let the payer know there were multiple procedures performed, the procedure was a staged procedure, or the procedure was a distinct procedural service.

Feedback: Multiple procedures = modifier 51; staged procedure = modifier 58; and distinct procedural service = modifier 59.

2. Explain why modifier 50, bilateral procedure, is not used with codes for the integumentary system.

Ans: The integumentary system or skin is considered one organ and there are no bilateral sites.

Feedback: The skin is considered one organ and there are no bilateral sites; therefore, if procedures are performed on the skin (such as right and left arm) at separate sites, it would be incorrect to use the bilateral modifier 50. This does not apply to breast procedures, instead assign LT and/or RT. Exercise 8.6 List other terms which could be used for the following in a physician dictation: Ans: 1. contusion, scrape, bruise 2. wound, cut, tear 3. procurement 4. Z-plasty, rotation flap, rearrangement 5. suture, revision, restore, closure 6. transverse incision 7. bulla, pustule, vesicle 8. cicatrix, callus 9. furuncle, carbuncle 10. urticaria Chapter Eight Review Using Terminology Ans: 1.

J Adjacent tissue transfer

9.

B Inflammation

2.

H Complex repair

10. I Intermediate repair

3.

E Debridement

11. L Laceration

4.

K Destruction

12 M Mohs surgery

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5.

A Epidermis

13. C Paring

6.

N Escharotomy

14. F Shaving

7.

O Incision and drainage

15. G Simple repair

8.

D Infection

Checking Your Understanding 1. The ________layer, made up of living cells that continue to divide and work their way to the surface, becoming keratin, is the deepest layer of the epidermis.

Ans: B basal layer Feedback: The basal layer, made up of living cells that continue to divide and work their way to the surface, becoming keratin, is the deepest layer of the epidermis.

2. Which layer of the skin consists of mainly adipose tissue and contains lipocytes, or fat cells, which store energy for the body?

Ans: C Subcutaneous Feedback: The subcutaneous layer of the skin consists of mainly adipose tissue and contains lipocytes, or fat cells, which store energy for the body.

3. Which modifier would not be used with the codes in the integumentary subsection?

Ans: D 50 Feedback: The modifier 50, bilateral procedures, would not be used since the integumentary system is considered a single organ.

4. One inch equals _______ centimeters.

Ans: C 2.54 Feedback: One inch equals 2.54 centimeters.

5. The correct CPT and ICD-10-CM codes for a complicated I&D of purulent material from the right upper arm are: Ans: B 10061, L02.413 Feedback: 10061 is specific to incision and drainage of an abscess, and the term purulent material should have led the coder to abscess. The ICD-10 code is specific to the right upper arm.

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6. An area of subcutaneous necrotic tissue from a nonhealing wound was debrided from a patient’s forearm. The area debrided was 2 x 4 cm. The appropriate CPT and ICD-10-CM codes are: Ans: B Feedback: 11042 is for debridement of subcutaneous tissue, first 20 square cm. The lesion size is 2 x 4 cm, which would be 8 square centimeters. When calculating square centimeters (sq cm), as needed for many grafting procedures, coders must know that the equation to do so is length times width, or L × W. 7. The __________ acts as a seal between the nail plate and the skin.

Ans: C cuticle Feedback: The cuticle acts as a seal between the nail plate and the skin.

8. The patient presented to the ED with two lacerations on the right arm. The first laceration measured 7 cm, and the second measured 9 cm. Intermediate repair was needed for these lacerations. There was also a 5 cm laceration of the face, and a simple closure was performed. Select the appropriate code(s): Ans: B 12035, 12013-51 Feedback: 12035 for the lacerations of the arm, as this was an intermediate repair. The laceration sizes would be added together for a total size of 16 cm. Modifier 51 (multiple procedures) would be added to CPT code 12013 to show the additional simple repair of the face.

9. The patient has an ischial ulcer that is excised, including an ostectomy with a skin flap closure. Select the appropriate code(s): Ans: B 15945 Feedback: 15945 includes the excision, the skin flap closure, and the ostectomy.

10. Which of the following is true about an adjacent tissue transfer?

Ans: D All of these Feedback: The following are present in an adjacent tissue transfer: One portion remains attached at some point along the flap to its original anatomical site.

Z-plasty and rotation flap are types of adjacent tissue transfer.

The flap is left attached to its donor site until vascularity has been established.

11. When coding flaps and tissue transfer, which of the following questions should a coder ask before choosing the appropriate code?

Ans: D All of these

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Feedback: Before selecting the appropriate codes for adjacent tissue transfers and flaps, coders need to find answers in the medical record to these questions:  Did the tissue remain in its original location?  What is the anatomical site of the defect?  What is the total size of the defect? (primary + secondary defect = total) 12. A porcine graft is a(n): Ans: A Xenograft Feedback: A porcine graft is a xenograft.

13. The patient presents with a burn that extends beyond the epidermis and deeper into the dermis. The patient is experiencing pain and blistering. If coders see this type of description in a report, they would code the condition as what degree of burn?

Ans: B Second Feedback: The pain, blistering, and depth described identify this as a second-degree burn.

Applying Your Knowledge Case Study Preoperative diagnosis: Lacerations of right palm and forearm and left leg Postoperative diagnosis: Same An 8-year-old male was brought to the emergency room. While playing basketball with friends, he ran through a sliding glass door. He suffered lacerations on his right hand and arm and on his left leg just above and at the knee.

Procedure: The patient was placed on the table in supine position. Satisfactory local anesthesia was obtained. All wounds were cleaned and examined, and no sign of glass or other foreign bodies was found. The laceration of the left thigh, right above the patella, was repaired first by layered closure, and the 4.8cm laceration was carefully sutured.

The lacerations on the hand and arm were attended to next. A 3-cm laceration on the right-hand palm and a 4-cm laceration on the right forearm proximal to the elbow were carefully sutured in a single layer with 4-0 Vicryl, as well.

Process 1: CPT 1. What is the procedure?

Ans: Repair, skin Feedback: The procedure is repair, skin.

2. Locate the main term in the index. What additional questions or set of question can be determined?

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Ans: Complex, intermediate, or simple; type of repair Feedback: The additional questions or set of questions are complex, intermediate, or simple and type of repair.

3. Upon review of all the code choices identified in the index, what additional questions can be determined?

Ans: Anatomic site, size of wound Feedback: The additional questions are anatomic site and size of wound.

4. Based on the documentation, what is (are) the correct code(s) for this case?

Ans: C. 12032, 12002 Feedback: The codes for this case are 12032 and 12002.

Process 2: ICD ICD-10-CM 1. Based on the operative report header, what is the preoperative diagnosis?

Ans: Lacerations of right palm and forearm and left leg Feedback: Per the operative report header, the preoperative diagnosis is lacerations of right palm and forearm and left leg.

2. Is the postoperative diagnosis the same as or different from the preoperative diagnosis?

Ans: Same as the preoperative diagnosis Feedback: The postoperative diagnosis was the same as the preoperative diagnosis.

3. Is the postoperative diagnosis supported?

Ans: Yes Feedback: Postoperative diagnosis is the same as the preoperative diagnosis and is supported in the body of the report with the description and locations of the lacerations 4. What is the main term for this condition?

Ans: Wound, open Feedback: The main term for this condition is wound, open.

5. Based on the subterm choices, what question(s) can be developed for this condition?

Ans: Anatomic location, type of wound, with amputation

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Feedback: Based on the subterm choices, the questions developed by this condition are: anatomic location, type of wound, and with amputation.

6. Based on the information in the Tabular List, is additional information needed to determine the appropriate diagnosis code?

Ans: No Feedback: Based upon the information in the Tabular List, no additional information is needed to determine the appropriate diagnosis code.

7. Is any sign, symptom, or additional condition documented?

Ans: No Feedback: There is no sign, symptom, or additional condition documented.

8. Is the additional condition, sign, or symptom an integral part of the primary (or other) condition coded?

Ans: Not applicable Feedback: Not applicable, since there is no additional condition, sign, or symptom.

9. Does the additional condition require or affect patient care, treatment, or management?

Ans: Not applicable Feedback: Not applicable, since there is no additional condition.

10. Based on the documentation, what are the correct ICD-10-CM codes for this case?

Ans: B. S71.112A, S61.411A, S51.811A Feedback: The laceration of the thigh would be sequenced first to match the CPT code 12032 which was sequenced first to show an intermediate repair followed by the lacerations of the hand and forearm. The ICD-10-CM codes are S71.112A, S61.411A, and S51.811A.

Process 3: Modifiers 1. Was the procedure performed different from that described by the nomenclature of the code?

Ans: No Feedback: The procedure performed was not different from that described by the nomenclature of the code.

2. Was the procedure performed on an anatomical site that has laterality?

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Ans: No, it was performed on the skin.

Feedback: The procedure was performed on the skin, which does not have laterality.

3. Was the procedure performed in the global period of another procedure?

Ans: No Feedback: The procedure was not performed in the global period of another procedure.

4. Were additional procedures performed during the operative session, and does the documentation support these?

Ans: Yes, additional repairs of the hand and forearm Feedback: Documentation supports the additional repairs of the hand and forearm during the operative session.

5. Did the surgeon have help from another surgeon or another appropriate person?

Ans: No Feedback: The surgeon did not have help from another surgeon or other appropriate person.

6. Did a physician different from the surgeon perform the preoperative or postoperative portion of the procedure?

Ans: No Feedback: No other physician performed the preoperative or postoperative portion of the procedure.

7. What modifier should be appended to the CPT code for this case?

Ans: B. 51 Feedback: The modifier 51, multiple procedures, is appended to the CPT 12002 to identify additional repairs of the hand and forearm.

Chapter 9 – Surgery Section: Musculoskeletal System LESSON PLANS Class Preparation: Teaching Focus and Resources This chapter aides the reader in reviewing the anatomy of the musculoskeletal system while recognizing and applying the guidelines for appropriate CPT and ICD-10-CM coding. Common medical and

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119 procedural terms used in operative reports are also examined.

Learning Outcomes After completing Chapter 9, students will be able to: LO 9.1 Review the anatomy of the musculoskeletal system.

LO 9.2 Recognize the general guidelines and format of ICD codes for the musculoskeletal system.

LO 9.3 Understand the general guidelines and format of the Musculoskeletal subsection in the CPT manual.

LO 9.4 Apply the subheading guidelines.

LO 9.5 Identify the modifiers most commonly used with codes in the Musculoskeletal subsection.

LO 9.6 Examine the common medical and procedural terms used in operative reports.

Class Presentation LO 9.1: Review the anatomy of the musculoskeletal system Slides 9-1 through 9-4



Introduction to chapter and key terms

Slide 9-5 and 9-6



Anatomy of the Musculoskeletal System - Muscular System

Slide 9-7



Anatomy of the Musculoskeletal System - continued - Structures of the musculoskeletal system

Slide 9-8



Anatomy of the Musculoskeletal System – continued - Skeletal System

LO 9.2: Recognize the general guidelines and format of ICD codes for the musculoskeletal system Slide 9-9



General ICD guidelines and format for the Musculoskeletal system

Slide 9-10



General ICD guidelines and format for the Musculoskeletal systemcontinued - Arthropathies and related disorders

Slide 9-11



General ICD guidelines and format for the Musculoskeletal system – continued - Dorsopathies - Polyarthropathies

Slide 9-12



General ICD guidelines and format for the Musculoskeletal system – continued

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120 -

Disorders of bone density

LO 9.3: Understand the general guidelines and format of the Musculoskeletal subsection in the CPT manual.

Slide 10-13



General format of the Musculoskeletal subsection of CPT - Coding Questions

Slide 10-14



General format of the Musculoskeletal subsection of CPT – continued - Subheadings

LO 9.4: Apply the subheading guidelines.

Slide 9-15



Subheading Format and Guidelines of Musculoskeletal system - Subheadings – continued General (20005 -20999)

Slide 9-16



Subheading Format and Guidelines of Musculoskeletal system– continued - Subheadings – continued - Fracture and/or Dislocation subheadings (table 9.6)

Slide 9-17



Subheading Format and Guidelines of Musculoskeletal system-continued - Subheadings – continued - Fracture and/or Dislocation subheadings - Closed treatment - Open treatment - Percutaneous skeletal fixation treatment

Slide 9-18



Subheading Format and Guidelines of Musculoskeletal system-continued - Subheadings – continued - Traction Skeletal Skin Manipulation

Slide 9-19



Subheading Format and Guidelines of Musculoskeletal system-continued - Subheadings – continued - Repair, Reconstruction, and Revision

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

Subheading Format and Guidelines of Musculoskeletal system-continued - Subheadings – continued

Slide 9-21



Subheading Format and Guidelines of Musculoskeletal system-continued - Subheadings – continued - -Arthrodesis (table 9.8)

Slide 9-22



Subheading Format and Guidelines of Musculoskeletal system-continued - Subheadings – continued - Spinal instrumentation (22840-22870 range)

Slide 9-23



Subheading Format and Guidelines of Musculoskeletal system-continued - Subheadings – continued - Application of cast and strapping

Slide 9-24



Subheading Format and Guidelines of Musculoskeletal system-continued - Subheadings – continued - Application of cast and strapping - continued

Slide 9-25



Subheading Format and Guidelines of Musculoskeletal system-continued - Subheadings – continued -Endoscopy/arthroscopy (29800- 29999)

LO 9.5 Identify the modifiers most commonly used with codes in the Musculoskeletal subsection.

Slide 9-26



Modifiers commonly used with Musculoskeletal subsection codes - 50 - 51 - 52 - 62 (table 9.10)

LO 9.6 Examine the common medical and procedural terms used in operative reports.

Slide 9-27



Common medical and procedural terms used in musculoskeletal system - Table 9.11 and 9.12

Summary Slides Slides 9-28 through 9-29



Synopsis of chapter

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Teaching Tips LO 9.1:  Recognizing the anatomy and specific medical terminology pertinent to the musculoskeletal system will aid the coder in selecting the appropriate codes.  Some of the functions of the muscular system are to hold the body erect, make movement possible, generate body heat, and move food through the digestive system.  Some of the functions of the skeletal system are to support and shape the body, protect internal organs, anchor muscles, and make blood cells.

Coding Tips and Guidelines o Check any medical terms you do not understand in a medical dictionary, and have additional anatomical resources available. o Deep fascia lies beneath the second layer of subcutaneous tissue.

LO 9.2:  Some of the more common conditions of the musculoskeletal system include diseases of the connective tissue, such as systemic lupus erythematosus; poliomyelitis; arthropathy; osteoarthrosis; derangement joint disorders; spondylosis; and disorders of muscles, ligaments, and fascia. When coding these conditions, coders must thoroughly review the provider documentation as well as the guidelines and instructional notes.  ICD-10-CM: Diseases of the musculoskeletal system and connective tissues are located in Chapter 13 in the ICD-10-CM manual, with the code range M00–M99.

Coding Tips and Guidelines o Category M00 pyogenic arthritis includes codes describing infections of joints of the bones, whereas infections of the bone are reported using codes from category M86. o

The excludes 1 note located under code M15 inform the coder that bilateral involvement of a single joint is coded to category (M16-M19)

LO 9.3:  The Musculoskeletal subsection of CPT is arranged in anatomical order from the head down.  Each anatomical site is then divided based on the approach or technique and on the type of treatment or condition.

Coding Tips and Guidelines o When complication defines the code, this can refer to infection or treatment delay. o Intermediate repair in this section is an integral part of the surgery and is not reported separately. o Surgical arthroscopies always include diagnostic arthroscopies. o Superficial injuries occurring at the site of a more serious injury are not coded separately. Examples are: contusions and abrasions at the site of dislocation or fracture. o When a fracture is not described as closed or open, the coder defaults to closed.

LO 9.4:

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Each anatomical heading is divided into the following subheadings consisting of approach, technique, treatment, or condition: Incision Excision Introduction or Removal Repair, Revision, and/or Reconstruction Fracture and/or Dislocation Manipulation Arthrodesis Amputation Coding Tips and Guidelines o Physicians often list this procedure as I&D of soft tissue or muscle without specifying the depth. o The trigger words to look for in an operative report for procedures performed on the musculoskeletal system are trauma, penetrating wound, gunshot wound, or stab wound. o Superficial removal of an implant usually requires a stab or small incision as well as a simple closure. o Removal of deep implants may require a large incision and a layered closure. Removal of scar tissue is inherent to the procedure. When multiple hardware is removed, the removal of the hardware is coded per incision, not per item. o Remember that an allograft is also a homograft. o Being familiar with the subheadings and the divisions of each speeds the location and selection of the code, aiding the coder when taking the CPC exam. o There can be open treatment of a closed fracture. Therefore, it is important that the coder understand and differentiate between the type of fracture and the type of treatment. o Internal fixation involves the use of wires, pins, screws, and the like, which are placed through or within the fracture site in order to stabilize the fracture. o External fixation involves skeletal pins attached to an external mechanism. o The definitions of fixation, traction, and manipulation are located in the general guidelines at the beginning of the Musculoskeletal subsection of the CPT manual. o CPT includes instructional notes below many open procedure codes which refer the coder to a different code if the procedure is performed arthroscopically. o When reviewing the documentation for spine procedures, the coder must first determine whether the procedure was performed on the bony structures (segments) or the disc (interspace). A simple means of determining this is the description of the procedure’s location. Bony structures are listed by each individual site, for example, T1, T2, T3.

Interspaces are identified by the two bony structures above and below the interspace, for example, T1–T2, T2–T3. This description also allows for quick determination of the number of interspaces: Just count the dashes between each identified bony structure.

LO 9.5:  In the Musculoskeletal subsection modifiers are most commonly used to indicate bilateral procedures, reduced services, multiple procedures, and/or two surgeons performing distinct parts of a single procedure.

LO 9.6:  There are many procedural and diagnostic terms that are specific to the musculoskeletal system or are shared with other organ systems. Coders need to be aware of when the terms used in the medical documentation define the procedure and/or service and diagnosis of the system they are coding.

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Chapter 9 Answer Key Exercise 9.1 1. Explain the difference between a tendon and a ligament.

Ans: A tendon is a narrow band of nonelastic, dense, fibrous connective tissue which attaches muscle to a bone. Ligaments are bands of fibrous tissue that connect two or more bones or cartilage.

Feedback: Tendons attach muscle to a bone, while ligaments connect two or more bones or cartilage.

2. Identify the functions of skeletal, smooth, and myocardial muscles.

Ans: Skeletal muscles are attached to bones of the skeleton and make motion such as walking possible.

They are striated and voluntary muscles.

Smooth muscles are located in the walls of internal organs and their function is to move and control flow of fluids. They are visceral (internal organ) muscles and are smooth in appearance and involuntary.

Cardiac muscles form the muscular wall of the heart. They are like striated muscles in appearance but are similar to smooth muscles in action.

Feedback: N/A 3. Where is the deep fascia?

Ans: The deep fascia lies beneath the second layer of subcutaneous tissue.

Feedback: The deep fascia is found beneath the second layer of subcutaneous tissue.

4. Describe the bones that make up the axial skeleton.

Ans: Bones of the skull: frontal, parietal, occipital, temporal, sphenoid, ethmoid Bones of the face: nasal, zygomatic, maxillary, palatine, lacrimal, vomer, mandible Vertebrae: Cervical, thoracic, lumbar Feedback: The axial skeleton is made up of the following: bones of the skull (frontal, parietal, occipital, temporal, sphenoid, and ethmoid), bones of the face (nasal, zygomatic, maxillary, palatine, lacrimal, vomer, and mandible), and vertebrae (cervical, thoracic, and lumbar).

5. Describe the bones that make up the appendicular skeleton.

Ans: Bones of the shoulder: clavicle, scapula, acromion Bones of the arms: humerus, radius, ulna, olecranon process Bones of the wrists, hands, fingers: carpals, metacarpals, phalanges Bones of the pelvis and hips: ilium, ischium, pubis Bones of the legs: femur, knees, patella, tibia, fibula Bones of the ankles and toes: tarsals, metatarsals, phalanges, sesamoid Feedback: The appendicular skeleton is made up of the following: bones of the shoulder (clavicle, scapula, and acromion); bones of the arms (humerus, radius, ulna, and olecranon process); bones of the wrists, hands, fingers (carpals, metacarpals, and phalanges); bones of the pelvis and hips (ilium, ischium, and pubis); bones of the legs (femur, knees, patella, tibia, and fibula); and bones of the ankles and toes (tarsals, metatarsals, phalanges, and sesamoid).

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Exercise 9.2 1. List some of the more common conditions associated with the musculoskeletal system that would be reported using codes from this chapter of ICD. Ans: Some of the more common conditions of the musculoskeletal system include diseases of the connective tissue, such as systemic lupus erythematosus; poliomyelitis; arthropathy; osteoarthosis; derangement joint disorders; spondylosis; and disorders of muscles, ligaments and fascia.

Feedback: Some of the more common conditions of the musculoskeletal system that would be reported using codes from this chapter of ICD include diseases of the connective tissue, such as systemic lupus erythematosus; poliomyelitis; arthropathy; osteoarthrosis; derangement joint disorders; spondylosis; and disorders of muscles, ligaments, and fascia.

2. List some of the other chapters of ICD containing codes that could be used to report conditions associated with the musculoskeletal system.

Ans: Fractures and dislocations are reported with codes located in the Injury and Poisoning Chapters of ICD along with sprains and strains. Other conditions associated with the musculoskeletal system are located in the Congenital Anomalies; Symptoms, Signs, and Ill Defined Conditions; Neoplasms; and Diseases of the Nervous System chapters of the ICD manual.

Feedback: Some conditions associated with the musculoskeletal system would be reported using codes in other chapters of ICD. For example, fractures and dislocations are reported with codes located in the Injury and Poisoning Chapters of ICD along with sprains and strains. Other conditions associated with the musculoskeletal system are located in the Congenital Anomalies; Symptoms, Signs, and Ill Defined Conditions; Neoplasms; and Diseases of the Nervous System chapters of the ICD manual.

3. In reporting osteoarthritis (OA), what elements of the condition are defined by the third, fourth, fifth, and sixth characters?

Ans: Category M15-M19 is used to report osteoarthritis (OA). Laterality, specific joint involved, and whether unilateral or bilateral are needed in order to give codes within this range the most specificity.

Feedback: Category M15-M19 is used to report osteoarthritis (OA). Laterality, specific joint involved, and whether unilateral or bilateral are needed in order to give codes within this range the most specificity.

Other factors contributing to specificity are primary OA, post-traumatic OA, or secondary OA. Exercise 9.3 1. List terms found in provider documentation that would lead the coder to assign the ICD code in which ―complicated‖ appears in the code description.

Ans: Infection or treatment delay Feedback: Infection or treatment delay are examples of terms that could appear in the documentation which would lead the coder to assign the code in which ―complicated‖ appears in the code description.

2. List some of the subheadings that contain specific instructional notes.

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126 Ans: Application of Casts and Strapping; Endoscopy/Arthroscopy; Head; Spine; Shoulder; Humerus and Elbow; Forearm and Wrist; Pelvis and Hip Joint; and Femur and Knee Joint Feedback: Some of the subheadings that contain some specific instructional notes include Application of Casts and Strapping; Endoscopy/Arthroscopy; Head; Spine; Shoulder; Humerus and Elbow; Forearm and Wrist; Pelvis and Hip Joint; and Femur and Knee Joint.

3. CPT codes for procedures of the upper arm are located in which range of codes?

Ans: 23930-24999 – Humerus and Elbow Feedback: CPT codes for procedures of the upper arm would be located in the range 23930-24999 – Humerus and Elbow.

4. CPT codes for procedures of the thigh region are located in which range of codes?

Ans: 27301-27599 – Femur and Knee Joint Feedback: CPT codes for procedures of the thigh region would be located in the range 27301-27599 – Femur and Knee Joint.

Exercise 9.4 1. How would a coder report a replantation of an incomplete amputation of an extremity or digit?

Ans: Coders are instructed when reporting a replantation of an incomplete amputation to see specific codes for repair of bone, ligaments, tendons, nerves, or blood vessels with the use of modifier -52 (reduced service).

Feedback: When reporting a replantation of an incomplete amputation, coders are instructed to see specific codes for repair of bone, ligaments, tendons, nerves, or blood vessels with the use of modifier 52 (reduced service). (Instructional note under CPT code 20802) 2. Code selection in the excision subheading is based on location of the tumor and the size of the tumor. How is the size of the tumor determined?

Ans: The size of the tumor is determined by measuring the greatest diameter of the tumor plus the margin required for complete excision of the tumor.

Feedback: The greatest diameter of the tumor plus the margin required determines the size of the tumor.

3. Explain the guidelines for coding excision of subcutaneous and fascial or subfascial soft tissue tumors.

Ans: Excision of subcutaneous soft tissue tumors involves tumors located below the skin but above the deep fascia.

Excision of fascial or subfascial soft tissue involves tumors confined to the tissue within or below the deep fascia.

Radical resection of soft tissue or bone tumors requires excision of surrounding soft tissue. Excision of this tissue is included in the tumor excision and is not coded separately.

Feedback: N/A refer back to guideline 4. Explain the difference between skeletal traction and skin traction.

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127 Ans: Skeletal traction is the application of force to a limb through a wire, pin, screw, or clamp that is attached to a bone.

Skin traction is the application of a force to a limb using felt or strapping applied directly to the skin only.

Feedback: Skeletal traction involves the application of force to a limb through a wire, pin, screw, or clamp that is attached to a bone, while skin traction involves the application of a force to a limb using felt or strapping applied directly to the skin only.

5. Explain why an arthrodesis or fusion procedure would be performed.

Ans: This procedure may be performed to strengthen an area, such as the spine, after other surgical procedures or to eliminate pain upon flexion and extension at the site of a joint.

Feedback: This procedure may be performed to strengthen an area after other surgical procedures or to eliminate pain upon flexion and extension at the site of a joint.

6. Explain when codes within the Application of Cast and Strapping subheading may be reported.

Ans: The procedures in this subheading ―apply 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(s) to stabilize or protect a fracture, injury, or dislocation and/or to afford comfort to a patient. Restorative treatment or procedure(s) rendered by another physician following the application of the initial cast/splint/strap may be reported with a treatment or fracture and/or dislocation code.‖ (CPT 2018). A physician who applies the initial cast, strap, or splint and also assumes all of the subsequent fracture, dislocation, or injury care cannot use an Application of Cast and Strapping code as an initial service, since the first cast/splint or strap application is included in the treatment of fracture and/or dislocation codes.

Feedback: The procedures in this subheading are applied ―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(s) to stabilize or protect a fracture, injury, or dislocation and/or to afford comfort to a patient. Restorative treatment or procedure(s) rendered by another physician following the application of the initial cast/splint/strap may be reported with a treatment or fracture and/or dislocation code.‖ (CPT 2018). A physician who applies the initial cast, strap, or splint and also assumes all of the subsequent fracture, dislocation, or injury care cannot use an Application of Cast and Strapping code as an initial service, since the first cast/splint or strap application is included in the treatment of fracture and/or dislocation codes.

Exercise 9.5 1. For what type of procedures within the Musculoskeletal subsection would it not be appropriate to append modifier 62?

Ans: It is not appropriate to append modifier 62, two surgeons, to spinal instrumentation codes or bone grafts.

Feedback: The guidelines under the heading spinal instrumentation in the CPT manual instruct the coder to not use Modifier 62, two surgeons, with spinal instrumentation codes 22840 – 22848, 22850, 22852, 22853, 22854-22859.

2. Arthrodesis may be performed in the absence of other procedures, but when it is performed with another procedure, such as a corpectomy, it would be appropriate to code using modifier 51 to

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128 report multiple procedures. Would it also be appropriate to use a modifier with a code such as 22614 when reporting arthrodesis of each vertebral segment?

Ans: No Feedback: Code 22614 has a ―+‖ in front of the code, which indicates that this is an add-on code.

Therefore, it would not be appropriate to use modifier 51.

Exercise 9.6 1. Explain the difference between a sprain and a strain.

Ans: Sprain: Injury to a joint (such as ankle, wrist, or knee), usually involving a stretched or torn ligament.

Strain: Injury to the body of the muscle or the attachment of a tendon; usually associated with overuse injuries that involve a stretched or torn muscle or tendon.

2. Explain the difference between osteoarthritis and osteoporosis.

Ans: Osteoarthritis is inflammation of the bone and joint. It occurs when protective covering on the ends of the bones wear down.

Osteoporosis is thinning of bone tissue and loss of bone density over time. Bones become weak and brittle.

3. If the word cautery, cryo, or laser is part of the description of the procedure performed, what main term could be used to describe all of these words?

Ans: Destruction Feedback: Destruction would be the main term used to describe cautery, cryo, or laser for the procedure performed.

Chapter Nine Review Using Terminology 1.

I

Axial skeleton

10.

N

Malunion

2.

L

Appendicular skeleton

11.

D

Manipulation

3.

G

Closed fracture

12.

E

Nonunion

4.

H

Diaphysis

13.

F

Open fracture

5.

C

Dislocation

14.

P

Osteoarthritis

6.

K

Epiphysis

15.

Q

Osteoporosis

7.

O

External fixation

16.

A

Pathologic fracture

8.

M

Internal fixation

17.

B

Tendon

9.

J

Ligament

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129

Checking Your Understanding Complete each of the following statements with the most appropriate answer or code.

1. The correct procedure code for subcutaneous foreign body removal from the elbow is _______________.

Ans: 24200, Removal of foreign body, upper arm or elbow area; superficial Feedback: When coding for removal of foreign bodies, check the site; in this case the foreign body was described as subcutaneous. Code 24201 would be used if the foreign body was documented as deep (subfascial or intramuscular).

2. When a fracture is not described as open or closed in the medical documentation, the coder defaults to using ___________ Ans: closed Feedback: The coder could also query the physician and remind the physician that the documentation needs to be specific as to the type of fracture. Remember, the physician may not use the words open or closed but by knowing the definition of an open fracture or a closed fracture, a coder may be able to make the distinction.

3. Some examples of irregular bones are _______________, ________________, and ____________.

Ans: zygomatic, maxillary, vertebrae Feedback: Some examples of irregular bones are zygomatic, maxillary, and vertebrae.

4. The Musculoskeletal subsection of CPT is arranged by anatomical order, and each anatomical site is then divided based on the approach or technique and also on the ____________.

Ans: type of treatment or condition being treated Feedback: The Musculoskeletal subsection of CPT is arranged in anatomical order from the head down.

Each anatomical site is then divided based on the approach or technique and also on the type of treatment or condition being treated.

5. Some trigger words to look for in an operative report to support using the wound exploration codes are ______________, _____________, and ___________.

Ans: trauma, penetrating wounds, gunshot wound Feedback: Some trigger words to look for in an operative report to support using the wound exploration codes are trauma, penetrating wounds, and gunshot wound.

Choose the most appropriate answer for the following questions.

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130 1. This lies beneath the layer of subcutaneous tissue of the integumentary system, lines extremities, and holds together groups of muscles: Ans: C Deep fascia Feedback: The deep fascia lies beneath the layer of subcutaneous tissue of the integumentary system, lines extremities, and holds together groups of muscles.

2. Skeletal muscles make motion such as walking possible and are: Ans: D Both striated and voluntary muscles Feedback: Skeletal muscles make motion such as walking possible and are both striated muscles and voluntary muscles.

3. What is the correct code for an open repair of an acute ruptured rotator cuff?

Ans: A 23410, repair of ruptured musculotendinous cuff (eg. Rotar cuff) open; acute Feedback: Code 23410 is the correct code for an open repair of an acute rotator cuff tear. The other codes are for reconstruction and/or chronic rotator cuff tear.

4. Report the appropriate code(s) for the following procedures: Diagnostic knee arthroscopy of the right knee, followed by surgical arthroscopy with synovectomy in both medial and lateral components of the right knee.

Ans: C 29876, Arthroscopy, knee, surgical synovectomy, major, 2 or more compartments (eg. Medial or lateral).

Feedback: 29876 is for the surgical arthroscopy with synovectomy of two or more compartments. If diagnostic and surgical arthroscopy are performed in the same setting on the same anatomical site, only the surgical arthroscopy is reported.

5. This type of joint is movable and also called a ball-and-socket joint: Ans: D Synovial and hinge joint Feedback: Synovial and hinge joint is the type of joint which is movable and is also called a ball-andsocket joint.

6. When the description of a code includes the term complicated, it can refer to: Ans: C Infection and delayed healing Feedback: When the description of a code includes the term complicated, it can refer to infection and delayed healing.

7. What is the appropriate code for arthrocentesis of the shoulder?

Ans: B 20610, Arthrocentesis, aspiration and/or injection, major joint or bursa (eg. Shoulder, hip, knee, subacromial bursa); without ultrasound guidance.

Feedback: Code 20610 is the appropriate code for arthrocentesis of the shoulder since the shoulder is considered a large or major joint.

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131 8. _________ is the attempted reduction or restoration of a fracture or joint dislocation to its normal alignment by the application of manually applied force.

Ans: B Manipulation Feedback: Manipulation is the attempted reduction or restoration of a fracture or joint dislocation to its normal alignment by the application of manually applied force.

9. When an arthroscopy is performed at the same time as an arthrotomy, which modifier would be appended?

Ans: C 51, Modifier 51, multiple procedures Feedback: When an arthroscopy is performed at the same time as an arthrotomy, the appropriate modifier would be 51, multiple procedures 10. A muscle that is like a striated muscle in appearance but similar to a smooth muscle in action is a: Ans: B Myocardial muscle Feedback: The myocardial muscle is like a striated muscle in appearance but similar to a smooth muscle in action.

Applying Your Knowledge Case Study Preoperative diagnosis: Cervical spondylosis, central stenosis C5-C6 Postoperative diagnosis: Cervical spondylosis, central stenosis C5-C6 Procedure: Anterior cervical arthrodesis anterior body C5-C6 using PEEK cages and DynaTran 18mm Stryker plate, autologous local bone, and putty Anesthesia: General anesthesia The patient was placed in a supine position on the operating table with an interscapular roll. The anterior aspect of the neck was prepped and draped in a sterile fashion. Interoperative fluoroscopy was used to center our incision over the C5 through C6 interspace. A transverse incision was made across the sternocleidomastoid on the right side, and the incision was carried down through the subcutaneous tissues, controlling bleeding with unipolar cautery. Initially, retraction was done using a small Weitlaner, and the anterior border of the sternocleidomastoid was identified. I followed a plane medial to this and medial to the carotid artery but lateral to the esophagus and trachea. I followed this plane until the prevertebral space was identified and the longus colli muscles were divided in the midline. The selfretaining blades of the Trimline retractor were placed underneath this muscle, and then we placed a marker at the C4–C5 level, which was the most inferior, still visible identifiable disc space.

From here I counted down to the C4–C5 level and proceeded with a minimal anterior cervical discectomy and decompression at C5–C6. The ventral osteophytes were removed using a Leksell rongeur, and then the disc was incised using a 15-blade knife in the interspace distracted using the Caspar distraction system. The discectomy was performed; the disc was quite collapsed using a combination of curettes and Midas Rex drill. The discectomy and bony removal was followed posteriorly until the posterior

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132 longitudinal ligament was identified. This was opened and removed, and then working carefully over the dura, bilateral foraminotomies were performed.

After verifying that the spinal cord was well decompressed in the midline, the roots out laterally, the area was irrigated with an antibiotic saline solution. I then selected a 6-mm in height PEEK cage, which was filled with some local bone that had been harvested as part of our bony removal combined with autologous bone putty. The cage was then tapped into position and distraction was released.

I then selected an 18 mm in length DynaTran translational plate, and this was secured with two variableangle screws into C5 and two into C6. Once the screws were partially in position, the translational stops were removed and the screws were secured beyond the backup stops for all screws. The muscles were reapproximated with 2-0 Vicryl, a 2-0 Vicryl subcutaneous closure including the platysma, and a running 4-0 Vicryl subcuticular stitch in the skin.

Process 1: CPT 1. What is the procedure?

Ans: Arthodesis and instrumentation, anterior and intervertebral Feedback: Arthodesis and instrumentation, anterior and intervertebral is the procedure.

2. Locate the main term in the index. What additional questions or set of question can be determined?

Ans: For arthrodesis: what joint or anatomic location? For instrumentation: insertion, removal, or reinsertion?

Feedback: For arthrodesis: what joint or anatomic location? For instrumentation: insertion, removal, or reinsertion?

3. Upon review of all the code choices identified in the index, what additional questions can be determined?

Ans: For arthrodesis: approach and vertebral bodies fused? For instrumentation: number of vertebral segments and number of interspaces?

Feedback: N/A

4. Based upon the documentation, what are the correct codes for this case?

Ans: C 22551, 22845, 22853 Feedback: 22551 represents arthrodesis below C2; 22845 is used to report the instrumentation (screws placed into C5 and C6); and 22853 is for the PEEK cage inserted into the C5-C6 interspace.

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133

Process 2: ICD ICD-10-CM 1. Based on the operative report header, what is the preoperative diagnosis?

Ans: Cervical spondylosis, central stenosis C5-C6 Feedback: Per the operative report header, the preoperative diagnosis is cervical spondylosis, central stenosis C5-C6.

2. Is the postoperative diagnosis the same as or different from the preoperative diagnosis?

Ans: Same Feedback: The postoperative diagnosis is the same as the preoperative diagnosis.

3. Is the postoperative diagnosis supported?

Ans: Yes Feedback: Postoperative diagnosis is the same as the preoperative diagnosis and is supported in the body of the report with the description and locations of the C5-C6 level.

4. What is the main term for this condition(s)?

Ans: Spondylosis and stenosis Feedback: The main term for this condition is spondylosis and stenosis.

5. Based on the subterm choices, what question(s) can be developed for this condition?

Ans: For spondylosis: anatomic site or level of the spine and with or without other associated conditions such as myelopathy or radiculopathy. For stenosis: anatomic site (foramina or spinal) and cause, such as bone or soft tissue.

Feedback: For spondylosis: anatomic site or level of the spine and with or without other associated conditions such as myelopathy or radiculopathy. For stenosis: anatomic site (foramina or spinal) and cause, such as bone or soft tissue.

6. Based on the information in the Tabular List, is additional information needed to determine the appropriate diagnosis code?

Ans: No Feedback: Based upon the information in the Tabular List, no additional information is needed to determine the appropriate diagnosis code.

7. Is any sign, symptom, or additional condition documented?

Ans: Yes Feedback: Yes, a sign, symptom, or additional condition is documented.

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134 8. Is the additional condition, sign, or symptom an integral part of the primary (or other) condition coded?

Ans: No Feedback: No, the additional condition, sign, or symptom is not an integral part of the primary (or other) condition coded.

9. Does the additional condition require or affect patient care, treatment, or management?

Ans: Yes, stenosis was also treated by removal of bony structures.

Feedback: Yes, the additional condition does require and affects patient care, treatment, or management.

Stenosis was also treated by removal of bony structures.

10. Based upon the documentation, what are the correct ICD-10-CM codes for this case?

Ans: D M47.12, M48.02 Feedback: M47.12, other spondylosis with myelopathy, cervical region would be the first listed diagnosis and M48.02, spinal stenosis, cervical region would also be reported.

Process 3: Modifiers 1. Was the procedure performed different from that described by the nomenclature of the code?

Ans: No Feedback: The procedure performed was not different than that described by the nomenclature of the code.

2. Was the procedure performed on an anatomical site that has laterality?

Ans: Yes, but not applicable in this case Feedback: Yes, the procedure was performed on an anatomic site which has laterality; however, it is not applicable in this case.

3. Was the procedure performed in the global period of another procedure?

Ans: No Feedback: The procedure was not performed in the global period of another procedure.

4. Were additional procedures performed during the operative session, and does the documentation support them?

Ans: Yes; however, all are modifier 51 exempt.

Feedback: Yes, additional procedures were performed during the operative session and the documentation does support these. However, all are modifier 51 exempt.

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135 5. Did the surgeon have help from another surgeon or other appropriate person?

Ans: No Feedback: The surgeon did not have help from another surgeon or other appropriate person.

6. Did a physician different from the surgeon provide the preoperative or postoperative portion of the procedure?

Ans: No Feedback: No physician different from the surgeon provided the pre- or postoperative portion of the procedure.

7. What modifier should be appended to the CPT for this case?

Ans: D None Feedback: No modifier should be appended to the CPT for this case.

Chapter 10 – Surgery Section: Respiratory System LESSON PLANS Class Preparation: Teaching Focus and Resources The anatomy of the respiratory system, chapter specific guidelines for procedures and diagnoses and medical terminology are reviewed in this chapter. Modifiers and their application in order to complete the story of the patient encounter are also identified in this chapter.

Learning Outcomes After completing Chapter 10, students will be able to: LO 10.1 Review the anatomy of the respiratory system.

LO 10.2 Understand the chapter-specific ICD guidelines and format for the respiratory system.

LO 10.3 Identify the guidelines and format of the Respiratory subsection of CPT. LO 10.4 Apply the modifiers most commonly used with codes in the Respiratory subsection.

LO 10.5 Examine the common medical and procedural terms used in operative reports.

Class Presentation LO 10.1: Review the anatomy of the respiratory system.

Slides 10-1 through 10-4



Chapter introduction and key terms

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136 

Slide 10-5

Anatomy of the Respiratory system - Upper respiratory tract - Lower respiratory tract - Table 10.1

LO 10.2: Understand the chapter-specific ICD guidelines and format for the respiratory system.

Slide 10-6



ICD Chapter-specific guidelines and format of the Respiratory system chapter

Slide 10-7



ICD Chapter-specific guidelines and format of the Respiratory system chapter – continued - Acute respiratory infections - Nasopharyngitis -Sinusitis -Pharyngitis -Tonsilitis

Slide 10-8



ICD Chapter-specific guidelines and format of the Respiratory system chapter – continued - Acute respiratory infections – continued -Laryngitis and tracheitis -Upper respiratory infections of multiple sites -Bronchitis and bronchiolitis

Slide 10-9



ICD Chapter-specific guidelines and format of the Respiratory system chapter – continued - Other Diseases of the upper respiratory tract -Deviated septum -Nasal polyps -Chronic pharyngitis and nasopharyngitis -Chronic sinusitis

Slide 10-10



ICD Chapter-specific guidelines and format of the Respiratory system chapter – continued Other Diseases of the upper respiratory tract – continued -Chronic diseases of the tonsils and adenoids -Peritonsillar abscess -Chronic laryngitis and laryngotracheitis -Other diseases of the upper respiratory tract

-

Slide 10-11

 -

ICD Chapter-specific guidelines and format of the Respiratory system chapter – continued Pneumonia and influenza

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137 

Slide10-12



Slide 10-13



Slide 10-14



Slide 10-15

-

ICD Chapter-specific guidelines and format of the Respiratory system chapter – continued Pneumonia and influenza – continued ICD Chapter-specific guidelines and format of the Respiratory system chapter – continued Chronic lower respiratory diseases ICD Chapter-specific guidelines and format of the Respiratory system chapter – continued Pneumoconioses and other lung diseases due to external agents ICD Chapter-specific guidelines and format of the Respiratory system chapter – continued Other diseases of the respiratory system

LO 10.3: Identify the guidelines and format of the Respiratory subsection of CPT. Slide 10-16



CPT guidelines and format of the Respiratory subsection - Indirect examination - Direct examination - External approach - Internal approach

Slide 10-17



CPT guidelines and format of the Respiratory subsection – continued - Coding questions for Respiratory subsection

Slide 10-18



Guidelines and format of the Respiratory subsection of CPT - Respiratory system subsection General Headings (table 10.3)

Slide 10-19



Guidelines and format of the Respiratory subsection of CPT – continued - Respiratory system subsection subheadings

Slide 10-20



Guidelines and format of the Respiratory subsection of CPT - continued - Nose subheading (30000-30999)

Slide 10-21



Guidelines and format of the Respiratory subsection of CPT – continued - Accessory sinuses (31000-31299)

Slide 10-22



Guidelines and format of the Respiratory subsection of CPT – continued - Larynx subheadings (31300-31599)

Slide 10-23



Guidelines and format of the Respiratory subsection of CPT – continued - Trachea and bronchi subheadings (31600-31899)

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138 Slide 10-24

 

Slide 10-25

Guidelines and format of the Respiratory subsection of CPT – continued - Lungs and pleura subheadings (32035-32999) Guidelines and format of the Respiratory subsection of CPT – continued - Lungs and pleura subheadings (32035-32999)- continued

LO 10.4: Apply the modifiers most commonly used with codes in the Respiratory subsection.

Slide 10-26



Commonly used modifiers in the Respiratory subsection - 50 - 51 - 52

LO 10.5: Examine the common medical and procedural terms used in operative reports.

Slide 10-27



Medical and procedural terms used in the respiratory subsection - continued - Table 10.5

Summary Slides Slides 10-28 through 10-30



Synopsis of the chapter

Teaching Tips LO 10.1:  The respiratory system is divided into the upper and lower respiratory tracts. The upper respiratory tract includes the nose, sinuses, pharynx, and larynx, and the lower respiratory system includes the trachea (windpipe), bronchial tubes, and lungs.  Flow of air through the respiratory system: enters nose (through the nasal cavities) travels through the paranasal sinuses nexts the pharynx then larynx followed by the trachea then the bronchi and finally reaches the lungs.

Coding Tips and Guidelines o There are instructional notes in CPT regarding procedures performed on the middle and superior turbinates.

LO 10.2:  Some common diseases coded to the Respiratory chapter of ICD are asthma, bronchitis, COPD, emphysema, influenza, pneumonia, respiratory failure, and TB. When coding these conditions, coders must thoroughly review the provider documentation as well as the guidelines and instructional notes.

Coding Tips and Guidelines o In ICD-10-CM sub-category acute bronchitis and bronchiolitis is now included in the category ―Other acute lower respiratory infections‖ (J20–J22).

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139 o o o o o

o o

o o

Be careful to watch for excludes and includes notes in each categories of codes. Often during the CPC exam, since time is a factor, coders will choose what they think is the appropriate code and move on without checking the instructional notes.

ICD-10-CM requires the identification of the organism causing sinusitis or tonsillitis.

ICD-10-CM has a new subcategory to report acute recurrent sinusitis.

Watch for instructional notes concerning congenital versus acquired and chronic versus acute.

For ventilator associated pneumonia (VAP), the documentation must indicate that mechanical ventilation is the cause of the pneumonia. This may also be documented as ventilator acquired or ventilator associated. It is coded to J95.851, and an instructional note directs coders to use an additional code to identify the organism.

Hypoxia is not inherent to COPD and can be an additional code (R09.02) if documented in the medical record. Hypoxia is considered inherent to acute respiratory failure and would not be reported in addition to the acute respiratory failure.

The ICD guidelines state: ―An acute exacerbation is a worsening or a decompensation of a chronic condition. An acute exacerbation is not equivalent to an infection superimposed on a chronic condition, though an exacerbation may be triggered by an infection.‖ ICD10-CM further defines asthma as mild, moderate, or severe.

Abscess of lung may be referred to in provider documentation as necrotic pneumonia or acute necrotizing pneumonia and is reported as ICD-10-CM code J85.0.

According to the ICD-10-CM guidelines, the sequencing of respiratory failure codes follows chapter-specific guidelines, with the guidelines for obstetrics, poisoning, HIV, and newborn taking precedence.

LO 10.3:  The Respiratory System subsection of the CPT manual is formatted by anatomical site from nose to lungs. The section has numerous endoscopic codes that are located under specific anatomical subheadings. A coder must be able to translate from the medical documentation the type of exam, such as indirect or direct, and the approach used, such as internal or external.

Coding Tips and Guidelines o Category J85 states ―abscess of lung and mediastinum.‖ The meaning of and in ICD is ―and/or‖; therefore, this category is used for abscess of the lung and/or mediastinum. o Determining where the procedure was performed can help the coder toward determining the appropriate code: simple or extensive. o Insertion of a nasal septal prosthesis could also be documented as insertion of a septal button. o Control of bleeding during a procedure is a normal part of the procedure and is not reported separately. However, if a nasal hemorrhage occurs as a complication of a procedure, report the control procedure with modifier 78. o Orbital exenteration is used for treatment of malignancies of ocular tissues. o Surgical sinus endoscopy includes sinusotomy and diagnostic endoscopy. Codes 31231 to 31297 are unilateral procedures unless otherwise specified. For example: 31231 Nasal endoscopy, diagnostic, unilateral or bilateral. o It is important to carefully read the full description of codes under the Larynx subheading. o An instructional notation below code 31520 states that modifier 63 is not reported with this code. o An instructional note below code 31526 states that code 69990 (microsurgical techniques, requiring use of operating microscope) is not to be used in addition to code 31526.

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140 o o o

o o

An instructional note directs the coder to report 31599 (unlisted code) if an allograft is used to reconstruct the vocal cord. It must be determined whether the graft used is an autograft or allograft.

Code 31654 (delete 31620) endobronchial ultrasound (EBUS) during bronchoscopic diagnostic or therapeutic intervention(s), is an add-on code that may be reported with codes 31622 to 31646.

Code 31627 is an add-on code and is to be used in addition to the primary procedure.

This code also includes 3-D reconstruction. Codes 31628 and 31629 should be reported only once regardless of how many biopsies are performed in a lobe or in the upper airway of a lobe. Codes 31622 to 31629 all include moderate sedation, and this would not be coded separately.

If imaging guidance is performed, the CPT manual instructs the coder to use code 75989 from the Radiology section. Delete this bullet point N/A Code 32561 is reported only on the initial day of treatment, and 32562 is reported only once per day of each subsequent day of treatment.

LO 10.4:  Modifiers are used in the Respiratory subsection to continue or modify the story of the patient’s encounter. In the Respiratory subsection, modifiers are most commonly used to indicate bilateral procedures, reduced services, multiple procedures, and/or two surgeons performing distinct parts of a single procedure.

LO 10.5:  The Respiratory subsection includes medical terms and procedural terms that are specific to the system. There are also some key terms that could appear in a provider’s documentation and act as a trigger for the coder to identify the diagnosis and/or procedure for the encounter.

Chapter 10 Answer Key Exercise 10.1 1. a. The upper respiratory tract includes which parts of the respiratory system anatomy?

Ans: Nose, sinuses, pharynx, and larynx Feedback: The upper respiratory tract includes the nose, sinuses, pharynx, and larynx.

1. b. The lower respiratory tract includes which parts of the respiratory system anatomy?

Ans: Trachea, bronchial tubes, and lungs Feedback: The lower respiratory tract includes the trachea, bronchial tubes, and lungs 2. a. Define inspiration/inhalation.

Ans: Inspiration/inhalation: Diaphragm and intercostal muscles contract. Air is drawn into the lungs.

Feedback: Inspiration/inhalation is defined as contraction of the diaphragm and intercostal muscles, which draws air into the lungs.

2. b. Define expiration/exhalation

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141 Ans: Expiration/exhalation: Opposite of inspiration; as the diaphragm and intercostal muscles relax, air is pushed out of the lungs.

Feedback: Expiration/exhalation is the opposite of inspiration; as the diaphragm and intercostal muscles relax, air is pushed out of the lungs.

3. What is the name of the partition of cartilage that divides the left and right nasal cavities?

Ans: Nasal septum Feedback: The partition of cartilage that divides the left and right nasal cavities is called the nasal septum.

4. Describe the pleura and the pleural space.

Ans: Pleura: Membrane surrounding the lung with two layers; one covers the lung and the other lines the chest cavity. Pleural space: Space between the two layers.

Feedback: N/A 5. Describe the function of the bronchioles.

Ans: Bronchioles end in small air sacs called alveoli where oxygen and carbon dioxide pass. Oxygen goes into the bloodstream and the rest of the body and carbon dioxide goes into the alveoli to be expelled during exhalation.

Feedback: N/A

Exercise 10.2 1. a. State what the abbreviation VAP stands for, and assign the appropriate ICD-10-CM code.

Ans: Ventilator associated pneumonia; ICD-10-CM code J95.851 Feedback: VAP stands for ventilator associated pneumonia and is assigned ICD-10-CM code J95.851.

1. b. What instruction is given to the coder by the instructional note included with the ICD-10-CM code?

Ans: Use additional code to identify organism, if known.

Feedback: The instructional note states to use additional code to identify organism, if known (B95.-, B96.-, B97.-).

2. a. List the other ways in which abscess of the lung may be referred to in provider documentation.

Ans: Necrotic pneumonia or acute necrotizing pneumonia Feedback: Other ways abscess of the lung may be referred to in provider documentation are necrotic pneumonia or acute necrotizing pneumonia.

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142 2. b. Select the appropriate ICD-10-CM code for this condition.

Ans: J85.0, gangrene and necrosis of lung Feedback: ICD-10-CM J85.0, gangrene and necrosis of lung would be the appropriate diagnosis code for this condition 3. How does the definition of pneumonia differ from the definition of pneumonitis?

Ans: Pneumonia is defined as infectious inflammation of lung tissue, and pneumonitis is defined as noninfectious inflammation of lung tissue.

Feedback: Pneumonia is defined as infectious inflammation of lung tissue, and pneumonitis is defined as noninfectious inflammation of lung tissue. Both involve inflammation of lung tissue, but one is infectious and the other noninfectious.

4. Select the appropriate ICD-10-CM code for acute bronchitis with COPD with an acute exacerbation.

Ans: J20.9; J44.0; J44.1 Feedback: J20.9 describes the acute bronchitis; J44.0 describes COPD with acute lower respiratory infection; and J44.1 describes COPD with acute exacerbation.

5. Define acute exacerbation.

Ans: An acute exacerbation is a worsening or a decompensation of a chronic condition.

Feedback: An acute exacerbation is a worsening or a decompensation of a chronic condition. An acute exacerbation is not equivalent to an infection superimposed on a chronic condition, though an exacerbation may be triggered by an infection.

6. a. Hypoxia is not inherent to COPD and can be reported with an additional code if it is documented in the medical record. Assign the appropriate ICD-10-CM code for documented hypoxia.

Ans: R09.02 Feedback: The ICD-10-CM code for documented hypoxia is R09.02 6. b. Is hypoxia reported in addition to acute respiratory failure?

Ans: No, ICD-10-CM code J96.01, acute respiratory failure with hypoxia, is used to report acute respiratory failure with hypoxia when documented in the medical record.

Feedback: ICD-10-CM code J96.01 includes both the acute respiratory failure and the hypoxia Exercise 10.3 1. What does a plus (+) sign in front of a CPT code mean about the code?

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143 Ans: A plus (+) sign indicates that the code is an add-on code.

Feedback: A plus sign in front of a CPT code means the code is an add-on code and must be used with the code for the primary procedure.

2. a. Code 31654 is an add-on code to be reported with which primary CPT codes?

Ans: 31622-31626; 31628; 31640; 31643; 31645; 31646 Feedback: Code 31654 is an add-on code to be reported with primary CPT codes 31622-31626; 31628; 31640; 31643; 31645; and 31646. It is to be reported only once per session.

2. b. What is the meaning of the abbreviation EBUS as used in this code?

Ans: Endobronchial ultrasound Feedback: The abbreviation EBUS means endobronchial ultrasound.

3. Assign the appropriate CPT code(s) for insertion of an indwelling tunneled pleural catheter with cuff with imaging guidance.

Ans: 32550 and 75989 Feedback: The CPT codes for insertion of an indwelling tunneled pleural catheter with cuff with imaging guidance are 32550 and 75989. The instructional note beneath code 32550 instructs the use of 75989 if imaging guidance is performed.

4. List the three distinct components of physician work that CPT includes in lung transplantation, and give the code or code ranges.

Ans: 1. Donor pneumonectomy(s) (including cold preservation), from cadaver donor CPT code 32850.

2. Backbench standard preparation of cadaver donor lung allograft prior to transplantation, including dissection of allograft from surrounding soft tissues to prepare pulmonary venous/atrial cuff, pulmonary artery, and bronchus; unilateral (CPT code 32855) or bilateral (CPT code 32856 3. Recipient lung allotransplantation; single, double with or without cardiopulmonary bypass (CPT codes 32851-32854) 5. Assign the appropriate CPT code for catheter aspiration, tracheobronchial with fiberscope, bedside.

Ans: 31725 Exercise 10.4 1. Explain modifier 50, and give an example of its use in the Respiratory System subsection of CPT. Ans: Bilateral procedure. Answers for the example will vary; one example is 30115 excision of nasal polyps (there are many other examples that can be used).

Feedback: Modifier 50 indicates bilateral procedure: one example of where this modifier can be used is 30115 excision of nasal polyps. (There are many other examples that can be used.)

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144 2. Explain modifier 51, and give an example of its use in the Respiratory System subsection of CPT. Ans: Multiple procedures. Answers for the example will vary; one example is 31500 intubation, endotracheal, emergency procedure.

Feedback: Modifier 51 indicates multiple procedures: one example of where this modifier can be used is 31500 intubation, endotracheal, emergency procedure. (There are many other examples that can be used.)

3. Explain modifier 52, and give an example of its use in the Respiratory System subsection of CPT. Ans: Reduced services. Answers for the example will vary; one example is 30465, repair of nasal vestibular stenosis. There is an instructional note with this code to use modifier 52, reduced services for a unilateral procedure Feedback: Modifier 52 indicates reduced services: one example of where this modifier can be used is 30465. (There are many other examples that can be used.)

4. Explain modifier 78, and determine whether it is a modifier that would be used with codes from the Respiratory subsection of CPT. Ans: Unplanned return to the operating/procedure room by the same physician or other qualified healthcare professional following initial procedure for a related procedure during the postoperative period Feedback: Modifier 78 indicates an unplanned return to the operating/procedure room by the same physician or other qualified healthcare professional following initial procedure for a related procedure during the postoperative period. This modifier would be used when a complication occurs during the postoperative period which requires a respiratory intervention that was not planned.

5. Explain modifier 59, and determine whether it is a modifier that would be used with codes from the Respiratory subsection of CPT. Ans: Distinct procedural service Feedback: Modifier 59 indicates a distinct procedural service. This modifier would be used when a separate and distinct respiratory procedure was performed. An example of this is given in the guidelines in the CPT manual for lungs and pleura: ―When a therapeutic wedge resection (32505, 32506, 32666, or 32667) is performed in a different lobe than the more extensive lung resection (e.g., lobectomy), report the therapeutic wedge resection with modifier 59.‖

Exercise 10.5 1. What does the abbreviation ABG stand for?

Ans: Arterial blood gas: Arterial blood is examined for levels of oxygen, carbon dioxide, or other gases.

Feedback: ABG stands for arterial blood gas; arterial blood is examined for levels of oxygen, carbon dioxide, or other gases.

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145 2. List the different types of biopsies that can be coded within the Respiratory System subsection of CPT. Ans: Incisional, excisional, needle aspiration, punch, and shave Feedback: The different types of biopsies that can be coded within the respiratory system subsection of CPT are incisional, excisional, needle aspiration, punch, and shave.

3. What is the meaning of the abbreviation ARDS, and what is another term for this condition that could be used in the documentation?

Ans: Adult Respiratory Distress Syndrome; capillary leak syndrome Feedback: ARDS stands for adult respiratory distress syndrome; capillary leak syndrome is another way this condition could be referred to in the documentation.

4. Break the word spirometry into its parts, and define the word.

Ans: Spir/o = breathing; -metry = measure; spirometry measures breathing or lung volume.

5. What is a V/Q scan?

Ans: Ventilation/perfusion scan is a nuclear medicine study which evaluates the circulation of air and blood within a patient's lungs to determine the ventilation/perfusion ratio.

Feedback: A V/Q scan is a ventilation/perfusion scan. This is a nuclear medicine study which evaluates the circulation of air and blood within a patient's lungs to determine the ventilation/perfusion ratio. The ventilation is the ability of air to reach all parts of the lungs, while the perfusion evaluates how well the blood circulates within the lungs.

Chapter Ten Review Using Terminology 1.

F

Alveoli

9.

L

Internal approach

2.

D

Anterior nasal hemorrhage control 10.

K

Larynx

3.

G

Bronchi

11.

B

Nasal hemorrhage

4.

C

Direct laryngoscopy

12.

N

Pharynx

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146 5.

H

Ethmoid sinus

13.

E

Posterior nasal hemorrhage control

6.

I

Epiglottis

14.

M

Sphenoid sinus

7.

J

External approach

15.

O

Trachea

8.

A

Indirect laryngoscopy

Checking Your Understanding 1. A pneumonectomy involves surgical removal of the: Ans: C Lungs Feedback: pneum/o = lungs; -ectomy = excision 2. Which test measures the amount of carbon monoxide and hemoglobin in the blood and is used to diagnose and manage carbon monoxide poisoning?

Ans: D Carboxyhemoglobin Feedback: Carboxyhemoglobin is a test that measures the amount of carbon monoxide and hemoglobin in the blood and is used to diagnose and manage carbon monoxide poisoning.

3. The use of a lighted endoscope to view the pleural spaces and thoracic cavity or to perform a surgical procedure is called: Ans: B Bronchoscopy Feedback: Bronchoscopy is the use of a lighted endoscope to view the pleural spaces and thoracic cavity or to perform a surgical procedure.

4. The pleura is made up of two layers, and the space between the layers is referred to as the: Ans: B Pleural space Feedback: The pleura is made up of two layers, and the space between the layers is referred to as the pleural space.

5. The term that identifies the measurement of oxygen saturation of the blood is: Ans: A Oximetry Feedback: The term that identifies the measurement of oxygen saturation of the blood is oximetry.

6. According to ICD guidelines, an acute exacerbation is a worsening or a _________________of a chronic condition. An acute exacerbation is not equivalent to an infection superimposed on a chronic condition, although an exacerbation may be _________ by an infection.

Ans: C decompensation; triggered Feedback: According to ICD guidelines, an acute exacerbation is a worsening or a decompensation of a chronic condition. An acute exacerbation is not equivalent to an infection superimposed on a chronic condition, although an exacerbation may be triggered by an infection.

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147 7. In coding pharyngitis using the ICD-10-CM manual, the identification of the ________________ causing the pharyngitis must be documented and reported.

Ans: A organism Feedback: In coding pharyngitis using the ICD-10-CM manual, the identification of the organism causing the pharyngitis must be documented and reported.

8. Assign the correct code for ablation of the soft tissue of the superior turbinate, bilateral by electrocautery, superficial: Ans: B 30999 Feedback: Instructional note takes the coder to 30999 for the superior or middle turbinate.

9. Assign the appropriate code for drainage of a nasal abscess by an internal approach: Ans: A 30000 Feedback: 30020 is for nasal septum, and 10060 and 10140 are for external approaches.

10. Assign the appropriate code(s) for a percutaneous needle biopsy of the lung with ultrasound guidance: Ans: C 32405, 76942 Feedback: 32400 is biopsy of pleura, and 76942 is a fine needle biopsy.

Applying Your Knowledge Case 1 PREOPERATIVE DIAGNOSIS: Tracheal stenosis, subglottic POSTOPERATIVE DIAGNOSIS: Same PROCEDURE PERFORMED: Fiber-optic bronchoscopy SURGEON: Stine, Frank, MD INDICATIONS: Tracheal stenosis Details of the procedure, and potential risks and alternatives, were explained, and patient consent was obtained.

MEDICATIONS: Xylocaine spray was applied to the throat and Xylocaine gel placed in the nostrils. The patient received 50 mcg of fentanyl and 8 mg of Versed intravenous.

PROCEDURE: The bronchoscope was placed orally once sufficient sedation was obtained. The vocal cords were visualized and the patient appeared to have some right true vocal cord weakness. Just below the vocal cords, in the subglottic area, scar tissue was noted and moderate narrowing of the upper trachea with almost complete closure of the airway on exhalation. Airways were immediately examined. The trachea; carina; right upper-, middle-, and lower-lobe bronchi; and left main stem bronchus and upperand lower-lobe bronchi were examined and found to be normal and without significant mucosal abnormalities. The patient tolerated the procedure well. No specimens were collected.

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148 Process 1: CPT 1. What is the procedure?

Ans: Fiber-optic bronchoscopy Feedback: The procedure is fiber-optic bronchoscopy.

2. Locate the main term in the index. What additional questions or set of questions can be determined?

Ans: Bronchoscopy. Was it diagnostic only? Was there a biopsy?

Feedback: The main term in the index is bronchoscopy. The additional questions include: Was it diagnostic only? Was there a biopsy?

3. Upon review of all the code choices identified in the index, what additional questions can be determined?

Ans: Brushing, lavage Feedback: Upon review of all the code choices identified in the index, the additional questions involve brushing and lavage.

4. Based upon the documentation, what is (are) the correct code(s) for this case?

Ans: 31622, Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; diagnostic with cell washing, when performed.

Feedback: The report supports that a diagnostic flexible bronchoscopy, CPT code 31622 was performed.

Process 2: ICD ICD-10-CM 1. Based on the operative report header, what is the preoperative diagnosis?

Ans: Tracheal stenosis, subglottic Feedback: Per the operative report header, the preoperative diagnosis is tracheal stenosis, subglottic.

2. Is the postoperative diagnosis the same as or different from the preoperative diagnosis?

Ans: Same Feedback: The postoperative diagnosis is the same as the preoperative diagnosis.

3. Is the postoperative diagnosis supported?

Ans: Yes Feedback: Yes, the postoperative diagnosis is supported.

4. What is the main term for this condition?

Ans: Stenosis

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149 Feedback: The main term for this condition is stenosis.

5. Based on the subterm choices, what question(s) can be developed for this condition?

Ans: Is the stenosis congenital, syphilitic, or tuberculous?

Feedback: Based upon the subterm choices, one question can be developed for this condition: Is the stenosis congenital, syphilitic, or tuberculous?

6. Based on the information in the Tabular List, is additional information needed to determine the appropriate diagnosis code?

Ans: No Feedback: Based upon the information in the Tabular List, no additional information is needed to determine the appropriate diagnosis code.

7. Is any sign, symptom, or additional condition documented?

Ans: No Feedback: No signs, symptoms, or additional conditions are documented.

8. Is the additional condition, sign, or symptom an integral part of the primary (or other) condition coded?

Ans: No Feedback: There are no additional signs or symptoms with this record.

9. Does the additional condition require or affect patient care, treatment, or management?

Ans: No Feedback: N/A

10. Based on the documentation, what is (are) the correct ICD-10-CM code(s) for this case?

Ans: J39.8 Other specified diseases of upper respiratory tract Feedback: The documentation states the diagnosis as tracheal stenosis. ICD-10-CM index for stenosis, trachea, leads the coder to J39.8 Process 3: Modifiers 1. Was the procedure performed different from that described by the nomenclature of the code?

Ans: No

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150 Feedback: The procedure performed was not different from that described by the nomenclature of the code.

2. Was the procedure performed at an anatomical site that has laterality?

Ans: No Feedback: The procedure was performed at an anatomical site which has no laterality.

3. Was the procedure performed in the global period of another procedure?

Ans: No Feedback: The procedure performed was not in the global period of another procedure.

4. Were additional procedures performed during the operative session, and does the documentation support them?

Ans: No additional procedures were performed.

Feedback: There were no additional procedures performed during the operative session.

5. Did the surgeon have help from another surgeon or other appropriate person?

Ans: No Feedback: The surgeon did not have help from another surgeon or other appropriate person.

6. Did a physician different from the surgeon provide the preoperative or postoperative portion of the procedure?

Ans: No Feedback: No physician different from the surgeon provided the pre- or postoperative portion of the procedure.

7. What modifier(s) should be appended to the CPT code for this case?

Ans: None Feedback: No modifiers should be appended to the CPT for this case.

Case 2 PREOPERATIVE DIAGNOSIS: Pulmonary infiltrates, bilateral.

POSTOPERATIVE DIAGNOSES: Bilateral pneumonia and tracheobronchitis, diffuse.

PROCEDURE PERFORMED: Bronchoscopy with biopsy.

SURGEON: Harold Potter, MD ANESTHESIA: Conscious sedation was provided and monitored by Dr. H. Granger, anesthesiologist Specimens gathered and sent to pathology include: Bronchoalveolar lavage and bronchial brushings sent for cytology

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151 Bronchial washings sent to pathology for culture, gram stain, C&S and DFA for Legionella.

Transbronchial biopsies for pathology.

FINDINGS: Trachea of this 61-year- old man was within normal limits. There appeared to be mild diffuse tracheobronchitis from the level of the carina and extending throughout the right and left bronchial trees. No endobronchial lesions or mucosal irregularities were found. During lavage of left lower lobe, yellow purulent mucous plugs were aspirated. All mucous plugs were cleared upon completion of lavage procedure.

PROCEDURE: The patient was brought to the endoscopy suite and local anesthesia of the left naris and posterior pharynx was administered followed by conscious sedation. After adequate conscious sedation was achieved the Olympus bronchofiberscope was inserted into the left naris and advanced to the posterior pharynx through the vocal cords and into the trachea. The entire tracheobronchial tree was then systematically inspected. The bronchoscope was advanced to the left upper lobe and the bronchoscope was wedged into the apical segment. Bronchoalveolar lavage was then performed at this segment utilizing 80 mL of saline. Bronchoscope was then pulled back at the level of the carina and advanced into the left lower lobe. Bronchial brushings were obtained from the medial and lateral segments of the left lower lobe under fluoroscopic guidance. Under fluoroscopic guidance, transbronchial biopsies x 3 were obtained from various subsegments of both the left lower lobe and left upper lobe. The areas were then inspected for any acute hemorrhage, none seen. The bronchoscope was withdrawn. The patient tolerated the procedure well, without complications.

Process 1: CPT 1. What is the procedure?

Ans: Transbronchial biopsy, bronchial alveolar lavage and bronchial brushings Feedback: The procedure is transbronchial biopsy, bronchial alveolar lavage and bronchial brushings.

2. Locate the main term in the index. What additional questions or set of questions can be determined?

Ans: Under main term bronchi, approach (endoscopy) then procedure (biopsy).

Under main term bronchial alveolar lavage, none.

Under main term bronchial brushings, method as by catheterization or protected.

Feedback: After locating the main term in the index, additional questions are as follows: under main term bronchi, approach (endoscopy) then procedure (biopsy); under main term bronchial alveolar lavage, none; under main term bronchial brushings, method as by catheterization or protected.

3. Upon review of all the code choices identified in the index, what additional questions should be determined?

Ans: How were the transbronchial biopsy(s) performed and in how many different lobes?

Feedback: Upon review of all the code choices identified in the index, the following additional questions can be determined: How were the transbronchial biopsy(s) performed and in how many different lobes?

4. Based on the documentation, what are the correct codes for this case?

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152 Ans: D 31628, 31632, 31624, 31623 Feedback: Based upon the documentation, 31628, bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed with transbronchial lung biopsy(s), single lobe; 31632 with transbronchial lung biopsy(s), each additional lobe; 31624, with bronchial alveolar lavage, and 31623, with brushing or protected brushings ICD-10-CM 1. Based on the operative report header, what is the preoperative diagnosis?

Ans: Pulmonary infiltrates, bilateral Feedback: Per the operative report header, the preoperative diagnosis is pulmonary infiltrates, bilateral.

2. Is the postoperative diagnosis the same as or different from the preoperative diagnosis?

Ans: Different: bilateral pneumonia and tracheobronchitis, diffuse Feedback: The postoperative diagnosis is different than the preoperative diagnosis: bilateral pneumonia and tracheobronchitis, diffuse.

3. Is the postoperative diagnosis supported?

Ans: Yes: ―yellow purulent mucous plugs were aspirated‖ Feedback: The postoperative diagnosis is supported by the following: ―yellow purulent mucous plugs were aspirated.‖ 4. What is the main term for this condition?

Ans: Pneumonia Feedback: Pneumonia is the main term for this condition.

5. Based on the subterm choices, what question(s) can be developed for this condition?

Ans: Anatomic site, type, underlying condition or cause, and additional related conditions Feedback: Based upon the subterm choices, the following question topics can be developed for this condition: anatomic site, type, underlying condition or cause, and additional related conditions.

6. Based upon the information in the Tabular List, is additional information needed to determine the appropriate diagnosis code?

Ans: Yes; additional information needed includes the presence of associated conditions, and for secondary diagnosis, age of the patient.

Feedback: Based upon the information in the Tabular List, the following additional information is needed to determine the appropriate diagnosis code: presence of associated conditions, and, for secondary diagnosis, age of the patient.

7. Is any sign, symptom, or additional condition documented?

Ans: Yes, tracheobronchitis

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153 Feedback: Tracheobronchitis is a sign, symptom, or additional condition documented.

8. Is the additional condition, sign, or symptom an integral part of the primary (or other) condition coded?

Ans: No Feedback: The additional condition, sign, or symptom is not an integral part of the primary (or other) condition coded.

9. Does the additional condition require or affect patient care, treatment, or management?

Ans: Yes, inspection Feedback: The additional condition does require or affect patient care, treatment, or management as it requires inspection.

10. Based on the documentation, what are the correct ICD-10-CM codes for this case?

Ans: D J18.9 pneumonia, unspecified organism; J40 Bronchitis, not specified as acute or chronic.

Feedback: Without further specificity J18.9 pneumonia, unspecified organism and J40 bronchitis, not specified as acute or chronic would be the appropriate codes .

Process 3: Modifiers 1. Was the procedure performed different then as described by the nomenclature of the code?

Ans: No Feedback: The procedure performed was not different than as described by the nomenclature of the code.

2. Was the procedure performed at an anatomical site that has laterality?

Ans: Yes Feedback: The procedure was performed at an anatomical site that has laterality.

3. Was the procedure performed in the global period of another procedure?

Ans: No Feedback: The procedure performed was not in the global period of another procedure.

4. Were additional procedures performed during the operative session, and does the documentation support them?

Ans: Yes Feedback: Yes, additional procedures were performed during the operative session and the documentation does support them.

5. Did the surgeon have help from another surgeon or another appropriate person?

Ans: No

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154 Feedback: The surgeon did not have help from another surgeon or other appropriate person.

6. Did a physician different from the surgeon provide the preoperative or postoperative portion of the procedure?

Ans: No Feedback: There was not a physician different from the surgeon providing the pre- or postoperative portion of the procedure.

7. What modifier(s) should be appended to the CPT for this case?

Ans: B Modifier 51, multiple procedures Feedback: Modifier 51, multiple procedures, would be the appropriate modifier to report

Chapter 11 – Surgery Section: Cardiovascular and Lymphatic Systems LESSON PLANS Class Preparation: Teaching Focus and Resources The anatomy and medical terminology specific to the cardiovascular system as well as the lymphatic system are reviewed in this chapter. Guidelines and modifiers needed to assist the coder in selecting the most appropriate codes are also examined.

Learning Outcomes After completing Chapter 11, students will be able to: LO 11.1 Review the anatomy of the cardiovascular system.

LO 11.2 Review the anatomy of the lymphatic system.

LO 11.3 Understand chapter-specific ICD guidelines and format for the circulatory system.

LO 11.4 Identify the guidelines and format of the Cardiovascular subsection of CPT. LO 11.5 Identify the guidelines and format of the Lymphatic subsection of CPT. LO 11.6 Apply the modifiers most commonly used with codes in the Cardiovascular subsections.

LO 11.7 Examine the common medical and procedural terms used in operative reports.

Class Presentation LO 11.1: Review the anatomy of the cardiovascular system.

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155 Slides 11-1 through 11-4



Introduction to chapter and key terms

Slide 11-5



Anatomy of the cardiovascular system

Slide 11-6



Anatomy of the cardiovascular system - continued - Anatomy of the heart

Slide 11-7



Anatomy of the cardiovascular system- continued - Heart - Great vessels

Slide 11-8



Anatomy of the cardiovascular system – continued - Heart – continued

LO 11.2: Review the anatomy of the lymphatic system.

Slide 11-9



Anatomy of the lymphatic system - Table 11.4

LO 11.3: Understand chapter-specific ICD guidelines and format for the circulatory system.

Slide 11-10



ICD chapter-specific guidelines and format for the Circulatory system chapter

Slide 11-11



ICD chapter-specific guidelines and format for the Circulatory system chapter - continued - Acute Rheumatic Fever

Slide 11-12



ICD chapter-specific guidelines and format for the Circulatory system chapter - continued -

Slide 11-13



ICD chapter-specific guidelines and format for the Circulatory system chapter - continued -

Slide 11-14





Hypertensive disease

ICD chapter-specific guidelines and format for the Circulatory system chapter - continued -

Slide 11-15

Chronic rheumatic heart disease

Hypertensive disease – continued

ICD chapter-specific guidelines and format for the Circulatory system chapter - continued -

Ischemic heart disease

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156 Slide 11-16



ICD chapter-specific guidelines and format for the Circulatory system chapter – continued -

Slide 11-17



ICD chapter-specific guidelines and format for the Circulatory system chapter – continued -

Slide 11-18







Cerebrovascular disease

ICD chapter-specific guidelines and format for the Circulatory system chapter – continued -

Slide 11-20

Other forms of heart disease

ICD chapter-specific guidelines and format for the Circulatory system chapter – continued -

Slide 11-19

Pulmonary Heart Disease and Diseases of Pulmonary Circulation

Diseases of arteries, arterioles, and capillaries

ICD chapter-specific guidelines and format for the Circulatory system chapter – continued -

Diseases of veins and lymphatics

LO 11.4: Identify the guidelines and format of the Cardiovascular subsection of CPT. Slide 11-21



CPT guidelines and format of the Cardiovascular subsection - Heart and pericardium (33016-33999) Pericardiocentesis (33016-33050) Pacemaker or Pacing cardioverter-defibrillator (33202–33249, 3326233264, 33270-33273) - Coding questions

Slide 11-22



CPT guidelines and format of the Cardiovascular subsection – continued - Heart and pericardium – continued Electrophysiologic operative procedures (33250-33266) Heart and great vessels (33300-33340)

Slide 11-23



CPT guidelines and format of the Cardiovascular subsection – continued -

Heart and pericardium – continued Cardiac valves (33361-33478) Coronary artery bypass grafting (33510-33548)

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157 Slide 11-24



CPT guidelines and format of the Cardiovascular subsection – continued -

Heart and pericardium – continued Septal defect (33641-33697) Heart/lung transplantation (33927-33945)

Slide 11-25



CPT guidelines and format of the Cardiovascular subsection – continued -

Slide 11-26



CPT guidelines and format of the Cardiovascular subsection – continued -

Slide 11-27







Arteries and veins – continued Vascular injection procedures (36000-36598) Nonselective placement Selective placement

CPT guidelines and format of the Cardiovascular subsection – continued -

Slide 11-29

Arteries and veins (34001-34490) Embolectomy/thrombectomy (34001-34490)

CPT guidelines and format of the Cardiovascular subsection – continued -

Slide 11-28

Heart and pericardium – continued Cardiac assist (33967–33983, 33990-33993) Endovascular Repair

Arteries and veins – continued Central venous access procedures (36555-36598)

CPT guidelines and format of the Cardiovascular subsection – continued -

Arteries and veins – continued Hemodialysis access (36800-36861)

LO 11.5: Identify the guidelines and format of the Lymphatic subsection of CPT. Slide 11-30



CPT guidelines and format of the Lymphatic subsection - Hemic and lymphatic systems (38100-38999) Spleen (38100-38200) Bone marrow or stem cell services (38204-38243) Lymph nodes and lymphatic channels (38300-38999)

LO 11.6: Apply the modifiers most commonly used with codes in the Cardiovascular subsections.

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158 Slide 11-31



Modifiers common with Cardiovascular subsection codes - 51 - 52 - 53 - 57 - 58 - 59 - 78 -

Table 11.9

LO 11.7: Examine the common medical and procedural terms used in operative reports.

Slide 11-32



Common medical and procedural terms used with the cardiovascular and lymphatic systems - Table 11.10 and 11.11

Summary Slides Slides 11-33 through 11-37



Synopsis of chapter

Teaching Tips LO 11.1:  The cardiovascular system consists of the heart, blood, and blood vessels which include arteries, veins, and capillaries.  It includes the pulmonary circulation system, where blood is pumped away from the heart by the pulmonary artery; to the lungs; and then returned to the heart by the pulmonary vein.  The systemic circulation system transports oxygenated blood away from the heart, to the rest of the body, and returns oxygen depleted blood back to the heart.

Coding Tips and Guidelines o Codes are often further defined by whether the vein is superficial or deep, so it is helpful to know which veins are considered superficial and which are considered deep. Often, the coding manual will help with this distinction.

LO 11.2:  The lymphatic system is made up of fluid or lymph, lymph vessels, and lymphoid tissue such as lymph nodes, the spleen, and the thymus.

LO 11.3:  The most common problems patients present with concerning this system are chest pain, hypertension, edema, murmur, palpitations, congestive heart failure, arrythmias, syncope, hyperlipidemia, claudication, and congenital heart disease. When coding these conditions, coders must thoroughly review the provider documentation as well as the guidelines and instructional notes.

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159

    



ICD-10-CM: Diseases of the Circulatory System is Chapter 9 in the ICD-10-CM manual, with the code range I00–I99.

Rheumatic fever codes are further defined by the type of heart involvement, such as endocarditis.

When coding for heart valve conditions, the coder needs to know which valve(s) was (were) involved, such as the mitral valve, and what the diagnosed disease of the involved valve(s) is, such as stenosis.

The chapter-specific guidelines should be referred to and followed when assigning codes from the hypertensive heart and/or kidney disease range.

When coding for heart failure, the coder must assign an additional code to identify the specific type of failure.

Before assigning a code for an AMI, the coder must identify the episode of care and the location of the myocardial infarction.

Coding Tips and Guidelines o Mitral valve with aortic valve involvement is divided further by the type of disease of each valve: Stenosis of both valves Insufficiency of both valves Stenosis of one valve and insufficiency of the other o Be sure to use the Alphabetic Index to guide you to the right code range or ranges. o ICD-10-CM does not list separate codes for benign, malignant, or unspecified hypertension. Code I10 is for essential primary hypertension and includes high blood pressure and hypertension (arterial, benign, essential, malignant, primary, and systemic).

There is also an includes note in ICD-10-CM that informs the coder to use an additional code to identify exposure to environmental tobacco smoke, history of tobacco use, occupational exposure to environmental tobacco smoke, tobacco dependence, or tobacco use. o Look for statements in the documentation such as ―heart disease due to hypertension‖ or ―hypertensive heart disease.‖ These statements lead to the I11-I13 code range. o Note that unstable angina falls into the 411 category and under the term intermediate coronary syndrome, while angina pectoris is defined by ICD-10-CM code I20.9 and has combination codes for atherosclerotic heart disease with angina pectoris: I25.11 and I25.7. Delete this bullet point N/A o Remember: The pericardium is the sac around the heart; the endocardium is the inner layer of the heart wall, and the myocardium is the muscle layer of the heart wall. o Be careful when reading the documentation to properly identify the site of the dysrhythmia as atrial or ventricular and the condition as fibrillation or flutter. o o

Right heart failure is included in the code description for congestive heart failure.

Late effects usually require two codes, one for the late effect and one for the condition or nature of the late effect. Late effects of cerebrovascular disease are reported with a combination code which includes the current condition and the late effect.

LO 11.4:  Before assigning the appropriate codes for a pacemaker or cardioverterdefibrillator procedure, coders must answer several questions, such as whether it was single- or dual-chamber, was an insertion or replacement, and involved a transvenous or epicardial approach.  There are three types of coronary bypass grafting: venous grafting only, arterial grafting only, and combined arterial-venous grafting.  Repair of an aneurysm is most commonly accomplished by a direct procedure or by endovascular repair.

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160 

CPT coding decisions for vascular injection or introduction procedures are based on whether the physician performed a selective or nonselective catheter placement.

Coding Tips and Guidelines o Highlight the boldface and italic items in this section of your CPT manual to remind yourself of these tips and guidelines when using the manual. o In most editions of the CPT manual there is a grid showing the code description of the transvenous procedure and the appropriate pacemaker or defibrillator code. This is a good resource for help with the selection of codes. o It is very helpful to highlight key terms in the description of the codes in this code range, specifically the words pacemaker and cardioverter-defibrillator. This helps to keep the coding ranges separate when taking the CPC exam. Often, coders will read the scenario and answer quickly, confusing the codes. o The guidelines before the range of codes 33250-33266 include definitions of limited and extensive operative ablation, and the coder should refer to them before making a code selection. o To assign codes in the 33300-33355 range, coders need to know which vessels are the great vessels.

Reminder: The great vessels include the superior vena cava, aorta, pulmonary arteries, pulmonary veins, and inferior vena cava. o There are very specific guidelines in the CPT manual for TAVR/TAVI procedures (TAVR— transcatheter aortic valve replacement; TAVI— transcatheter aortic valve implantation). Coders should become familiar with these guidelines before choosing codes from this code range. o All of the codes in range 33517–33530 (combined arterial-venous grafting for coronary bypass) have a plus (+) sign in front of them, indicating that these codes are add-on codes and may not be used alone or as primary codes. o When assigning a code from this range, coders should use the appropriate code from range 33533–33548 (arterial grafting for coronary bypass) as the primary code. o Open procurement (harvesting) of the saphenous vein or internal mammary artery is included in the code descriptions of CABG and is not reported separately. This is noted in the guidelines before each section of the grafting code ranges in the CPT manual. o When coding for a CABG, remember that you are determining what type of graft was used and the number of grafts used to bypass the affected artery. Also remember that you are counting the number of grafts, not the number of veins or arteries. o The same rules apply for the venous side, using the vena cava as the point of Advancement for selective vascular injections. Think of the aorta or vena cava as a hallway: If the catheter does not move from the hallway, the placement is considered nonselective. If the catheter moves beyond the hallway through a door and into one of the rooms, or orders, of a vascular family, this is a selective placement. o Appendix L of the CPT manual outlines the branches and orders of the vascular families. o A centrally inserted catheter uses the jugular, subclavian, or femoral vein or the inferior vena cava as the entry site. A peripherally inserted catheter is generally placed in the basilic or cephalic vein and then moved forward into the subclavian vein. o A peripherally inserted catheter is often referred to in documentation as a PICC (peripherally inserted central catheter). o Many editions of the CPT manual include a central venous access procedures table that should be used as a resource when selecting the appropriate code(s) from this code range.

LO 11.5:

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161 

Codes within the hemic and lymphatic ranges include those for procedures involving the spleen, bone marrow or stem cell services, and lymph nodes and lymph channels.

LO 11.6:  Modifiers are used in the Cardiovascular subsection to continue or modify the story of the patient’s encounter. Some of the more common modifiers used in this section are: • Bilateral services, 51 • Discontinued procedure, 53 • Staged or related procedure or service by the same physician during the postoperative period, 58 • Distinct procedural service, 59 • Unplanned return to the operating/procedure room by the same physician or another qualified healthcare professional following the initial procedure for a related procedure during the postoperative period, 78 LO 11.7:  The Cardiovascular and Lymphatic subsections include medical terms and procedural terms that are specific to the system involved. There are also some key terms that could appear in a provider’s documentation and act as a trigger for the coder to identify the diagnosis and/or procedure for the encounter.

Coding Tips and Guidelines o Documentation of an elevated blood pressure reading without a diagnosis of hypertension is not coded to hypertension.

Chapter 11 Answer Key Exercise 11.1 1. Between which two chambers of the heart is the tricuspid valve located?

Ans: Right atrium and right ventricle Feedback: The tricuspid valve is located between the right atrium and right ventricle.

2. What is the name of the muscle layer of the heart-wall tissue?

Ans: Myocardium Feedback: The muscle layer of the heart-wall tissue is called the myocardium.

3. What is the name of the heart’s natural pacemaker?

Ans: S-A (sinoatrial) node Feedback: The heart’s natural pacemaker is called the sinoatrial (SA) node.

4. Which coronary vessel is a branch of the Left Circumflex Artery and supplies blood to the left atrium and back of the left ventricle?

Ans: Circumflex

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162 Feedback: The circumflex is the coronary vessel that is a branch of the LCA and supplies blood to the left atrium and the back of the left ventricle.

Exercise 11.2 1. Which structure of the lymphatic system produces T cells?

Ans: Thymus Feedback: The thymus is the structure of the lymphatic system that produces T cells.

2. Where are lymph nodes located?

Ans: Along the lymph vessels Feedback: The lymph nodes are located along the lymph vessels.

3. What is (are) the function(s) of the lymph nodes?

Ans: They act as filters and produce antibodies and lymphocytes.

Feedback: The lymph nodes act as filters and produce antibodies and lymphocytes.

Exercise 11.3 1. The patient presents with a diagnosis of congestive heart failure (CHF) due to hypertension (HTN). What is (are) the correct ICD-10-CM code(s)?

Ans: I11.0, I50.9 Feedback: I11.0 defines hypertensive heart disease with heart failure and I50.9 reports the heart failure, unspecified.

2. The mitral valve regulates blood flow between the __________ and the __________.

Ans: Left atrium and left ventricle.

Feedback: The mitral valve regulates blood flow between the left atrium and the left ventricle.

3. The patient is diagnosed with acute rheumatic fever with severe inflammation of the heart muscle. What is the appropriate ICD-10-CM code?

Ans: I01.2 Feedback: The appropriate ICD-10-CM code for this situation is I01.2, acute rheumatic myocarditis.

4. A patient presents with a diagnosis of DVT of lower limb. Assign the appropriate ICD-10-CM code.

Ans: I82.409

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163 Feedback: I82.409, acute embolism and thrombosis of unspecified deep veins of unspecified lower extremity. More specific codes are available if more specificity, such as laterality and specific vein involved.

5. List the types of heart failure that affect code assignment.

Ans: Congestive heart failure, left heart failure, systolic heart failure, and diastolic heart failure Feedback: The types of heart failure that affect code assignment are congestive heart failure, left heart failure, systolic heart failure, and diastolic heart failure.

Exercise 11.4 1. What are the three types of coronary artery bypass grafting?

Ans: Arterial only, venous only, and combination arterial and venous Feedback: The three types of coronary artery bypass grafting are arterial only, venous only, and combination arterial and venous.

2. Identify the code to be assigned for insertion of a PICC without subcutaneous port or pump in a patient younger than 5 years of age.

Ans: 36568 Feedback: The correct code for insertion of a PICC without subcutaneous port or pump in a patient younger than 5 years of age is 36568.

3. To qualify as a central venous access device, where must the tip of the catheter terminate?

Ans: In the subclavian, brachiocephalic (innominate), or iliac veins; the superior or inferior vena cava; or the right atrium Feedback: The guidelines at the beginning of this range of codes instruct the coder that to qualify as a central venous access device, the tip of the catheter must terminate in the subclavian, brachiocephalic (innominate), or iliac veins; the superior or inferior vena cava; or the right atrium.

4. Identify the appropriate code for removal of a transvenous electrode only, single lead system, for an implantable cardioverter-defibrillator.

Ans: 33244 Feedback: The appropriate code for removal of a transvenous electrode only, single lead system, for an implantable cardioverter-defibrillator is 33244.

Exercise 11.5 1. What is the appropriate code for the injection procedure for identification of a sentinel node?

Ans: 38792, Injection procedure radioactive tracer for identification of sentinel node

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164 Feedback: The injection procedure of a radioactive tracer for identification of sentinel node is reported with CPT code 38792 2. Assign the appropriate code for a surgical laparoscopy with multiple retroperitoneal lymph node sampling.

Ans: 38570 Feedback: The code description informs the coder that this code would be used for either single or multiple sampling.

Exercise 11.6 1. The patient presents in the office with atrial fibrillation, and the physician decides to insert a dual-chamber pacemaker the next day. The physician completes a medically appropriate history and/or exam and medical decision making of low complexity for this established patient. . Assign the appropriate CPT code along with any needed modifier.

Ans: 33208, Insertion of new or replacement of permanent pacemaker with transvenous electrode(s) atrial and ventricular; 99213, office or outpatient visit established patient, modifier 57, decision for surgery.

Feedback: 33208 reports the placement of a dual chamber pacemaker while the 99213 reports the office visit the day before the surgery where the decision for surgery was made. The modifier 57, decision for surgery, is needed to show this visit is not part of the global package.

2. Procedures of the atrial and mitral valves were performed. Is a modifier needed? If so, which one would be appropriate?

Ans: Yes, modifier 51 Feedback: Modifier 51, multiple procedures, is needed.

3. The physician starts a valvuloplasty procedure, and the patient becomes tachycardic and the valvuloplasty is stopped. Which modifier would be used to tell the story of this patient encounter?

Ans: Modifier 53 Feedback: Modifier 53, discontinued service, is needed.

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165 Exercise 11.7 1. An opening or hole between the right and left atria is a(n)_____.

Ans: ASD, or atrial septal defect Feedback: An opening or hole between the right and left atrium is described as an ASD, or atrial septal defect.

2. What is the abbreviation for a group of signs and/or symptoms indicating that the SA node is not functioning adequately?

Ans: SSS (sick sinus syndrome) Feedback: A group of signs and/or symptoms indicating the SA node is not functioning adequately would be abbreviated as SSS, for sick sinus syndrome.

3. An abnormal blowing sound heard on ausculation could be indicated in the documentation as a ____________.

Ans: bruit Feedback: An abnormal blowing sound heard upon auscultation could be indicated in the documentation as a bruit.

4. What are the two types of cardioversion?

Ans: Internal and external Feedback: The two types of cardioversion are internal and external.

5. What is the difference between a shunt and a stent?

Ans: A stent is used to keep a vessel open. A shunt is used to bypass fluids.

Feedback: The difference between a shunt and a stent is that a stent is used to keep a vessel open, while a shunt is used to bypass fluids.

Chapter Eleven Review Using Terminology 1.

F

Ablation

9.

K

Defibrillator

2.

D

Aneurysm

10.

B

Embolus

3.

G

Angina pectoris

11.

E

Infarction

4.

C

Angiography

12.

M

Ischemia

5.

H

Aorta

13.

J

Lymph node

6.

I

Arrhythmia

14.

P

Lymph vessel

7.

A

Coronary artery bypass graft (CABG)

15.

O

Pacemaker

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166 8.

L

Deep vein thrombosis (DVT)

16.

N

Thrombus

Checking Your Understanding 1. A mass of undissolved matter that is transported in the blood is called a(n): Ans: D. embolus Feedback: An embolus is a mass of undissolved matter that is transported in the blood. A clot is a type of embolus, an abscess is a collection of pus, and a neoplasm is a new growth.

2. A 32-year-old patient is admitted for fever, shortness of breath, and night sweats. The patient has just returned from a mission trip for her church during which she traveled to Africa for 3 weeks. Blood tests, cultures, and echocardiograms reveal endocarditis due to blastomycosis. She will remain in the hospital for IV antibiotics. Select the appropriate ICD-10-CM codes: Ans: A. B40.9 Blastomycosis, unspecified; I39 Endocarditis and heart valve disorders in diseases classified elsewhere.

Feedback: Both codes need to be listed; B40.9 is listed first by ICD-10-CM direction.

3. The patient is diagnosed with acute coronary insufficiency and is admitted for CABG using four veins harvested endoscopically from the left saphenous vein. Select the appropriate ICD-10-CM and CPT codes: Ans: A. 33513, 33508, I24.8 change I24.8 to I24.89 Feedback: Since the saphenous vein was harvested endoscopically, code 33508 should be reported along with 33513, which describes the bypass using four vein grafts.

4. Abnormal heart rhythms that are too slow are identified as: Ans: C. Bradycardia Feedback: Bradycardia are abnormal heart rhythms that are too slow. Tachycardia is a rapid heart rate, and dysrhythmia and arrhythmia are both irregular heart rates.

5. A patient is admitted to the cardiac unit with an acute ST elevation (type 1) MI of the inferolateral wall and a third-degree AV block. The patient has no history of prior MI. Select the appropriate ICD-10-CM codes: Ans: A. I21.19, I44.2 Feedback: I21.19 defines an ST elevation myocardial infarction involving other coronary artery of inferior wall, and I44.2 describes an AV block, third degree..

6. A physician inserts a single temporary transvenous pacing catheter into the right atrium and connects the electrode to an external pulse generator. How should the physician report these services?

Ans: C. 33210 Feedback: 33210 reports a temporary pacemaker.

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167 7. Choose the appropriate ICD-10-CM code for diagnosis of ataxia due to CVA: Ans: A. I69.993 Feedback: I69.993 describes the sequalae or late effect (ataxia) of a CVA and requires only one code.

8. Jack Smith was diagnosed with a thoracic aortic aneurysm. He was admitted to the hospital and underwent transverse arch graft to repair the aneurysm. Cardiopulmonary bypass was provided as well. Select the correct CPT and ICD-10-CM codes: Ans: B. 38871, I71.22 new answer is 33877, I71.22 Feedback: 38871 change 38871 to 33877 includes the repair and the cardiopulmonary bypass while I71.22 describes thoracic aortic arch aneurysm without rupture.

9. The heart wall is composed of three layers. They are the epicardium, myocardium, and: Ans: C. Endocardium Feedback: The endocardium is the third layer of the heart wall. Echocardium is not a term. Epithelium pertains to the covering of internal and external surfaces of the body. Valves are a membranous fold in a canal or passage, which prevent the reflux of the contents passing through.

10. Maria has hypertensive chronic kidney disease, stage III. She also has congestive heart failure and osteoarthritis in her right shoulder. She was seen by her cardiologist for routine maintenance.

Reporting only the ICD-10-CM codes, select the correct codes.

Ans: D. I13.0, I50.9, N18.30, M19.011 Feedback: I13.0 describes hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease or unspecified chronic kidney disease. There is an instructional note under this code to use an additional code to identify the type of heart failure (I50.-) and to identify the stage of chronic kidney disease (N18.-). M19.011 describes osteoarthritis of the right shoulder.

Applying Your Knowledge Case Study: Cardio Note PROCEDURE PERFORMED: Placement of permanent pacemaker, dual chamber.

INDICATIONS: A definite diagnosis of atrial fibrillation was made, and I determined during the office visit yesterday that a permanent dual-chamber pacemaker device would be inserted today.

POST-OPERATIVE DIAGNOSIS: Atrial fibrillation.

PROCEDURE: The patient was prepped and draped in the usual sterile fashion. A needle was passed into the left subclavian vein, and good blood was noted. The guide wire was passed through the needle, and

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168 the needle was removed. The dilator and introducer were then passed over the wire. Once in position, the dilator and guide wire were removed and leads were placed.

Leads were placed in the right ventricle and atrium, sequentially.

I then turned to placement of the pulse generator. A subcutaneous pacemaker pocket was created in the right anterior chest wall, and the pulse generator was placed in the pocket. A subcutaneous tunnel was made, and the leads were threaded thru and attached to the generator. The pocket was sutured in the usual sterile fashion, and the patient tolerated the procedure well. A chest x-ray was ordered to verify placement of leads and generator upon completion of the procedure.

Process 1: CPT 1. What is the procedure?

Ans: Insertion of permanent pacemaker, dual chamber Feedback: The procedure is insertion of permanent pacemaker, dual chamber.

2. Locate the main term in the index.

Ans: Insertion Feedback: The main term in the index is insertion.

3. What additional questions or set of questions can be determined?

Ans: Pacemaker, Heart; Pacing, Cardio-defibrillator Feedback: Additional questions can be related to the following topics: Pacemaker, Heart; and Pacing, Cardio-defibrillator.

4. Upon review of all the code choices identified in the index, what additional questions can be determined?

Ans: Pulse Generator Only, Leads Feedback: Upon review of all the code choices identified in the index, the following additional question topics can be determined: Pulse Generator Only and Leads.

5. Based on the documentation, what is (are) the correct code(s) for this case?

Ans: C 33208 Feedback: Based upon the documentation, the correct code for this case is 33208. The documentation tells the coder the device was a pacemaker. The documentation tells the coder this was an insertion of the generator and the leads. The documentation tells the coder this was dual chamber placement of leads (―leads were placed in the right ventricle and atrium, sequentially‖). The documentation tells the coder the approach was transvenous.

Process 2: ICD ICD-10-CM 1. Based on the operative report header, what is the preoperative diagnosis?

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169 Ans: Atrial fibrillation Feedback: Per the operative report header, the preoperative diagnosis is atrial fibrillation (which is located in the indication section of the report).

2. Is the postoperative diagnosis the same as or different from the preoperative diagnosis?

Ans: Same Feedback: The postoperative diagnosis is the same as the preoperative diagnosis.

3. What is the main term for this condition?

Ans: Fibrillation Feedback: The main term for this condition is fibrillation.

4. Based on the subterm choices, what question(s) can be developed for this condition?

Ans: Was the fibrillation atrial or ventricular? Since in this case study the fibrillation is defined as atrial, the next question that needs to be asked to determine further specificity is paroxysmal, persistent, or chronic.

Feedback: Based upon the subterm choices, the questions that can be developed for this condition are as follows: Was the fibrillation atrial or ventricular? If atrial, paroxysmal, persistent, or chronic?

5. Is any sign, symptom, or additional condition documented?

Ans: Yes: ―Patient has been experiencing palpitations and an awareness of an irregular heartbeat with some dizziness and weakness.‖ Feedback: Yes, signs, symptoms, or additional conditions are documented: ―Patient has been experiencing palpitations and an awareness of an irregular heartbeat with some dizziness and weakness.‖ 6. Is the additional condition, sign, or symptom an integral part of the primary (or other) condition coded?

Ans: Yes Feedback: The additional condition, sign, or symptom is an integral part of the primary (or other) condition coded.

7. Based on the documentation, what is the correct ICD-10-CM code for this case?

Ans: A I48.91, unspecified atrial fibrillation Feedback: Based upon the documentation, the correct ICD-10-CM code for this case is I48.91, unspecified atrial fibrillation (unspecified since it was not documented as paroxysmal, persistent, or chronic).

Process 3: Modifiers 1. Was the procedure performed different from that described by the nomenclature of the code?

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170 Ans: No Feedback: The procedure performed was not different from that described by the nomenclature of the code.

2. Was the procedure performed on an anatomical site that has laterality?

Ans: No Feedback: The procedure was performed on an anatomical site that does not have laterality.

3. Was the procedure performed in the global period of another procedure?

Ans: No Feedback: The procedure performed was not in the global period of another procedure.

4. Were additional procedures performed during the operative session, and does the documentation support them?

Ans: No Feedback: There were no additional procedures performed during the operative session.

5. Did the surgeon have help from another surgeon or another appropriate person?

Ans: No Feedback: The surgeon did not have help from another surgeon or other appropriate person.

6. Did a physician different from the surgeon provide the preoperative or postoperative portion of the procedure?

Ans: No Feedback: There was no physician different from the surgeon providing the pre- or postoperative portion of the procedure.

7. What modifier should be appended to the CPT for this case?

Ans: C None Feedback: No modifier(s) should be appended to the CPT for this case. Note: The report does mention that the decision for surgery was determined during the office visit the day before the pacemaker insertion; therefore, the office visit would be reported with a 57 modifier.

Unit 3 Exam Answer Key 1. Amy presents to the office for destruction of a malignant 2.3-cm lesion of the skin of the neck.

Select the appropriate ICD-10-CM and CPT codes for today’s encounter: Ans: C. 17273, C44.40

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171 Feedback: 17273 correctly identifies the destruction of a malignant lesion of the neck, lesion diameter, and 2.1 to 3.0 cm. C44.40 reports unspecified malignant neoplasm of skin of the neck.

2. Amara presents to the office today as an established patient to have irritated skin tags removed from her neck and shoulders. Dr. Rose prepped her for the procedure and removed 20 skin tags using liquid nitrogen. Select the appropriate CPT code(s) for Amara’s visit today: Ans: C. 11200, 11201 Feedback: 11200 correctly identifies the removal of skin tags up to the first 15, and 11201 identifies the additional 5 skin tags. Because 11201 is an add-on code, the usage of a modifier is not needed. The office visit 99212 would not be coded since the visit was for the removal of the skin tags and there was not a separately identified evaluation and management service provided.

3. The form of skin cancer that rarely metastasizes is known as: Ans: C. Basal cell carcinoma Feedback: Basal cell carcinoma is the most common form of skin cancer that begins in the stratum basal cells and rarely metastasizes.

4. A female patient had breast cancer 3 years ago, underwent a radical mastectomy, and received radiation and chemotherapy. She has not had treatment in the last 20 months. How is the status of the cancer reported for the patient?

Ans: D. Z85.44 Feedback: Code Z85.44 would be assigned for the personal history of malignant neoplasm of the breast. There is no mention of a family history of breast cancer; therefore, the other codes would be incorrect.

5. Operation: Left transaxillary subpectoral mammoplasty with saline-filled implant.

Preoperative diagnosis: Left hypomastia.

Postoperative diagnosis: Left hypomastia.

Anesthesia: General.

Procedure: After first obtaining a suitable level of general anesthesia with the patient in the supine position, the breasts were prepped with Betadine scrub and solution. Sterile towels, sheets, and drapes were placed in the usual fashion for surgery of the breasts. Following prepping and draping, the anterior axillary folds and the inframammary folds were infiltrated with a total of 20 cc of 0.5 percent Xylocaine with 1:200,000 units of epinephrine.

After a suitable hemostatic waiting period, transaxillary incisions were made, and dissection was carried down to the edge of the pectoralis fascia. Blunt dissection was then used to form a bilateral subpectoral pocket. Through the subpectoral pocket a sterile suction tip was introduced, and copious irrigation with sterile saline solution was used until the irrigant was clear.

Following completion of irrigation, 250-cc saline-filled implants were introduced. They were first filled with 60 cc of saline and checked for gross leakage; none was evident. They were overfilled to

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172 300 cc of saline each. The patient was then placed in the seated position, and the left breast needed 10 cc of additional fluid for symmetry.

Following completion of the filling of the implants and checking the breasts for symmetry, the patient’s wounds were closed with interrupted vertical mattress sutures of 4-0 Prolene. Flexan dressings were applied, followed by the patient’s bra. She seemed to tolerate the procedure well.

Choose the appropriate CPT and ICD-10-CM codes: Ans: C. 19325-LT, N64.82 Feedback: CPT 19325 correctly reports a mammoplasty: augmentation of the left breast using a prosthetic implant, indicated by the introduction of saline. The modifier LT is indicated because the procedure was only performed on the left breast. ICD-10-CM code N64.82 identifies hypomastia of the breast.

6. A 35-year-old female patient receives biopsies of both breasts. The biopsies are done using fineneedle aspiration without imaging guidance. What is the correct CPT code to use for this procedure?

Ans: A. 10021, 10004 Feedback: 10021 delete -50 indicates fine-needle aspiration without imaging guidance. Delete some payers may require LT/RT opposed to modifier 50. Add -10004 is used instead of modifier 50 to report bilateral biopsies.

7. Boris presents to the clinic today for completion of a series of injections into his shoulder for shoulder pain. The physician gives the patient an injection into the left shoulder. Choose the correct CPT and ICD-10-CM codes: Ans: B. 20610-LT, M25.512 Feedback: 20610 correctly identifies arthrocentesis, aspiration and/or injection, of a major joint, the shoulder being defined as a major joint and M25.512 - Pain in left shoulder. An E/M code would not be assigned with this procedure because the shoulder pain was the only diagnosis the patient was seen for, and he went to the clinic just to have the injection.

8. Gavin presents to the hospital for an outpatient procedure for a diagnostic arthroscopy of the right knee. As the physician is performing the procedure, she identifies a medial meniscal tear and repairs it at that time. Choose the correct CPT and ICD-10-CM codes for this procedure: Ans: D. 29882-RT, S83.241A Feedback: 29882 is the correct CPT code because it reports arthroscopy, knee, surgical with meniscus repair (medial OR lateral) and only the medial meniscus was repaired, not both the medial and lateral.

S83.241A Other tear of medial meniscus, current injury, right knee, initial encounter reports the reason fot the encounter. Any time a surgical arthroscopy is performed at the time a diagnostic arthroscopy was initiated, you always code just the surgical arthroscopy. You never code both procedures because the diagnostic is inclusive with the surgical arthroscopy.

9. Operative Report

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173 Postoperative diagnosis: 1. Retained hardware, left foot.

2. Decreased range of motion, left ankle.

Procedure: The patient was placed under general anesthesia; her left lower extremity was prepped and draped in a sterile fashion. A time-out procedure was performed.

The patient then had a hardware removal performed on the transcutaneous K-wires, followed by examination of her ankle, which had approximately 5 to 10 degrees lacking of neutral. Gentle manipulation was performed, giving her dorsiflexion to 10 degrees. C- arm fluoroscopy was introduced to the field, taking confirmatory x-ray, and at this point the patient had a sterile dressing applied and was awakened from general anesthesia.

Select the appropriate CPT codes: Ans: A. 20670-LT, 27860-LT, 76000-26 Feedback: 20670 correctly identifies removal of the K wires as a separate procedure; the LT modifier identifies the left foot, along with 27860-LT identifying the manipulation of the ankle under anesthesia.

76000-26 defines a fluoroscopy imaging guidance used to confirm removal of all wires.

10. Sarah, a 24-year-old female, was walking her dog this morning, and when she wasn’t paying attention, she tripped and fell over the curb. The patient states that she fell to the ground using her right hand and arm to brace herself. She states that she heard a ―crunch‖; the resultant x-ray indicated a compound fracture to the ulna of her right arm. With the patient under general anesthesia, the area was opened and irrigated. The shaft of the ulna was fractured and had to be repaired using screws to hold it into place. The surrounding tissue was repaired, irrigated, and closed in a usual manner. Select the correct CPT code for the repair of the ulna: Ans: C. 25545 Feedback: 25545 correctly reports open treatment of the ulnar shaft with internal fixation, which is indicated in the report by the ―screws to hold into place.‖ 11. Jeremy presents to the clinic today for severe wrist pain. After Dr. Wilkins examines it, she diagnoses him with a ganglion cyst of the right wrist. Dr. Wilkins decides to give Jeremy a cortisone injection as a treatment plan. Code the correct CPT and ICD-10-CM: Ans: D. 20612-RT, M67.431 Feedback: 20612 correctly reports the injections into the ganglion cyst; since it was only one cyst with multiple injections you would not use X2 or a modifier -59 to report multiple injections to ganglion cysts.

The correct modifier of –RT is attached, indicating the ganglion cyst was on the right wrist. Diagnosis M76.431 correctly reports ganglion cyst of the tendon sheath, right wrist.

12. A chronic or acute infection of the bone usually caused by bacteria or fungi is called: Ans: D. Osteomyelitis Feedback: Osteoporosis is the lack of bone density or softening of the bone. Osteomalacia is the loss of bone due to pregnancy. Osteogenesis is a lack of collagen in the bone.

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174 13. A 15-year-old patient has a surgical nasal endoscopy with biopsy of a nasal polyp. What is the correct CPT code for this procedure?

Ans: C. 31237 Feedback: 31237 indicates nasal/sinus endoscopy, surgical, with biopsy, polypectomy, or debridement.

14. Timmy, a 5-year-old, was playing with his toys and decided to stick a bead from his sister’s necklace up his nose. The bead was lodged in his nasal passage, and after several unsuccessful attempts by his mother and father to remove it, they took him to the emergency room. After triaging the patient, the physician utilized a surgical instrument to help remove the bead from Timmy’s nasal passage. Code the physician services: Ans: D. 30300, T17.1XXA Feedback: 30300 identifies the removal of a foreign body, intranasal, office type procedure. This was performed in the Emergency Room, and the procedure does not indicate anesthesia was used. The diagnosis T17.1XXA correctly reports foreign body in nostril, initial encounter.

15. The physician performed thoracentesis with tube insertion to treat pleural effusion caused by small cell cancer of the middle lobe of the right lung. Select the appropriate CPT and ICD codes: Ans: D 32557, C34.2, J91.0 Feedback: J91.01 is specific to malignant pleural effusion, there is an instructional note with J91.0 instructing the coder to code first the underlying neoplasm, C34.2.

16. Which of the following is the area of the sinus that is located at the top of the nasal cavities between the eyes?

Ans: C. Ethmoid Feedback: The frontal is either of two cavities within the frontal bone and superior to the eye. The sphenoid is one of two cavities in the sphenoid bone and located in the center of the skull base. The maxillary is one of the cavities in the upper jaw and located under the eyes.

17. The patient presents to the ED with severe shortness of breath. After testing, the ED physician diagnoses the patient as having ARDS. Select the appropriate ICD-10-CM code: Ans: A. J80 Feedback: This code is used for Adult Respiratory Distress Syndrome unrelated to trauma or a procedure.

18. The patient underwent radical neck dissection with laryngectomy for carcinoma of the larynx and true vocal cords. Choose the correct codes: Ansr: D. 31365, C32.8 Feedback: 31360 is larygectomy, total, without radical neck dissection. C32.1 includes false vocal cords in the description, and the scenario states true vocal cords.

19. The patient presents for submucous resection of the middle turbinate, complete. Select the appropriate CPT code: Ans: C. 30999

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175 Feedback: There is an instructional note which directs the coder to 30999 for submucous resection of the middle or superior turbinate. 30140 is used to report a submucous resection of the inferior middle turbinate, complete. 30520 is used to report a submucous resection of the nasal septum. 30130 is used to report an excision of the inferior turbinate, partial or complete.

20. Michael, a 40-year-old male, presented for insertion of a permanent pacemaker by transvenous approach. A pocket was created for the insertion of the generator, and the electrodes were placed in the right atrium and ventricle. Michael is diagnosed with atrial fibrillation. Select the correct codes: Ans: B. 33208, I48.91 Feedback: CPT code 33208 represents insertion of a permanent pacemaker generator and electrodes atrium and ventricle (dual chamber) for atrial fibrillation, I48.91.

21. Which of the following great vessels carries deoxygenated blood from the right ventricle to the lungs?

Ans: B. Pulmonary arteries Feedback: Vena cava carries blood from the body back to the heart. Aorta takes oxygenated blood from the left ventricle to the body. Pulmonary veins take oxygenated blood from the lungs to the left atrium.

22. The patient presents for a direct repair of an aneurysm and graft insertion without a patch graft for an aneurysm of the common iliac artery. Select the appropriate CPT code: Ans: B. 35131 Feedback: 35131 specifies direct repair of the iliac artery. 35122 specifies hepatic, celiac, renal, or mesenteric artery. 35103 is for abdominal aorta.

23. If the starting point is catheterization of the aorta, to which of the following order branches in the vascular family reporting would the left internal carotid artery belong?

Ans: B. Second Feedback: Appendix L in the CPT manual is a good source for the vascular groupings.

24. Gary sees Dr. G on Monday regarding his atrial fibrillation. Gary is a new patient, and Dr. G performs a medically appropriate history and/or exam and moderate medical decision making. Dr. G decides to insert a permanent dual-chamber pacemaker. The pacemaker is inserted on Tuesday.

Dr. G sees Gary in the hospital on Wednesday and discharges Gary on Thursday. Which of the following is the correct coding of Gary’s visits and procedures for Monday through Thursday?

Ans: B. 99204-57, 33208 Feedback: The patient is a new patient with a medically appropriate history and/or examand moderate medical decision making, so the appropriate E/ M code is 99204. The modifier 57 needs to be appended to show this visit was the one in which the decision for surgery was made. The procedure 33208 is the only other code to be reported since the subsequent hospital visit and discharge service are included in the global surgery package for the pacemaker insertion.

25. A patient is diagnosed with deep vein thrombosis of a lower extremity. Which of the following veins could be involved?

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176 Answer: C. Popliteal Feedback: The popliteal vein is a deep vein in the lower extremity. The saphenous vein is a superficial vein of a lower extremity. The cephalic vein is a superficial vein of an upper extremity. The brachial vein is a deep vein of an upper extremity.

Chapter 12 – Surgery Section: Digestive System LESSON PLANS Class Preparation: Teaching Focus and Resources This chapter focuses on reviewing anatomy and medical terminology knowledge of the digestive system needed to accurately translate provider documentation and also examines guidelines and modifiers which will aid in the selection of appropriate codes.

Learning Outcomes After completing Chapter 12, students will be able to: LO 12.1 Review the anatomy of the digestive system.

LO 12.2 Understand the chapter-specific ICD guidelines and format for the digestive system.

LO 12.3 Identify the guidelines and format of the Digestive subsection of CPT. LO 12.4 Apply the modifiers most commonly used with codes in the Digestive subsection.

LO 12.5 Examine the common medical and procedural terms used in operative reports.

Class Presentation LO 12.1: Review the anatomy of the digestive system.

Slides 12-1 through 12-4



Chapter introduction and key terms

Slide 12-5



Anatomy of the digestive system

Slide 12-6



Anatomy of the digestive system – continued - Mouth

Slide 12-7



Anatomy of the digestive system – continued - Esophagus - Stomach

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177 Slide 12-8



Anatomy of the digestive system – continued - Small intestine - Large intestine

Slide 12-9



Anatomy of the digestive system – continued - Anus - Accessory organs

LO 12.2: Understand the chapter-specific ICD guidelines and format for the digestive system.

Slide 12-10



ICD Chapter-specific guidelines and format of the digestive chapter

Slide 12-11



ICD Chapter-specific guidelines and format of the digestive chapter – continued - Disease of oral cavity, salivary glands, and jaw

Slide 12-12



ICD Chapter-specific guidelines and format of the digestive chapter – continued - Disease of oral cavity, salivary glands, and jaw – continued

Slide 12-13



ICD Chapter-specific guidelines and format of the digestive chapter – continued - Disease of esophagus, stomach and duodenum

Slide 12-14



ICD Chapter-specific guidelines and format of the digestive chapter – continued - Disease of esophagus, stomach and duodenum – continued

Slide 12-15



ICD Chapter-specific guidelines and format of the digestive chapter – continued - Appendicitis

Slide 12-16



ICD Chapter-specific guidelines and format of the digestive chapter – continued - Hernia of abdominal cavity

Slide 12-17



ICD Chapter-specific guidelines and format of the digestive chapter – continued - Noninfectious enteritis and colitis

Slide 12-18



ICD Chapter-specific guidelines and format of the digestive chapter – continued - Other diseases of the intestines and peritoneum

Slide 12-19



ICD Chapter-specific guidelines and format of the digestive chapter – continued

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178 Slide 12-20



 Slide 12-21

Other diseases of the intestines and peritoneum - continued

ICD Chapter-specific guidelines and format of the digestive chapter – continued - Other diseases of the digestive system ICD Chapter-specific guidelines and format of the digestive chapter – continued - Other diseases of the digestive system – continued

LO 12.3: Identify the guidelines and format of the Digestive subsection of CPT. Slide 12-22



CPT guidelines and format of the Digestive subsection - Endoscopy - Coding questions

Slide 12-23



CPT guidelines and format of the Digestive subsection - Lips (40490-407699)

Slide 12-24



CPT guidelines and format of the Digestive subsection - continued - Digestive system subsection - continued Vestibule of mouth (40800-40899)

Slide 12-25



CPT guidelines and format of the Digestive subsection - continued - Digestive system subsection - continued Tongue and floor of the mouth (41000-41019)

Slide 12-26



CPT guidelines and format of the Digestive subsection - continued - Digestive system subsection – continued Dentoalveolar structures (41800-41899)

Slide 12-27



CPT guidelines and format of the Digestive subsection - continued - Digestive system subsection - continued Palate and Uvula (42000-42299)

Slide 12-28



CPT guidelines and format of the Digestive subsection - continued - Digestive system subsection - continued Salivary glands and ducts (42300-42699)

Slide 12-29



CPT guidelines and format of the Digestive subsection - continued - Digestive system subsection - continued Pharynx, adenoids, and tonsils (42700-42999)

Slide 12-30



CPT guidelines and format of the Digestive subsection - continued - Digestive system subsection - continued Esophagus (43020-43499)

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179 Slide 12-31

 

CPT guidelines and format of the Digestive subsection - continued - Digestive system subsection - continued Esophagus – continued (43020-43499)

Slide 12-32



CPT guidelines and format of the Digestive subsection - continued - Digestive system subsection – continued Esophagus – continued

Slide 12-33



CPT guidelines and format of the Digestive subsection - continued - Digestive system subsection – continued Stomach (43500-43999)

Slide 12-34



CPT guidelines and format of the Digestive subsection - continued - Digestive system subsection – continued Stomach - continued

Slide 12-35



CPT guidelines and format of the Digestive subsection - continued - Digestive system subsection – continued Intestines, except rectum (44005-44799)

Slide 12-36



CPT guidelines and format of the Digestive subsection - continued - Digestive system subsection – continued Intestines, except rectum – continued

Slide 12-37



CPT guidelines and format of the Digestive subsection - continued - Digestive system subsection – continued Appendix (44900-44979)

Slide 12-38



CPT guidelines and format of the Digestive subsection - continued - Digestive system subsection – continued Rectum (45000-45999)

Slide 12-39



CPT guidelines and format of the Digestive subsection - continued - Digestive system subsection – continued Anus (46020-46999)

Slide 12-40



CPT guidelines and format of the Digestive subsection - continued - Digestive system subsection – continued Liver (47000-47399)

Slide 12-41



CPT guidelines and format of the Digestive subsection - continued - Digestive system subsection – continued Biliary tract (47000-47999)

Slide 12-42



CPT guidelines and format of the Digestive subsection - continued - Digestive system subsection – continued

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180 Pancreas (48000-48999) Slide 12-43



CPT guidelines and format of the Digestive subsection - continued - Digestive system subsection – continued Abdomen, peritoneum, and omentum (49000-49999)

Slide 12-44



CPT guidelines and format of the Digestive subsection - continued - Digestive system subsection – continued Abdomen, peritoneum, and omentum – continued

LO 12.4: Apply the modifiers most commonly used with codes in the Digestive subsection.

Slide 12-45



Modifiers commonly used with Digestive subsection codes - 52 - 53 - 58 - 59 - 78 -

Table 12.5

LO 12.5: Examine the common medical and procedural terms used in operative reports.

Slide 12-46



Common medical and procedural terms used with the Digestive system - Table 12.6 and 12.7

Summary Slides Slides 12-47 through 12-50



Synopsis of chapter

Teaching Tips LO 12.1:  The digestive system consists of the mouth, esophagus, stomach, small intestine, large intestine, and Accessory organs consisting of the salivary glands, liver, gallbladder, and pancreas.  Flow of the digestive system: mouth, esophagus, stomach, small, intestine, large intestine, and anus.

Coding Tips and Guidelines o There is a difference between ilium and ileum. Ilium, with the i, refers to the hip, and ileum, with the e, refers to the small intestine. An easy way to remember the distinction between the two is that medical terms relating to the small intestine begin with ―e,‖ such as enteritis.

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181

LO 12.2:  Some common diseases coded to the Digestive chapter of ICD are gingivitis, GERD, jaundice, pancreatitis, cirrhosis, portal hypertension, esophagitis, appendicitis, and hernias. When coding these conditions, coders must thoroughly review the provider documentation as well as the guidelines and instructional notes. o ICD-10-CM: The Digestive subsection is Chapter 11 in the ICD-10-CM manual, with the code range K00–K94.

Coding Tips and Guidelines o ICD-10-CM has a note informing the coder that if the tooth is broken due to trauma, a code from the Injury chapter is reported. o The sections on diseases of pulp and periapical tissues and on gingival and periodontal diseases contain separate codes for acute and for chronic conditions. o There are four classifications of malocclusion: normal occlusion, Class 1 malocclusion, Class II malocclusion, and Class III malocclusion. A diagram showing these different classifications is included in some editions of the ICD-10-CM manual. o In ICD-10-CM, codes for dentofacial anomalies, including malocclusion, have been moved to the Diseases of the Musculoskeletal chapter. o In ICD-10-CM, several subsections within the subheading ―Diseases of the Oral Cavity‖ require the use of an additional code to identify alcohol abuse, environmental and occupational exposure to tobacco smoke, history of tobacco use, and exposure to tobacco in the perinatal period. o Some excludes notations in ICD-9-CM for the 530-539 range of codes includes congenital conditions and traumatic perforations. Delete this bullet point n/a o Codes for digestive system ulcers have a high degree of specificity assigned to them, such as whether they are acute, chronic, obstructed, perforated, or hemorrhaging. o The coder must be very careful when coding from the Other Diseases of Digestive System sections to determine whether the calculus is located in the gallbladder alone, biliary tract alone, or both the gallbladder and the biliary tract. The coder must also determine whether there is mention of acute cholecystitis.

LO 12.3:  The Digestive System subsection of the CPT manual is formatted by anatomical site from mouth to anus. It has numerous endoscopic codes that are located within specific anatomical subheadings. The subsection includes specific guidelines regarding endoscopic procedures. When a diagnostic procedure is done and then surgical treatment is performed through the scope during the same operative session at the same anatomical site, only the surgical endoscopic procedure is reported.  There are several questions a coder needs to ask when reading an operative report and coding a procedure from this section. The following questions will help the coder, when reading through the report, to understand what actually was done and how the procedure should be translated and coded: • Where is the anatomical site at which the procedure was performed?

• Was the treatment for a traumatic injury (acute) or a medical condition (chronic)?

• Was the approach internal or external?

• Was the type of the exam open, endoscopic, or laparoscopic?

• Was the procedure performed at a single site or multiple sites?

Coding Tips and Guidelines

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182 o o o o o o o o

o o o o o o o o o

o

Surgical endoscopy or laparoscopy always includes the diagnostic endoscopy or laparoscopy procedure when performed at the same anatomical site during the same operative session.

Repair of the lip can also be documented in the medical record as cheiloplasty.

Both ICD and CPT have codes specific to cleft lip and cleft palate.

Be sure to watch for definitions throughout the CPT manual. This can help during the CPC exam if you get stuck on medical terminology or anatomy.

The codes for repair of the mouth (40830-40845) are dependent on size, site, anterior/posterior, laterality, entire arch, and complexity. Look for these elements in the documentation.

When coding for an I&D in this area (tongue and floor of mouth (41000-41599)), first determine whether the approach is intraoral or extraoral. For intraoral, look for documentation describing manipulation of the tongue.

Review the documentation for the specific anatomical site, such as tongue, below tongue, below the jaw, cheek, or tongue base.

To code from the excision subheading, carefully evaluate the documentation for the type, location, and amount of tissue excised before assigning the appropriate code. Use an anatomical chart when reviewing the codes. The anterior portion is also known as the oral two-thirds. The posterior one-third begins at the sulcus terminalis.

When coding for excision or destruction, review the documentation for terms such as cryo, chemical, or thermal. These terms lead to coding destruction versus excision of a lesion.

Terms listed on page 304 further define code Selection for endoscopies and should be identified when reviewing the documentation of the procedure.

If the documentation does not state ―congenital,‖ default to acquired.

To determine the correct code for gastrointestinal reconstruction procedures, review the documentation for additional sites and procedures that are components of each procedure code.

The codes for the backbench work are not found in the excision range of codes but are included in the other procedures range, 44700–44799.

Watch for exteriorization with all enterostomy codes (44300–44346) when reviewing the documentation to determine the correct code.

Multiple instructional notes in the intestinal laparoscopy range of codes (44180–44227) guide the coder to the appropriate CPT code for an open procedure.

Using an anatomical chart of the digestive system while reviewing these codes will help the coder ―see‖ the procedure and the difference between procedures while preparing for the certification exam.

The guideline at the beginning of subheading section for the rectum (45000-45999) contains information regarding the extent and anatomical location of the scope. Be sure to highlight this information as these terms directly relate to the first division of these codes.

The guidelines before the replacement range of codes state if an existing gastrostomy, duodenostomy, jejunostomy, gastrojejunostomy, or colostomy tube is removed and then a new tube is placed via a separate access site, the placement of the new tube is not considered a replacement and would be reported using a code from the initial-placement range, 49440–49442.

LO 12.4:  Modifiers are used in the Digestive subsection to continue or modify the story of the patient’s encounter. Some of the more common modifiers used in this subsection are: • Reduced services, 52

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183 • Discontinued procedure, 53 • Staged or related procedure or service by the same physician and/or other qualified healthcare professional during the postoperative period, 58 • Distinct procedural service, 59 • Unplanned return to the operating/procedure room by the same physician or another qualified healthcare professional following the initial procedure for a related procedure during the postoperative period, 78 LO 12.5:  The Digestive subsection includes medical terms and procedural terms that are specific to the system involved. There are also some key terms that could appear in a provider’s documentation and act as a trigger for the coder to identify the diagnosis and/or procedure for the encounter.

Chapter 12 Answer Key Exercise 12.1 1. What structure located in the mouth triggers a gag reflex and assists in speech and sound?

Ans: Uvula Feedback: The uvula is the structure located in the mouth that triggers the gag reflex and assists in producing sounds and speech.

2. The mixture of food and digestive enzymes in the saliva is called a __________.

Ans: Bolus Feedback: The mixture of food and digestive enzymes in the saliva is called a bolus.

3. Name the accessory organs of the digestive system, and explain their functions.

Ans: Salivary glands: Produce saliva that when mixed with food starts the digestive process.

Liver: Produces bile which is necessary for digestion of fats.

Gallbladder: Main function is storage of bile.

Pancreas: Functions as both a digestive and endocrine organ.

Feedback: The accessory organs of the digestive system and their functions are as follows. Salivary glands produce saliva, which when mixed with food starts the digestive process. Liver produces bile, which is necessary for digestion of fats. Gallbladder stores bile. Pancreas functions as both a digestive and endocrine organ.

4. Name the third segment of the small intestine.

Ans: The ileum Feedback: The third segment of the small intestine is the ileum (note: make sure the ileum was identified and not the ilium).

5. Which structure connects the small and large intestines?

Ans: The cecum

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184 Feedback: The cecum connects the small and large intestines.

Exercise 12.2 1. What questions should be asked before selecting the appropriate ICD code for a hernia diagnosis?

Ans: Where is the hernia located?

Is gangrene present?

Is there an obstruction?

Was it bilateral or unilateral?

Was it recurrent?

Feedback: The questions that should be asked before selecting the appropriate ICD code for a hernia diagnosis are as follows: Where is the hernia located? Is gangrene present? Is there an obstruction? Was it bilateral or unilateral? Was it recurrent?

2. What are the four classifications used for dentofacial malocclusions?

Ans: Normal, Class I, Class II, Class III Feedback: The four classifications used for dentofacial malocclusions are normal, Class I, Class II, and Class III. 3. Which type of hernia is defined as a protrusion through a tear in the lower abdominal wall and can be direct or indirect?

Ans: Inguinal Feedback: An inguinal hernia is defined as a protrusion through a tear in the lower abdominal wall and can be direct or indirect.

4. If a tooth is broken due to trauma, a code would be selected from which chapter in ICD-10-CM? Ans: Injury chapter Feedback: Index under broken, tooth leads coder to fracture, tooth which leads the coder to S02.5(fracture of tooth, traumatic) in the injury section. There is an excludes 1 note with this code for cracked tooth (nontraumatic) (K03.81) reported.

5. Codes for digestive system ulcers in ICD-10-CM have a high degree of specificity assigned to them, such as whether they are _______________.

Ans: acute, chronic, obstructed, perforated, or hemorrhaging and specific anatomic location Feedback: Codes for digestive system ulcers in ICD-10-CM have a high degree of specificity assigned to them such as whether they are acute, chronic, obstructed, perforated, or hemorrhaging and their specific anatomic location.

Select the appropriate ICD-10-CM code for the following: 6. A patient with history of gastric ulcers presents to the ER with nausea, vomiting, and rectal bleeding. The discharge diagnosis is acute gastric ulcer perforation with bleeding.

ICD-10-CM code: _______

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185 Ans: K25.2 Feedback: K25.2, acute gastric ulcer with both hemorrhage and perforation. The nausea, vomiting, and rectal bleeding would not be reported since they are considered inherent to the acute gastric ulcer with bleeding. There is an instructional note with this code to use additional code to identify alcohol abuse and dependence, if known.

7. The patient presents with severe abdominal pain, fever, and vomiting. This has been occurring for the past 2 days. The final diagnosis is acute cholecystitis.

ICD-10-CM code _____: Ans: K81.0 Feedback: K81.0, acute cholecystitis. There was no mention of stone, calculus, or lithiasis with this diagnosis.

8. The patient presents to dental office complaining of pain within a dental implant. The final diagnosis is fracture of a dental implant.

ICD-10 code _________: Ans: M27.69 Feedback: M27.69, other endosseous dental implant failure (dental implant failure NOS). There are more specific codes for biological or mechanical failure of dental implant.

Exercise 12.3 1. For conversion of a gastrostomy tube (G tube) to a gastrojejunostomy tube (G-J tube), CPT code _________is the appropriate code to use.

Ans: 49446 Feedback: 49446 is the appropriate CPT code to use for conversion of a gastrostomy tube (G tube) to a gastrojejunostomy tube (G-J tube). There is a note with this code instructing for conversion to a G-J tube at the time of initial G tube placement, use 49446 with 49440.

2. What are the three common components for physician work involving transplantation?

Ans: Cadaver or living donor, backbench, recipient Feedback: The three common components for physician work involving transplantation are cadaver or living donor, backbench, and recipient.

3. During an open abdominal procedure, exploration of the surgical field is routinely performed. In this case, should an exploratory laparoscopy, CPT code 49000, be reported along with the open procedure?

Ans: No; this code would be bundled into the open procedure.

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186 Feedback: N/A 4. What is the code range for an ERCP? Ans: 43260-43265; 43273-43278 Feedback: The CPT code range for an ERCP (endoscopic retrograde cholangiopancreatography) is 43260-43265; 43274-43278.

Exercise 12.4 1. The patient is returned to the operating room by the same physician following the initial procedure for an unplanned procedure and this happens during the postoperative period for a procedure that has a 90-day global period. The coder should append modifier _______ to the appropriate CPT code from the Digestive System section.

Ans: Modifier 78 Feedback: If the patient is returned to the operating room by the same physician following the initial procedure for an unplanned procedure and this happens during the postoperative period for a procedure which has a 90-day global period, modifier 78 is appended.

2. An incidental appendectomy during intra-abdominal surgery is usually not reported separated.

If necessary to report, modifier __________should be appended to CPT code 44950, appendectomy.

Ans: Modifier 52 Feedback: Modifier 52 indicates a reduced service. There is an instructional note with code 44950 referencing the use of this modifier.

3. An esophagogastroduodenoscopy (EGD) performed for a separate condition should be reported with modifier __________ to let the payer know that it was a distinct procedure.

Ans: Modifier 59.

Feedback: Modifier 59 indicates a distinct procedural service.

Exercise 12.5 1. The patient presents with abdominal pain and a swollen belly. The physician is concerned about bleeding into the abdomen and orders a procedure in which the abdomen will be punctured and fluid will be drained. This procedure is called a(n) ____________.

Ans: Abdominocentesis Feedback: Abdominocentesis is the surgical puncture of the abdomen.

2. The physician orders an examination the entire rectum and sigmoid colon and a possible examination of a portion of the descending colon. A __________ has been ordered.

Ans: Sigmoidoscopy

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187 Feedback: Sigmoidoscopy is the examination of the entire rectum and sigmoid colon; it may include examination of a portion of the descending colon.

3. The patient presents with difficult and painful swallowing. The diagnosis on the chart could be _____________.

Ans: dysphagia Feedback: Dysphagia is a term for difficulty swallowing.

4. Symptoms of tender abdomen and rebound pain could be indications of __________.

Ans: Peritonitis Feedback: Symptoms of peritonitis include tender abdomen and rebound pain (i.e., pain when manual pressure is applied).

Chapter 12 Review Understanding Terminology 1. F

Bolus

8. A

Endoscopic retrograde cholaniopancreatography

2. D

Cecum

9. L

Gastroesophageal reflux disease (GERD)

3. G

Choledocholithiasis

10. K

Ileum

4. C

Cholelithiasis

11. B

Intusssception

5. H

Diverticulitis

12. N

Jejunum

6. I

Diverticulosis

13. E

Laprascopy

7. J

Duodenum

14. M Volvulus

Checking Your Understanding 1. The patient was brought to the operating room for a diaphragmatic hernia. A transthoracic repair was performed. Select the appropriate CPT and ICD-10-CM code: Ans: A 43334, K44.9 Feedback: A diaphragmatic hernia without documentation of obstruction or gangrene codes to K44.9.

CPT code 43334 indicates the transthoracic repair. CPT code 43336 would indicate a thoracoabdominal incision, which is not indicated in the statement.

2. An operative report states in the header that an EGD was performed. What type of procedure was performed?

Ans: B Esophagogastroduodenoscopy Feedback: EGD is an esophagogastroduodenoscopy. This is a visual examination of the esophagus, stomach, and duodenum through a scope.

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188 3. Which one of the following statements best describes a hiatal hernia?

Ans: A A protrusion of part of the stomach through the diaphragm Feedback: One way to find this answer in the ICD-10-CM index in many of the editions is under ―hernia, hiatal,‖ then cross-reference to this code set and review the codes for definitions.

4. A 60-year-old man is brought to the operating room for a biopsy of the liver. A wedge biopsy is taken and sent to pathology. The report comes back the same day as surgery indicating that primary malignant cells are present. The decision is made to perform a total left lobotomy. Code the operative procedure and diagnosis: Ans: C 47125, 47100-51, C22.8 Feedback: 47125 identifies the total left lobotomy, and 47100-51 identifies the wedge biopsy of the liver.

Sequencing is important with this in that the major procedure is always coded first. The diagnosis code reports the primary malignant cancer of the liver.

5. A patient was brought back to the operating room 60 days after an initial surgical repair on a strangulated inguinal hernia; this procedure was performed by the physician who previously performed the initial surgery. The surgical decision was made due to the patient’s presenting to the ER for lower abdominal pain and radiological testing that confirmed a restrangulation of the hernia. Select the appropriate ICD-10-CM and CPT codes:

Ans: A 49521-78, K40.91 Feedback: 49521 identifies a recurrent inguinal hernia that is strangulated. The modifier 78 reports an unplanned return back to the OR during a postoperative global period and the patient returned 60 days after the initial procedure. K40.91 reports an inguinal hernia, recurrent, strangulated.

6. A 45-year-old patient presents for a flexible sigmoidoscopy for three rectal polyps; the procedure involved the use of hot biopsy forceps. Select the appropriate ICD-9-CM and CPT codes: Ans: D 45333, K62.1 Feedback: 45333 identifies the flexible sigmoidoscopy with the removal of polyps using hot biopsy forceps. Diagnosis code K62.1 reports polyp of the rectum.

7. Emily had been complaining of abdominal pain for the past 4 months. It seemed to be worse she ate fatty foods or ice cream. She was diagnosed with gallbladder disease and underwent a laparoscopic cholecystectomy that revealed chronic cholecystitis and cholelithiasis. Select the appropriate ICD-10-CM and CPT codes to report Emily’s encounter: Ans: C 47562, K80.10 Feedback: K80.10 code description is calculus of gallbladder with chronic cholecystitis without obstruction. There is a note under this code stating cholelithiasis (calculus of gallbladder) with cholecystitis NOS. There was no obstruction documented. The documentation states a laparoscopic

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189 cholecystectomy was performed which is represented with CPT code 47562. There was no mention of a cholangiography being performed so 47563 would be incorrect.

8. A patient presented in the office with symptoms of severe upper gastric pain. After the examination and blood tests, the physician diagnosed hepatitis resulting from infectious mononucleosis. Select the ICD-10-CM codes: Ans: C B27.99, B19.9 Feedback: Code B27.99 reports the infectious mononucleosis, unspecified with other complication. Code B19.9 reports unspecified viral hepatitis without hepatic coma (viral hepatitis NOS).

9. Which of the following is not a part of the stomach?

Ans: D Ileum Feedback: The ileum is the last section of the small intestine.

10. Which type of ulcer occurs in the first, or upper, section of the intestine?

Ans: B Duodenal ulcer Feedback: Duodenal ulcer; the duodenum is the first section of the small intestine.

Applying Your Knowledge Case 1 Preoperative Diagnosis: Chronic tonsillitis and enlarged adenoids Postoperative Diagnosis: Chronic tonsillitis and enlarged adenoids Procedure: Tonsillectomy with adenoidectomy The patient, a 6-year-old male, was placed under general anesthesia for bilateral removal of tonsils with adenoids. The tonsils were grasped with an Allis forceps, and the incision made around the anterior tonsillar pillar. The tonsillar capsule was identified, and the tonsils bluntly dissected free.

Next we turned our attention to the nasopharynx, which was viewed indirectly. There was a considerable amount of hypertrophic adenoids present; they were removed by curette, and all nubbins of adenoid tissue were removed. All bleeding was controlled with pressure sponges, and several small bleeding areas were touched with electrocoagulation. At the close of both procedures, there was no bleeding present. Blood loss was minimal, and the postoperative condition of the patient was good.

Process 1: CPT 1. What is the procedure?

Ans: Tonsillectomy with adenoidectomy Feedback: Tonsillectomy with adenoidectomy is the procedure performed.

2. Locate the main term in the index.

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190 Ans: Tonsillectomy Feedback: Tonsillectomy is the main term.

3. What additional questions or set of questions can be determined?

Ans: None Feedback: There are no additional questions or set of questions.

4. Upon review of all the code choices identified in the index, what additional questions can be determined?

Ans: With adenoidectomy, primary or secondary, and age of patient Feedback: Upon review of all the code choices identified in the index, the following additional question topics can be determined: with adenoidectomy, primary or secondary, and age of patient.

5. Based on the documentation, what is the correct code for this case?

Ans: C 42820 Feedback: Based upon the documentation, the correct code for this case is 42820 since it reports both the tonsillectomy and adenoidectomy, younger than age 12.

Process 2: ICD ICD-10-CM 1. Based on the operative report header, what is the preoperative diagnosis?

Ans: Chronic tonsillitis and enlarged adenoids Feedback: Per the operative report header, the preoperative diagnosis is chronic tonsillitis and enlarged adenoids.

2. Is the postoperative diagnosis the same as or different from the preoperative diagnosis?

Ans: Same Feedback: The postoperative diagnosis is the same as the preoperative diagnosis.

3. Is the postoperative diagnosis supported?

Ans: Yes Feedback: The postoperative diagnosis is supported by the ―hypertrophic adenoids‖ and the discussion of the tonsil removal.

4. What is the main term for this condition?

Ans: Tonsillitis

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191 Feedback: Tonsillitis is the main term for this condition.

5. Based on the subterm choices, what question(s) can be developed for this condition?

Ans: Are other conditions present? Chronic or acute? Due to hypertrophic (enlarged), infection, or another condition?

Feedback: Based upon the subterm choices, the following questions can be developed for this condition: Are other conditions present? Chronic or acute? Due to hypertrophic (enlarged), infection, or another condition?

6. Based on the information in the Tabular List, is additional information needed to determine the appropriate diagnosis code?

Ans: No Feedback: Based upon the information in the tabular listing, there is no additional information needed to determine the appropriate diagnosis code.

7. Is any sign, symptom, or additional condition documented?

Ans: Yes, hypertrophied adenoids Feedback: Yes, a sign, symptom, or additional condition—hypertrophied adenoids—was documented.

8. Is the additional condition, sign, or symptom an integral part of the primary (or other) condition coded?

Ans: No Feedback: No, the additional condition, sign, or symptom is not an integral part of the primary (or other) condition coded.

9. Does the additional condition require or affect patient care, treatment, or management?

Ans: Yes, excision of adenoids Feedback: Yes, the additional condition does require or affect patient care, treatment, or management: excision of adenoids.

10. Based on the documentation, what is (are) the correct ICD-10-CM code(s) for this case?

Ans: A J35.01; J35.2 Feedback: Based upon the documentation, the correct ICD-10-CM codes for this case are J35.01 and J35.2.

Process 3: Modifiers 1. Was the procedure performed different from that described by the nomenclature of the code?

Ans: No Feedback: The procedure performed was not different than as described by the nomenclature of the code.

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192 2. Was the procedure performed at an anatomical site that has laterality?

Ans: Yes Feedback: Yes, the procedure was performed at an anatomical site that has laterality.

3. Was the procedure performed in the global period of another procedure?

Ans: No Feedback: The procedure performed was not in the global period of another procedure.

4. Were additional procedures performed during the operative session, and does the documentation support them?

Ans: Yes; however, a single code supports both procedures.

Feedback: Yes, additional procedures were performed during the operative session; however, a single code supports both procedures.

5. Did the surgeon have help from another surgeon or another appropriate person?

Ans: No Feedback: The surgeon did not have help from another surgeon or other appropriate person.

6. Did a physician different from the surgeon provide the preoperative or postoperative portion of the procedure?

Ans: No Feedback: There was no physician different from the surgeon providing the preoperative or postoperative portion of the procedure.

7. What modifier(s) should be appended to the CPT for this case?

Ans: D Feedback: No modifiers should be appended to the CPT code for this case.

Case 2 Procedure: Small bowel enteroscopy Anesthesia: Premedication: Versed slow IV push, Blucagon 0.2mg in increments during the procedure Indications: The patient is a 77-year-old woman admitted for recurrent anemia and angina pectoris related to her anemia.

The patient has profound microcytic, hypochromic anemia, initially presenting with a hemoglobin of 6.5. A few weeks ago, she was transfused, discharged, and then returned with a hemoglobin of 6.4 with recurrent anginal symptoms and marked fatigue. Most recent stool Hemoccults have been negative. She did, however, report having black tarry stool immediately prior to admission.

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193 Operative Procedure: The instrument was passed through the oropharynx into the stomach. The esophagus was well seen and was normal. On retroversion, the cardia and fundus were well seen and were unremarkable. There was a small hiatal hernia but no evidence of erosions in the gastric mucosa and nothing to suggest a lesion. The body of the stomach distended well and had normal rugal pattern. The antrum was well seen and was normal, as was the duodenal bulb. The instrument was withdrawn into the stomach at this point, and the overtube, which had been premounted on the scope, was then passed into the antrum. The enteroscope was then passed into the duodenal bulb, the descending duodenum, distal duodenum to the ligament of Treitx and the jejunum to what was felt to be the mid jejunum, which at least was well seen. The patient was given Glucagons to facilitate visualization of the small bowel. No abnormalities were noted specifically with nothing to suggest inflammatory change, AVMs, or neoplasia.

Impression: Unremarkable enteroscopy and upper gastrointestinal tract.

Plans: Will discuss the situation with Dr. Smith. An option will be to follow the patient and consider reassessing her distal bowel in the event of recurrent bleeding. The patient did, however, have a significant drop in hemoglobin and hematocrit just this past week from reasons that are still entirely unclear.

Process 1: CPT 1. What is the procedure?

Ans: Endoscopy Feedback: Endoscopy is the procedure.

2. Locate the main term in the index.

Ans: Endoscopy Feedback: Endoscopy is the main term.

3. What additional questions or set of questions can be determined?

Ans: Anatomical site and definitive procedure Feedback: The additional questions or set of questions should be regarding anatomical site and definitive procedure.

4. Upon review of all the code choices identified in the index, what additional questions can be determined?

Ans: Depth or extent of the scope Feedback: Upon review of all the code choices identified in the index, the additional questions should inquire about depth or extent of the scope.

5. Based on the documentation, what is the correct code for this case?

Ans: C 44360 Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, not including ileum; diagnostic, including collection of specimen(s) by brushing or washing, when performed Feedback: Based upon the documentation, the correct code for this case is 44360.

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194 Process 2: ICD ICD-10-CM 1. Based on the operative report header, what is the preoperative diagnosis?

Ans: Microcytic, hypochromic anemia; anginal symptoms; fatigue; tarry stools Feedback: Per the operative report header, the preoperative diagnosis is microcytic, hypochromic anemia; anginal symptoms; fatigue; and tarry stools.

2. Is the postoperative diagnosis the same as or different from the preoperative diagnosis?

Ans: Same Feedback: The postoperative diagnosis is the same as the preoperative diagnosis.

3. Is the postoperative diagnosis supported?

Ans: Yes Feedback: Yes, the postoperative diagnosis is supported.

4. What is the main term for this condition?

Ans: Anemia Feedback: Anemia is the main term for this condition.

5. Based on the subterm choices, what question(s) can be developed for this condition?

Ans: Type of anemia, causes (due to), and associated disorders or conditions Feedback: Based upon the subterm choices, the following question topics can be developed for this condition: type of anemia, causes (due to), and associated disorders or conditions.

6. Based on the information in the Tabular List, is additional information needed to determine the appropriate diagnosis code?

Ans: Yes: underlying cause of anemia Feedback: Based upon the information in the Tabular List, the underlying cause of anemia is needed to determine the appropriate diagnosis code.

7. Is any sign, symptom, or additional condition documented?

Ans: Yes: angina, fatigue and tarry stools.

Feedback: Yes, the following signs, symptoms, or additional conditions wer documented: angina, fatigue, and tarry stools .

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195 8. Is the additional condition, sign, or symptom an integral part of the primary (or other) condition coded?

Ans: Yes, fatigue; others (tarry stools [melena] and angina) are not.

Feedback: Yes, fatigue is an integral part of the primary (or other) condition coded; however, the others (tarry stools [melena] and angina) are not.

9. Does the additional condition require or affect patient care, treatment, or management?

Ans: Yes, melena supports the need for endoscopy Feedback: Yes, the additional condition melena supports the need for endoscopy.

10. Based on the documentation, what are the correct ICD-10-CM code(s) for this case?

Ans: A D50.9, K92.1, I20.9 Feedback: Based upon the documentation, the correct ICD-10-CM codes for this case are D50.9, K92.1, and I20.9.

Process 3: Modifiers 1. Was the procedure performed different from that described by the nomenclature of the code?

Ans: No Feedback: The procedure performed was not different than as described by the nomenclature of the code.

2. Was the procedure performed at an anatomical site that has laterality?

Ans: No Feedback: No, the procedure was not performed at an anatomical site that has laterality.

3. Was the procedure performed in the global period of another procedure?

Ans: No Feedback: The procedure performed was not in the global period of another procedure.

4. Were additional procedures performed during the operative session, and does the documentation support them?

Ans: No Feedback: No, additional procedures were not performed during the operative session.

5. Did the surgeon have help from another surgeon or another appropriate person?

Ans: No Feedback: The surgeon did not have help from another surgeon or another appropriate person.

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196 6. Did a physician different from the surgeon provide the preoperative or postoperative portion of the procedure?

Ans: No Feedback: There was no physician different from the surgeon providing the preoperative or postoperative portion of the procedure.

7. What modifier should be appended to the CPT for this case?

Ans: D none Feedback: No modifiers should be appended to the CPT code for this case.

Chapter 13 – Surgery Section: Urinary System and Male Reproductive System LESSON PLANS Class Preparation: Teaching Focus and Resources The material in Chapter 13, Surgery Section: Urinary System and Male Reproductive System, reviews the anatomy of these two body systems. The guidelines and format for CPT, ICD-9-CM and ICD-10-CM are also examined along with the common modifiers needed for accurate coding of these body systems.

Learning Outcomes After completing Chapter 13, students will be able to: LO 13.1 Review the anatomy of the urinary system.

LO 13.2 Review the anatomy of the male reproductive system.

LO 13.3 Understand chapter-specific ICD guidelines and format for the genitourinary system.

LO 13.4 Identify the CPT guidelines and format for the urinary system.

LO 13.5 Identify the CPT guidelines and format for the male reproductive system.

LO 13.6 Apply the modifiers most commonly used with codes for the genitourinary system.

LO 13.7 Examine the common medical and procedural terms used in operative reports.

Class Presentation LO 13.1: Review the anatomy of the urinary system.

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197 Slides 13-1 through 13-4



Chapter introduction and key terms

Slide 13-5



Anatomy of the Urinary system

Slide 13-6



Anatomy of the Urinary system – continued - Kidneys

Slide 13-7



Anatomy of the Urinary system – continued - Regions of the kidneys

Slide 13-8



Anatomy of the Urinary system – continued - Ureters

Slide 13-9



Anatomy of the Urinary system – continued - Urinary bladder

Slide 13-10



Anatomy of the Urinary system – continued - Urethra

LO 13.2: Review the anatomy of the male reproductive system.

Slide 13-11



Anatomy of the Male Reproductive System

LO 13.3: Understand chapter-specific ICD guidelines and format for the genitourinary system.

Slide 13-12



ICD Guidelines and Format for the Genitourinary and Male Reproductive systems – Introduction - Conditions

Slide 13-13



ICD Guidelines and Format for the Genitourinary system - continued - Glomerular Diseases, renal tubule- interstitial diseases, and acute kidney failure, chronic kidney disease

Slide 13-14



ICD Guidelines and Format for the Genitourinary system – continued - Glomerular Diseases, renal tubule- interstitial diseases, and acute kidney failure, chronic kidney disease– continued

Slide 13-15



ICD Guidelines and Format for the Genitourinary system – continued - Glomerular Diseases, renal tubule- interstitial diseases, and acute kidney failure, chronic kidney disease – continued

Slide 13-16



ICD Guidelines and Format for the Genitourinary system – continued - Other diseases of the Urinary System

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198 Slide 13-17



ICD Guidelines and Format for the Male Reproductive system - Disease of Male Genital Organs

LO 13.4: Identify the CPT guidelines and format for the urinary system.

Slide 13-18



CPT General Guidelines for Urinary system subsection

Slide 13-19



CPT Guidelines and format of the Urinary system subsection - Coding questions

Slide 13-20



CPT Guidelines and format of the Urinary system subsection – continued - General headings

Slide 13-21



CPT Guidelines and format of the Urinary system subsection – continued - Kidney Incision (50010-50135) Excision (50200-50290)

Slide 13-22



CPT Guidelines and format of the Urinary system subsection – continued - Kidney - continued Renal Transplantation (50300-50380) Introduction (50382-50389) Repair (50400-50540)

Slide 13-23



CPT Guidelines and format of the Urinary system subsection – continued - Kidney Laparoscopy (50541-50549) - Ureter Incision (50600-50630) Repair (50700-50940)

Slide 13-24



CPT Guidelines and format of the Urinary system subsection – continued - Bladder Urodynamics (51725-51798) Endoscopy (52000-52010)

Slide 13-25



CPT Guidelines and format of the Urinary system subsection – continued - Urethra Incision (53000-53085) Repair (53400-53520)

LO 13.5: Identify the CPT guidelines and format for the male reproductive system.

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199

Slide 13-26



CPT General guidelines for the Male Reproductive system subsection

Slide 13-27



CPT Guidelines and format of the Male Reproductive system subsection continued - Coding questions

Slide 13-28



CPT Guidelines and format of the Male Reproductive system subsection – continued - Subheadings

Slide 13-29



CPT Guidelines and format of the Male Reproductive system subsection – continued - Penis Incision (54000-54015) Excision (54100-54164) Repair (54300-54440)

Slide 13-30



CPT Guidelines and format of the Male Reproductive system subsection – continued - Testis Excision (54500-54535) - Prostate Incision (55700-55725) Excision (55801-55867)

LO 13.6: Apply the modifiers most commonly used with codes for the genitourinary system.

Slide 13-31



Modifiers commonly used with codes from the Urinary and Male Reproductive subsections - 50 - 51 - 58 - 59 - 78

LO 13.7: Examine the common medical and procedural terms used in operative reports.

Slide 13-32



Common medical and procedural terms used in the urinary and male reproductive systems - table 13.7 and 13.8

Summary Slides

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200 Slides 13-33 through 13-38



Synopsis of chapter

Teaching Tips LO 13.1:  Kidneys: regulate blood volume and composition, help to regulate blood pressure and pH, participate in red blood cell production, and excrete waste products and foreign substances.  Ureters: transport urine from the kidneys to the urinary bladder.  Urinary bladder: stores urine and expels urine into the urethra.  Urethra: discharges urine from the body.

Coding Tips and Guidelines o To distinguish between the ureters and the urethra, remember that the ureters transport urine from the kidneys to the urinary bladder and the urethra transports urine from the urinary bladder to the outside of the body.

LO 13.2:  External structures: • Penis: three parts—root, body, and glans • Scrotum: protective pouch for the testes • Testes: function is the production of testosterone and sperm Internal structures: • Vas deferens: transports mature sperm to the urethra • Ejaculatory ducts: formed by fusion of the vas deferens and the seminal vesicles; empty into the urethra • Urethra: carries urine from the urinary bladder to the outside of the body • Seminal vesicles: produce seminal fluid • Prostate gland: produces additional fluid that aids in the nourishment of the sperm • Cowper’s glands: produce fluid that empties into the urethra and acts as a lubricant for the urethra and neutralizer for urine.

LO 13.3:  ICD-10-CM: Diseases of the Genitourinary System (urinary system and male reproductive systems) is Chapter 14 of the ICD-10-CM manual, with the code range N00–N51.

Coding Tips and Guidelines o Highlight the instructional notes in this section of your ICD manual to remind yourself of these tips and guidelines when using the manual. o Acute kidney failure, unspecified (nontraumatic), is included in category 584 with an excludes instructional note directing the coder to code range 866.00–866.13 if the documentation describes a traumatic kidney injury. o If both CKD and ESRD are documented, code only ESRD (585.6, ICD-9-CM). o Patients can experience some signs and symptoms that involve the urinary system but are not coded to the Diseases of the Genitourinary System chapter of ICD. They include renal colic or kidney pain, dysuria, retention of urine, urinary incontinency, urinary frequency, and polyuria. They are coded in Chapter 16 of ICD-9-CM, under ―Symptoms Involving the Urinary System‖ (category 788), and Chapter 18 of ICD-10-CM, under ―Symptoms and Signs Involving the Genitourinary System (category R30–R39). o Other conditions listed under the category 593 include nephrolithiasis, renal calculus, kidney stone, and staghorn calculus for the kidney and ureteric stone and ureterolithiasis for the ureter.

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201 o o

In ICD-9-CM hematuria is included in category 599 (other disorders of the urethra and urinary tract), while in ICD-10-CM hematuria, unspecified, is included in R31.9 (symptoms and signs of the genitourinary system).

Benign prostatic hypertrophy is most commonly documented as BPH.

LO 13.4:  General guidelines for the Urinary System subsection of CPT: • Insertion of a urinary bladder catheter is part of the global surgical package.

• Placement of a catheter for postoperative drainage is not reported separately.

• Cystourethroscopy with one or more biopsies includes all biopsies performed during the procedure.

• Irrigation or drainage procedures integral to the primary procedure are not reported separately.

• When an endoscopic procedure is performed as part of an open procedure, only the open procedure is coded. (E.g., the endoscopic procedure is confirmatory or is used to evaluate the surgical field.)

• A surgical endoscopic or laparoscopic procedure includes the diagnostic procedure.

• When multiple endoscopic approaches are attempted during the same procedure, only the completed approach is coded.

Coding Tips and Guidelines o Highlight the instructional notes in this section of your CPT manual to remind yourself of these tips and guidelines when using the manual.

LO 13.5:  General guidelines for the Male Reproductive System subsection of CPT: • Placement of a catheter for postoperative drainage is not reported separately.

• Irrigation or drainage procedures integral to the primary procedure are not reported separately.

• A surgical laparoscopic procedure includes the diagnostic procedure.

• Exploration of the surgical field is not reported separately.

LO 13.6:  Modifiers are used in the Genitourinary subsection to continue or modify the story of the patient’s encounter. Some of the more common modifiers used in this subsection are: • Bilateral services, 50 • Multiple procedures, 51 • Staged or related procedure or service by the same physician or other qualified healthcare provider during the postoperative period, 58 • Distinct procedural service, 59 • Unplanned return to the operating/procedure room by the same physician or other qualified healthcare professional following the initial procedure for a related procedure during the postoperative period, 78 LO 13.7:  Acute renal failure (ARF): the sudden onset of kidney failure from causes such as accidents that injure the kidneys, the loss of a lot of blood, or some drugs or poisons  Chronic kidney disease (CKD): the gradual reduction of kidney function, which may lead to permanent kidney failure or end-stage renal disease (ESRD)  Nephrolithiasis: a condition of stones, or calculi, in the kidney  TURP: transurethral resection of the prostate

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202 

Vasectomy: male sterilization o

.

Chapter 13 Answer Key Exercise 13.1 1. What hormone released by the kidneys stimulates the production of red blood cells?

Ans: Erythropoietin Feedback: Erythropoietin is the hormone released by the kidneys which stimulates the production of red blood cells.

2. Illustrate the flow of urine through the urinary system.

Ans: Urine starts in the kidneys, then flows through the ureters to the urinary bladder and then to the urethra where it is excreted from the body.

Feedback: The flow of urine through the urinary system starts with the kidneys, then flows to the ureters, to the urinary bladder, and then to the urethra where it is excreted from the body.

3. List the functions of the kidneys.

Ans: Filter blood; form urine; regulate blood volume, blood pressure, and pH level; produce red blood cells; excrete waste products (urea) Feedback: The functions of the kidneys are to filter blood; form urine; regulate blood volume, blood pressure, and pH; produce red blood cells; and excrete waste products (urea).

4. Explain the functions of the female urethra and male urethra.

Ans: The female urethra acts only as an outlet for the urinary system. The male urethra acts as an outlet for the reproductive and urinary systems.

Feedback: Both the female and male urethra act as an outlet for the urinary system. The male urethra also acts as an outlet for the reproductive system.

5. If the ureters and urinary bladder are not able to prevent the backflow of urine, what condition can develop?

Ans: Cystitis, which can develop into a kidney infection Feedback: If the ureters and urinary bladder are not able to prevent the backflow of urine, cystitis can develop, which can then turn into a kidney infection.

Exercise 13.2 1. Which structure of the male reproductive system has the functions of transportation, storage, and maturation of the sperm cell?

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203 Ans: Epididymis Feedback: The epididymis is the structure of the male reproductive system which has the functions of transportation, storage, and maturation of sperm cells.

2. List the three part of the penis.

Ans: Root, body, and glans Feedback: The three parts of the penis are: root, body, and glans.

3. Which structure of the male reproductive system protects and controls the climate for the testes?

Ans: The scrotum Feedback: The scrotum protects and controls the climate for the testes.

4. List the external and internal structures of the male reproductive system.

Ans: External: penis, scrotum, and testes (including the epididymis) Internal: Vas deferens, ejaculatory ducts, urethra, seminal vesicles, prostate gland, and Cowper’s glands Feedback: The external structures of the male reproductive system are the penis, scrotum, and testes (including the epididymis). The internal structures of the male reproductive system are the vas deferens, ejaculatory ducts, urethra, seminal vesicles, prostate gland, and Cowper’s glands.

Exercise 13.3 1. Both CKD and ESRD are documented in the report. Assign the appropriate code.

Ans: N18.6 Feedback: Only ESRD is coded, with ICD-10-CM code N18.6. There is an instructional note with this code to use additional code to identify dialysis status (Z99.2) 2. Chronic nephritic syndrome is an advanced stage of kidney disease in which the glomeruli are destroyed over time, affecting the ability of the kidneys to filter blood. How are the codes in this relative range further defined?

Ans: The codes in this range are also defined as to the type of glomerulonephritic lesion or other specified pathological lesion.

Feedback: The codes in this category are also defined by the type of glomerulonephritic lesion or other specified pathologic lesion.

3. Assign the appropriate code for a diagnosis of staghorn calculus.

Ans: N20.0, calculus of kidney Feedback: A staghorn calculus is a large kidney stone, and the Alphabetic Index under calculus; staghorn; see kidney takes the coder to N20.0.

4. Encysted hydrocele of the spermatic cord is diagnosed. Assign the appropriate code(s).

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204 Ans: N43.00

5. The diagnosis is an abscess of the epididymis with streptococcus identified as the organism.

Assign the appropriate code(s).

Ans: N45.4, B95.5 Feedback: N45.4, abscess of epididymis or testis and B95.5, unspecified streptococcus as the cause of diseases classified elsewhere (instructional note with N45.4 to use additional code (B95-B97 to identify infectious agent) Exercise 13.4 1. What is the difference between an indwelling ureteral stent and an externally accessible ureteral stent?

Ans: An internal placement has no part of the stent protruding from the body, whereas an externally accessible stent protrudes outside of the body and is attached to a drainage tube.

Feedback: An indwelling, or internal placement, stent has no part of the stent protruding from the body, while an externally accessible stent protrudes outside of the body and is attached to a drainage tube.

2. Describe a nephrectomy procedure and the different approaches.

Ans: This procedure can be performed as an open procedure through a single large incision in the abdomen or side (open nephrectomy) or through a series of small incisions in the abdomen (laparoscopic nephrectomy).

Feedback: A nephrectomy is most often performed to remove a seriously damaged or diseased kidney.

3. Define urodynamic procedure.

Ans: Urodynamic studies are performed to evaluate the bladder’s function and efficiency. Urodynamic testing provides volume and pressure information.

Feedback: Urodynamic studies are performed to evaluate the bladder’s function and efficiency.

Urodynamic testing provides volume and pressure information.

4. The cystectomy codes (51550-51596) are further defined by whether the procedure is partial or complete. Explain the difference between a partial cystectomy and a complete cystectomy.

Ans: The removal of part of the bladder occurs during a partial or segmental cystectomy; during a complete or radical cystectomy, the bladder is removed along with other pelvic organs and/or structures.

Feedback: A cystectomy is a surgical procedure to remove all or part of the urinary bladder and is often performed to treat malignant neoplasms of the bladder. The cystectomy codes (51550–51596) are further defined by whether the procedure is partial or complete. In a partial or segmental cystectomy, part of the bladder is removed; in a complete or radical cystectomy, the bladder is removed along with other pelvic organs and/or structures. The complete cystectomy is often performed for treatment of a malignant neoplasm that has invaded the bladder muscle.

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205 Exercise 13.5 1. How are orchiectomy codes further defined?

Ans: Simple, partial, radical, and laparoscopic Feedback: Orchiectomy procedures are further defined as simple, partial, or radical. A surgical laparoscopic orchiectomy is reported with CPT codes 54690 to 54699.

2. What code range covers urethroplasty procedures, and how are the codes further defined?

Ans: Code range 54300-54440; further defined by first, second, or third stage; size of lesion; and with or without skin flaps Feedback: Urethroplasty procedures are identified by codes in the range 54300-54440. They are further defined by the following:  First, second, or third stage  Size of lesion  With or without skin flaps Exercise 13.6 1. A bilateral procedure was performed, but the CPT code description does not define the code as unilateral or bilateral. Which modifier would be assigned?

Ans: 50 Feedback: Modifier 50 indicates a bilateral procedure.

2. The patient is being taken back to the operating room during the postoperative period for an unplanned procedure of the urinary system or male reproductive system. Which modifier would be used?

Ans: 78 Feedback: Modifier 78 indicates an unplanned return to the operating/procedure room by the same physician or another qualified health care professional following the initial procedure for a related procedure during the postoperative period.

3. When multiple procedures are performed in the same investigative session of urodynamic procedures, which modifier would be reported?

Ans: 51 Feedback: Modifier 51 indicates multiple procedures.

Exercises 13.7 1. List three types of renal failure and define each.

Ans: Acute renal failure (ARF) is the sudden onset of kidney failure. Some of the causes include accidents that injure the kidneys, loss of a lot of blood, or some drugs or poisons.

Chronic kidney disease (CKD) is the gradual reduction of kidney function, which may lead to permanent kidney failure or end stage renal disease (ESRD).

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206 Feedback: Three types of renal failure are: Acute renal failure (ARF): the sudden onset of kidney failure; causes include accident that injures the kidneys, loss of a lot of blood, or some drugs or poisons Chronic kidney disease (CKD): the gradual reduction of kidney function which may lead to permanent kidney failure End stage renal disease (ESRD): permanent kidney failure 2. The process in which the bladder contracts and expels urine can be defined three different ways.

List these three different ways.

Ans: Urination, voiding, and micturition Feedback: The process in which the bladder contracts and expels urine can be defined as urination, voiding, or micturition.

3. What is the term used to describe a congenital defect in which the urethra opens on the underside of the penis?

Ans: Hypospadias Feedback: Hypospadias is the term used to describe a congenital defect in which the urethra opens on the underside of the penis.

4. Define TURP procedure.

Ans: Transurethral resection of the prostate (surgical removal of all or part of the prostate gland) Feedback: TURP procedure, or transurethral resection of the prostate, is the surgical removal of all or part of the prostate gland.

5. What is the procedure in which an undescended testicle is lowered into the scrotum and fixed in place?

Ans: Orchiopexy or orchidopexy Feedback: Orchiopexy or orchidopexy is the procedure in which an undescended testicle is lowered into the scrotum and fixed in place.

6. Describe ESWL. Ans: Extracorporeal shock wave lithotripsy, or the crushing of stones or calculi Feedback: ESWL stands for extracorporeal shock wave lithotripsy, which is the crushing of stones or calculi.

Chapter 13 Review Understanding Terminology 1. G

BPH

8. B

Nephrons

2. K

Cowper gland

9. L

Prepuce

3. H

Epididymis

10. M Testes

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207 4. I

Erythropoiesis

11. J

Ureters

5. F

Glomerulus

12. E

Urethra

6. C

Male reproductive system

13. A

Urinary system

7. D

Micturition

14. N

Vas deferens

Checking Your Understanding 1. A 1-year-old boy has a midshaft hypospadias with a very mild degree of chordee. He also has a persistent right hydrocele. The surgeon brought the boy to the operating room to perform a right hydrocele repair and one-stage repair of the hypospadias with a preputial onlay flap. Select the appropriate CPT and ICD-10-CM codes: Ans: C 54324, 55060-51, Q54.1, Q54.4, N43.3 Feedback: CPT code 54324 reports the one stage repair of the hypospadias with the preputial flap while 55060 represents the hydrocele repair.

2. An acute or chronic inflammation that is located in the glomeruli of the kidney is called: Ans: A Nephritis Feedback: Nephritis is an acute or chronic inflammation that is located in the glomeruli of the kidney.

3. A 31-year-old male presents with chronic glomerulonephritis due to type 2 diabetes. Select the appropriate ICD-10-CM code(s): Ans: C E11.21 Feedback: E11.21 type 2 diabetes with diabetic nephropathy (index, diabetes, type 2 with glomerulonephrosis – E11.21). There is an instructional note with category E11 to use additional code to identify control using insulin (Z79.4), oral antidiabetic drugs (Z79.84), or oral hypoglycemic drugs (Z79.84).

4. A 63-year-old female with chronic kidney disease, stage V, presents for adequacy for hemodialysis. Select the appropriate ICD-10-CM code(s): Ans: D Z49.31, N18.6, Z99.2 Feedback: Code Z49.31 is reported for encounter for adequacy testing for hemodialysis, N18.6 is assigned for the CKD stage V, and Z99.2 shows dialysis status.

5. An elderly gentleman has worsening bilateral hydronephrosis. He did not have much of a postvoid residual on a bladder scan. The physician performed a bilateral cystoscopy and retrograde pyelogram. The results came back as gross prostatic hyperplasia. Select the appropriate CPT and ICD-10-CM codes: Ans: C 52005-50, N40.0, N13.30 Feedback: The scenario states that the patient had a bilateral procedure performed, so the modifier 50 should be appended. N40.0 represents benign prostatic hyperplasia without lower urinary tract symptoms, and N13.30 is for the hydronephrosis, unspecified.

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208 6. Kidney stones are also called: Ans: D Renal calculi and nephrolithiasis Feedback: Renal calculi and nephrolithiasis are other terms used to define kidney stones.

7. A capillary tuft that performs the first step in filtering blood to form urine is called the: Ans: D Glomerulus Feedback: Medulla is the term used for the innermost part of an organ; cortex refers to an external layer; and a ureter is the tube which conveys the urine from the kidney to the bladder.

8. Procedure: Meatotomy infant Diagnosis: Congential meatal stenosis Operative Note: The patient was taken to the operating room and was placed in the supine position on the operating table. A general inhalation anesthesia was administered. The patient was prepped and draped in the usual sterile fashion. The urethral meatus was calibrated with a small mosquito hemostat and was gently dilated. Next, a midline ventral type incision was made, opening the meatus. This was done after clamping the tissue to control bleeding. The meatus was opened to about 3mm. Next, the meatus was easily calibrated from 8 to 12 French with bougis sounds. Next, the mucosal edges were everted and reapproximated to the glans skin edges with approximately five interrupted 6-0 vicryl sutures. The meatus still calibrated between 10 and 12 French.

Antibiotic ointment was applied. The procedure was terminated. The patient was awakened and returned to the recovery room in stable condition. Select the appropriate CPT and ICD-10-CM codes: Ans: A 53025, Q64.33 Feedback: The procedure is a meatotomy, infant; therefore, 53025 would be the correct code since it is specifically for an infant. There is an instructional note that directs the coder not to use modifier 63 with this code. The meatus is the end of the urethra, so the correct ICD-10-CM code is Q64.33.

9. The patient was diagnosed with cystitis due to Escherichia coli. Choose the appropriate ICD-10CM code(s): Ans: C N30.90, B96.20 Feedback: There is an instructional note under category N30 instructing the use of an additional code to identify the organism.

10. A nephrolithotomy after ESWL for staghorn calculus would be coded with which of the following ICD-10-CM and CPT codes?

Ans: B 50590, 50075, N20.0 Feedback: Code 50075 is specific for staghorn calculus.

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209

Applying Your Knowledge Case 1 PREOPERATIVE DIAGNOSIS: Spontaneous rupture of bladder POSTOPERATIVE DIAGNOSIS: Same PROCEDUR: Repair of bladder tear.

INDICATIONS FOR PROCEDURE: 2.7-cm tear of the bladder dome. During surgical inspection no other injuries were found.

The patient was prepped and draped in the usual fashion. A Pfannenstiel incision was made at previous cesarean section scar. Inspection of the bladder shows no other injury. The tear was a 2.7cm transverse tear in the dome of the bladder.

A two-layer closure was done of the mucosa using 4-0 continuous Vicryl. The muscularis was closed using interrupted 2-0 Vicryl. Postrepair inspection revealed good hemostasis. No other tears were noted. Minimal blood loss was noted.

Process 1: CPT 1. What is the procedure?

Ans: Repair of bladder tear Feedback: Repair of bladder tear is the procedure.

2. Locate the main term in the index.

Ans: Repair, bladder, wound Feedback: The main terms are repair, bladder, wound.

3. What additional questions or set of questions can be determined?

Ans: Was the wound simple or complicated?

Feedback: Additional question: Was the wound simple or complicated?

4. Upon review of all the code choices identified in the index, what additional questions can be determined?

Ans: Was the wound simple or complicated? Answer: Simple Feedback: Upon review of all the code choices identified in the index, the additional question should be: Was the wound simple or complicated? The wound was simple.

5. Based on the documentation, what is the correct code for this case?

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210 Ans: A 51860 Feedback: Based upon the documentation, the correct code for this case is 51860, cystorrhaphy, suture of bladder wound, injury or rupture, simple.

Process 2: ICD ICD-10-CM 1. Based on the operative report header, what is the preoperative diagnosis?

Ans: Spontaneous rupture of bladder Feedback: Per the operative report header, the preoperative diagnosis is spontaneous rupture of bladder.

2. Is the postoperative diagnosis the same as or different from the preoperative diagnosis?

Ans: Same Feedback: The postoperative diagnosis is the same as the preoperative diagnosis.

3. Is the postoperative diagnosis supported?

Ans: Yes Feedback: The postoperative diagnosis is supported.

4. What is the main term for this condition?

Ans: Rupture Feedback: The main term for this condition is rupture.

5. Based on the subterm choices, what question(s) can be developed for this condition?

Ans: Was the rupture due to obstetrical condition, trauma, or spontaneous?

Feedback: Based upon the subterm choices, a question can be developed: Was the rupture due to obstetrical condition, trauma, or spontaneous?

6. Based on the information in the Tabular List, is additional information needed to determine the appropriate diagnosis code?

Ans: No Feedback: Based upon the information in the Tabular List, no additional information is needed to determine the appropriate diagnosis code.

7. Is any sign, symptom, or additional condition documented?

Ans: No Feedback: No signs, symptoms, or additional conditions were documented.

8. Is the additional condition, sign, or symptom an integral part of the primary (or other) condition coded?

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211 Ans: N/A 9. Does the additional condition require or affect patient care, treatment, or management?

Ans: N/A 10. Based on the documentation, what is the correct ICD-10-CM code for this case?

Ans: C N32.89 Feedback: Based upon the documentation, the correct ICD-10-CM code for this case is N32.89.

Process 3: Modifiers 1. Was the procedure performed different from that described by the nomenclature of the code?

Ans: No Feedback: The procedure performed was not different from that described by the nomenclature of the code.

2. Was the procedure performed at an anatomical site that has laterality?

Ans: No Feedback: The procedure was not performed at an anatomical site that has laterality.

3. Was the procedure performed in the global period of another procedure?

Ans: No Feedback: The procedure performed was not in the global period of another procedure.

4. Were additional procedures performed during the operative session, and does the documentation support them?

Ans: No Feedback: There were no additional procedures performed during the operative session.

5. Did the surgeon have help from another surgeon or another appropriate person?

Ans: No Feedback: The surgeon did not have help from another surgeon or other appropriate person.

6. Did a physician different from the surgeon provide the preoperative or postoperative portion of the procedure?

Ans: No Feedback: There was no physician different from the surgeon providing the pre- or postoperative portion of the procedure.

7. What modifier(s) should be appended to the CPT code for this case?

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212 Ans: D none Feedback: No modifiers should be appended to the CPT code for this case.

Case 2 PROCEDURE: Bilateral segmental vasectomy, transscrotal PREOPERATIVE DIAGNOSIS: Elective vasectomy POSTOPERATIVE DIAGNOSIS: Same INDICATIONS: This 32-year-old father of 3 request sterilization via vasectomy.

ANESTHESIA: Local with 1% Xylocaine infiltration.

PROCEDURE: The patient was placed in the supine position, prepped, and draped in routine fashion for a scrotal procedure. The right vas deferens was identified and isolated adjacent to the scrotal skin. Local anesthesia was obtained using infiltration of 1% Xylocaine without epinephrine.

An incision was made overlying the vas deferens. The vas deferens was identified and delivered to the operative field. A 2.1-cm segment of the vas deferens was then excised between hemostats. The ends of the vasa were then cauterized with Bovie electrocautery. The distal end was suture-ligated and folded back upon itself with 3-0 chromic. The proximal end was suture-ligated. Hemostasis was obtained using suture of 3-0 chromic. The distal end was then buried in surrounding adventitia with a figure-of-eight suture of 3-0 chromic. Next, attention was directed to the left side and the procedure was repeated.

After confirming adequate hemostasis, the vasa deferentia were returned to the normal locations within the scrotum. The skin was closed using interrupted sutures of 3-0 chromic. After confirming adequate hemostasis, the patient was returned to the recovery room in good condition.

No complications were noted, with minimal blood loss.

Process 1: CPT 1. What is the procedure?

Ans: Bilateral segmental vasectomy, transscrotal Feedback: The procedure is bilateral segmental vasectomy, transscrotal.

2. Locate the main term in the index.

Ans: Vasectomy Feedback: The main term is vasectomy.

3. What additional questions or set of questions can be determined?

Ans: The approach and method are needed.

Feedback: Additional questions are related to the approach and method.

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213 4. Upon review of all the code choices identified in the index, what additional questions can be determined?

Ans: Was this a reversal?

Feedback: Upon review of all the code choices identified in the index, the additional question is as follows: Was this a reversal?

5. Based on the documentation, what is the correct code for this case?

Ans: D 55250 Feedback: Based upon the documentation, the correct code for this case is 55250, vasectomy, unilateral or bilateral, including postoperative semen examination.

ICD-10-CM 1. Based on the operative report header, what is the preoperative diagnosis?

Ans: Sterilization Feedback: Per the operative report header, the preoperative diagnosis is sterilization.

2. Is the postoperative diagnosis the same as or different from the preoperative diagnosis?

Ans: Same Feedback: The postoperative diagnosis is the same as the preoperative diagnosis.

3. Is the postoperative diagnosis supported?

Ans: Yes Feedback: The postoperative diagnosis is supported.

4. What is the main term for this condition?

Ans: Sterilization Feedback: Sterilization is the main term for this condition.

5. Based on the subterm choices, what question(s) can be developed for this condition?

Ans: Status, such as tubal ligation or vasectomy Feedback: Based upon the subterm choices, the question topic developed for this condition is status, such as tubal ligation or vasectomy.

6. Based on the information in the Tabular List, is additional information needed to determine the appropriate diagnosis code?

Ans: No Feedback: Based upon the information in the Tabular List, there is no additional information needed to determine the appropriate diagnosis code.

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214 7. Is any sign, symptom, or additional condition documented?

Ans: No Feedback: There were no signs, symptoms, or additional conditions documented.

8. Is the additional condition, sign, or symptom an integral part of the primary (or other) condition coded?

Ans: N/A Feedback: N/A 9. Does the additional condition require or affect patient care, treatment, or management?

Ans: N/A Feedback: N/A 10. Based on the documentation, what is the correct ICD-10-CM code for this case?

Ans: A Z98.52 Feedback: Based upon the documentation, the correct ICD-10-CM code for this case is Z98.52.

Process 3: Modifiers 1. Was the procedure performed different from that described by the nomenclature of the code?

Ans: No Feedback: The procedure performed was not different from that described by the nomenclature of the code.

2. Was the procedure performed on an anatomical site that has laterality?

Ans: Yes, CPT description is unilateral or bilateral Feedback: Yes, the procedure was performed on an anatomical site that has laterality. The CPT description is unilateral or bilateral.

3. Was the procedure performed in the global period of another procedure?

Ans: No Feedback: The procedure performed was not in the global period of another procedure.

4. Were additional procedures performed during the operative session, and does the documentation support them?

Ans: No Feedback: No additional procedures were performed during the operative session.

5. Did the surgeon have help from another surgeon or another appropriate person?

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215 Ans: No Feedback: The surgeon did not have help from another surgeon or other appropriate person.

6. Did a physician different from the surgeon provide the preoperative or postoperative portion of the procedure?

Ans: No Feedback: There was not a physician different from the surgeon providing the pre- or postoperative portion of the procedure.

7. What modifier should be appended to the CPT code for this case?

Ans: D none Feedback: There are no modifiers appended to the CPT code for this case.

Chapter 14 – Surgery Section: Female Reproductive System and Maternity Care and Delivery LESSON PLANS Class Preparation: Teaching Focus and Resources This chapters aids the coder in reviewing the anatomy of the female reproductive system. Medical and procedural terms commonly seen in operative reports are also examined.

Guidelines for the Female Genital System, including complications of pregnancy, childbirth, and the puerperium, and Maternity Care and Delivery are identified in Chapter 14.

Learning Outcomes After completing Chapter 14, students will be able to: LO 14.1 Review the anatomy of the female reproductive system.

LO 14.2 Understand chapter-specific ICD guidelines and format for complications of pregnancy, childbirth, and the puerperium.

LO 14.3 Identify the guidelines and format of the Female Genital System and Maternity Care and Delivery subsections of CPT. LO 14.4 Apply the modifiers most commonly used with codes in the Female Genital System and Maternity Care and Delivery subsections.

LO 14.5 Examine the common medical and procedural terms used in operative reports.

Class Presentation

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216 LO 14.1: Review the anatomy of the female reproductive system.

Slides 14-1 through 14-4



Chapter introduction and key terms

Slide 14-5



Anatomy of the Female Genital system - Introduction

Slide 14-6



Anatomy of the Female Genital system – continued - Ovaries - Fallopian tubes

Slide 14-7



Anatomy of the Female Genital system – continued - Uterus - Corpus uteri Endometrium Myometrium

Slide 14-8



Anatomy of the Female Genital system – continued - Uterus – continued Cervix uteri - Vagina

Slide 14-9



Anatomy of the Female Genital system – continued - Vulva Bartholin’s glands

LO 14.2: Understand chapter-specific ICD guidelines and format for complications of pregnancy, childbirth, and the puerperium.

Slide 14-10



ICD Guidelines and format of the Female Reproductive system and Complications of Pregnancy, Childbirth, and Puerperium chapters - Introduction

Slide 14-11



ICD Guidelines and format of the Female Reproductive system – continued - Inflammatory disease of Female Pelvic Organs

Slide 14-12



ICD Guidelines and format of the Female Reproductive system – continued - Noninflammatory disease of femail pelvic organs

Slide 14-13



ICD Guidelines and format of Complications of Pregnancy, Childbirth and Puerperium chapter - Pregnancy, childbirth, and the puerperium

Slide 14-14



ICD Guidelines and format of Complications of Pregnancy, Childbirth and - Pregnancy, childbirth, and the puerperium– continued

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217 Slide 14-15



ICD Guidelines and format of Complications of Pregnancy, Childbirth and Puerperium chapter – continued - Pregnancy with Abortive Outcome

Slide 14-16



ICD Guidelines and format of Complications of Pregnancy, Childbirth and Puerperium chapter – continued - Pregnancy with Abortive Outcome - continued

Slide 14-17



ICD Guidelines and format of Complications of Pregnancy, Childbirth and Puerperium chapter – continued - Supervision of high-risk pregnancy (O09); Edema, Proteinuria, and Hypertensive Disorders in Pregnancy, Childbirth, and the Puerperium (O10–O16); Other Maternal Disorders Predominantly Related to Pregnancy (O20–O29):

Slide 14-18



ICD Guidelines and format of Complications of Pregnancy, Childbirth and Puerperium chapter – continued - Maternal Care Related to the Fetus and Amniotic Cavity and Possible Delivery Problems (O30–O48); Encounter for Delivery (O80–O82)

Slide 14-19



ICD Guidelines and format of Complications of Pregnancy, Childbirth and Puerperium chapter – continued - Complications of labor and delivery

Slide 14-20



ICD Guidelines and format of Complications of Pregnancy, Childbirth and Puerperium chapter – continued - complications of labor and delivery - continued

Slide 14-21



ICD Guidelines and format of Complications of Pregnancy, Childbirth and Puerperium chapter – continued - Complications of the Puererium

Slide 14-22



ICD Guidelines and format of Complications of Pregnancy, Childbirth and Puerperium chapter – continued - Other obstetric conditions

LO 14.3: Identify the guidelines and format of the Female Genital System and Maternity Care and Delivery subsections of CPT. Slide 14-23



CPT General guidelines for the Female Genital System and Maternity Care and Delivery Subsections - Coding questions

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218 Slide 14-24



CPT General guidelines for the Female Genital System subsection - Bundled procedures/services

Slide 14-25



CPT guidelines for the Female Genital System subsection - Vulva, Perineum, and Introitus (56405-56821)

Slide 14-26



CPT guidelines for the Female Genital System subsection – continued - Vagina (57000-57426) Incision (57000-57023) Destruction (57061-57065) Excision (57100-57135) Introduction ( 57150-57180) Repair (57200-57335)

Slide 14-27



CPT guidelines for the Female Genital System subsection – continued - Cervix Uteri (57425-57800) Endoscopy (57452-57461) Excision (57500-57558)

Slide 14-28



CPT guidelines for the Female Genital System subsection – continued- Corpus Uteri (58100-58579) Excision (58100-58294) Introduction (58300-58356) Repair (58400-58540) Laparoscopy/Hysteroscopy (58541-58579)

Slide 14-29



CPT guidelines for the Female Genital System subsection – continued - Oviduct/Ovary (58600-58770) Incision ( 58600-58615) Laparoscopy (58660-58679) Excision (58700-58720) Repair (58740-58770)

Slide 14-30



CPT guidelines for the Female Genital System subsection – continued - Ovary (58800-58960) Incision (58800-58825) Excision (58900-58960)

Slide 14-31



CPT General guidelines and format for the Maternity Care and Delivery subsection - Maternity care and delivery (59000–59899)

Slide 14-32



CPT guidelines and format for the Maternity Care and Delivery subsection - Antepartum and Fetal Invasive Services (59000-59076)

Slide 14-33



CPT guidelines and format for the Maternity Care and Delivery subsection –

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219 continued - Delivery Services and procedures, global package Antepartum Slide 14-34



CPT guidelines and format for the Maternity Care and Delivery subsection – continued - Delivery Services and procedures, global package – continued Delivery Postpartum care

Slide 14-35



CPT guidelines and format for the Maternity Care and Delivery subsection – continued - Abortion (59812-59857)

LO 14.4: Apply the modifiers most commonly used with codes in the Female Genital System and Maternity Care and Delivery subsections.

Slide 14-36



Modifiers commonly used with codes from the Female Genital and Maternity Care and Delivery subsections of CPT - 50 - 52 - 58 - 59 - 78 - Table 14.6

LO 14.5: Examine the common medical and procedural terms used in operative reports.

Slide 14-37



Common medical and procedural terms used with the female genital system and maternity care and delivery - table 14.7 and 14.8

Summary Slides Slides 14-38 through 14-43



Synopsis of chapter

Teaching Tips LO 14.1:  The female reproductive system includes both internal and external organs and structures. The internal organs and tissue include the vagina, uterus, ovaries, and fallopian tubes, including the

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220



fimbriae of each. The external structures include the vulva, labia majora, labia minora, Bartholin’s glands, and clitoris.

Flow of the female reproductive system (path of the oocyte): ovaries, fallopian tubes, uterus, vagina, vulva.

LO 14.2:  Some common diseases coded to these chapters of ICD are endometriosis, uterine prolapse, menstrual disorders, infertility, and pregnancy and pregnancy-related disorders and complications.  ICD-10-CM: The Female Reproductive subsection is found in Chapter 14 of the ICD-10-CM manual, with the code range N70–N799.89. should be N70- N77  ICD-10-CM: Pregnancy, Childbirth, and the Puerperium is Chapter 15 of the ICD-10-CM manual, with the code range O00–O9A.212.

Coding Tips and Guidelines o When coding for several of the conditions included in the Inflammatory Disease of the Female Pelvic Organs section (N70-N77), coders must use additional codes to identify infectious organisms, associated infertility, associated or underlying conditions, or external causes. o The descriptions of postpartum and peripartum periods are located in Section 1,C 15,o,1 of the ICD-10-CM Official Coding Guidelines. Highlighting the description of these terms allows the coder to quickly locate this information when using codes from this chapter. o Complete coding of conditions in the O00-O02 range may require two or more codes.

Highlight the directional note located below the section header, which informs the coder to use additional codes to identify complications when using codes from this section. o As with other chapters of the ICD further clarification or breakdown of the fourth or fifth digit can be found at the beginning of the section. Coders should make it a habit to return to the beginning of each section or chapter to locate this information to aid in correct coding of the condition. o The code Z37.0 (single live-born infant) is the only appropriate outcome-of-delivery code when code O80, normal delivery, is used to identify the episode of delivery. o Labor is divided into three stages: Stage 1 From onset of labor to complete dilation and effacement of cervix.

Stage 2 From complete dilation to birth.

Stage 3 Directly following birth until the placenta is expelled.

In prolonged labor (dystocia) or labor that fails to progress, the total of these stages may last many hours to days. o At the beginning of the complications of the puerperium section is an instructional note.

Highlighting this note and each of the categories relating to the note provides coders with a visual cue for which codes of this section are appropriate for use during the antepartum period.

LO 14.3:  The following questions will help a coder, when reading through an operative report, to understand what actually was done and how the procedure should be translated and coded: • At which anatomical site was the procedure performed?

• Was the treatment obstetrical or nonobstetrical?

• Was the approach internal or external?

• What was the extent of the surgical procedure?

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221



• Was the procedure done at a single site or multiple sites?

General Subsection Guidelines Included in all gynecologic procedures: • Diagnostic pelvic examinations and routine evaluation of the surgical field.

• Vaginal or cervical dilation for procedures done by vaginal approach unless the CPT code states ―without cervical dilation.‖ • Diagnostic scopes (laparoscopy, peritoneoscopy, colposcopy, and hysteroscopy) are included in the surgical scope procedure.

• Surgical laparoscopic procedures include lysis of adhesions.

• Anesthesia when performed by the surgeon.

Coding Tips and Guidelines o The definitions of the terms simple, radical, partial and complete are listed at the beginning of this subheading. Highlight this guideline and the corresponding terms in each of the codes in range 56620–56640 to aid in selection of the correct code when coding for this procedure. o Highlight the approach description of each of the proceduresi n the repair (57200-57335) range to aid in differentiating each code by the approach. o The term cervical stump is used only after the uterus has been removed, indicating previous hysterectomy. o Many student coders find that highlighting only the approach and uterine weight in each of the hysterectomy codes speeds location of the correct code. o When coding for radical hysterectomy procedures, as with other radical procedures, this term means that the organ, surrounding tissue, and lymph nodes at that site are removed. o The laparoscopic/hysteroscopic category does not list a diagnostic scope. Located directly below the laparoscopy/hysteroscopy category header is a guideline that instructs the coder to use 49320 to indicate a diagnostic laparoscopy and 58555 to indicate a diagnostic hysteroscopy. o Prior to sitting for the certification exam, review each of the scope categories and highlight this directional note to speed the coding process within this subsection. o Many services and procedures listed are included in the delivery whether or not the delivery is part of a global delivery package or reported separately. (see page 370 for list of services and procedures) o CPT includes a parenthetical note to guide the coder regarding assignment of E/M codes when three or fewer visits are provided during the antepartum period.

LO 14.4:  Modifiers are used in the Female Genital System and Maternity Care and Delivery subsections to continue or modify the story of the patient’s encounter. Some of the more common modifiers used in these subsections are: o 50, bilateral procedure o 52, reduced services o 58, staged or related procedure or service by the same physician during the Postoperative period o 59, distinct procedural service o 78, unplanned return to the operating/procedure room by the same physician or another qualified healthcare professional following the initial procedure for a related procedure during the postoperative period.

Learning Outcome Key Concepts/Example LO 14.5:  Episiotomy: an incision on the perineum and posterior vaginal wall during labor

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222    

Conization: removal of cone-shaped tissue or a segment of the cervix for diagnostic or therapeutic purposes; also referred to as cone biopsy Colposcopy: visualization of the vagina and cervical tissue by means of a scope Endometriosis: growth or presence of tissue outside the uterus that normally grows inside the uterus Dystocia: difficult, painful, or prolonged labor

Chapter 14 Answer Key Exercise 14.1 1. What are the primary functions of the ovaries?

Ans: Production of oocytes and ovum, and production of estrogen and progesterone 2. The portion of the cervix that projects into the vagina is known as the ___________.

Ans: portiovaginalis or exocervix Feedback: The portiovaginalis, or exocervix, is the portion of the cervix that projects into the vagina.

3. What is the myometrium?

Ans: Smooth muscle which forms the wall of the uterus 4. Name the parts of the pudendum.

Ans: Labia majora, labia minora, and clitoris 5. The lowest, narrow part of the uterus where it joins with the vagina is known as the__________.

Ans: cervix uteri Exercise 14.2 1. List and define the three stages of labor.

Ans: Stage 1: From onset of labor to complete dilation and effacement of cervix Stage 2: From complete dilation to birth Stage 3: Directly following birth until placenta is expelled

2. Which categories in ICD-10-CM describe conditions of the fetus that affect how the provider manages the pregnancy in the mother?

Ans: ICD-10-CM: O35 and O36

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223 3. Conditions coded in categories N70-N77, which encompass inflammatory diseases of female pelvic organs, are further divided based on _______and ________.

Ans: anatomic site and status (such as chronic or acute)

4. Define the time frame of each trimester.

Ans: First trimester: less than 14 weeks; second trimester: 14 weeks to 28 weeks; third trimester: 28 weeks to delivery 5. Delivery occurred prior to admission, and the mother is admitted for postpartum care without any complications. Assign the appropriate ICD-10-CM codes.

Ans: Z39.0 Exercise 14.3 1. Describe a total hysterectomy.

Ans: A total hysterectomy is the complete removal of the uterus and cervix with or without the tubes and ovaries.

2. CPT defines the codes for myomectomy by_______ and ________.

Ans: weight of the tumor; approach, such as vaginal or abdominal 3. CPT codes in the ectopic pregnancy code range (59120–59151) are determined based on what criteria?

Ans: Approach, location of the ectopic pregnancy, and excision/resection of tubes and uterus 4. What is included in the normal global delivery package?

Ans: Monthly visits to 28 weeks; biweekly visits from 28 weeks to 36 weeks; weekly visits from 36 weeks until delivery; delivery; and hospital and outpatient postpartum visits up to 6 weeks postpartum Feedback: CPT defines the global delivery package at the beginning of the Maternity Care and Delivery subsection.

5. CPT defines codes of a destruction of vaginal lesions as simple (57061) and extensive (57065).

Explain the difference between simple destruction and extensive destruction.

Ans: Simple destruction is defined as a few small lesions that are simple to destroy. Extensive destruction involves numerous large lesions that are difficult to destroy.

Exercise 14.4 1. When a procedure such as a vulvectomy is performed bilaterally and the code is not inherently bilateral or there is no specific code for the bilateral procedure, which modifier should be appended to the report?

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224 Ans: Modifier 50 Feedback: Modifier 50 indicates bilateral procedure. This case refers to code 56640 Vulvectomy, radical, complete with inguinofemoral, iliac, and pelvic lymphadenectomy.

2. What does appending modifier 52 to a code such as 58565, which is inherently bilateral, tell the payer?

Ans: Less than what the code describes was performed (reduced service), such as a unilateral procedure when the code description is bilateral 3. How would you indicate to the payer that the diagnostic procedure led to an open procedure and should be reported separately?

Ans: Append modifier 59 to the code.

Feedback: Modifier 59 indicates distinct procedural service.

Exercise 14.5 1. Premature separation of the placenta could be documented in a medical record as ________.

Ans: abruptio placentae 2. An x-ray of a patient’s uterus and fallopian tubes was ordered. How would this be documented on the medical record?

Ans: Hysterosalpingography Feedback: Hysterosalpingography is an x-ray of a patient’s uterus and fallopian tubes.

3. A procedure that is performed during labor to prevent perineal laceration or tearing and is considered part of the normal-delivery ICD code is called a(n) _________ .

Ans: episiotomy 4. What procedure is performed as treatment for an incompetent cervix?

Ans: Cerclage Feedback: Cerclage is the procedure performed as treatment for an incompetent cervix to hold the cervix closed until delivery.

5. When indexing the condition uterine fibroid, the Alphabetic Index of ICD-10-CM directs the coder to see also _________.

Ans: leiomyoma Feedback: The Alphabetic Index of ICD directs the coder to see also leiomyoma when indexing the condition uterine fibroid.

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225

Chapter 14 Review Using Terminology Ans: 1. O

Antepartum

9. M

Labia minora

2. E

Bartholin’s glands

10. I

Myometrium

3. J

Colposcopy

11. G

Ovary

4. A

Cervix uteri

12. N

Peripartum

5. C

Corpus uteri

13. B

Puerperium

6. F

Endometrium

13. B

Puerperium

7. D

Fimbriae

15. L

Vulva

8. K

Labia majora

Checking Your Understanding 1. Preoperative diagnosis: Ovarian cyst, right Postoperative diagnosis: Ovarian cyst, right Anesthesia: General Procedure: Open, drainage of cyst The patient was taken to the operating room, prepped, and draped in the usual manner, and adequate anesthesia was induced. An infraumbilical incision was made, and an abdominal entrance was made.

The abdomen was visualized. The cyst was noted on the right, a 4-cm ovarian cyst. This was needled, and a hole was cut in it with scissors and the cyst was drained. Instruments were removed.

The patient was awakened and taken to the recovery room in good condition.

Select the appropriate CPT and ICD-10-CM codes for this scenario: Ans: B 58805, N83.201 Feedback: CPT code 58805 correctly identifies drainage of an ovarian cyst using an abdominal approach; this was indicated in the report by an incision being made into the abdomen. Diagnosis code N83.201 correctly identifies an unspecified ovarian cyst, right side.

2. A patient who is 32 weeks’ pregnant is admitted because of an HIV-related illness. The patient spent 3 days in the hospital and was sent home in stable condition. The baby was not delivered during the hospital stay. Select the appropriate ICD-10-CM codes for this encounter:

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226 Ans: D O98.713, B20, Z3A.32

Feedback: ICD-10-CM code 098.713, Human immunodeficiency virus [HIV] disease complicating pregnancy, childbirth and the puerperium, third trimester. The 6th character “1” is used to indicate complicating pregnancy, third trimester (the other character choices “2” and “3” indicate complicating childbirth or the puerperium); 7th character “3” reflects the third trimester. The guidelines instruct the pregnancy code should be sequenced first. B20= Human immunodeficiency virus [HIV] disease. Z3A.32= 32 weeks gestation of pregnancy.

3. The patient is 25 weeks’ pregnant with her first child. She undergoes a routine prenatal examination without complications. Select the appropriate ICD-10-CM code: Ans: A Z34.02 Feedback: Z34.02 is the code for encounter for supervision of normal first pregnancy, second trimester.

The statement indicates this is her first child and there are no complications. Note: There is a note at the beginning of Chapter 15, Pregnancy, Childbirth and the Puerperium in the ICD-10 manual instructing to use an additional code from Category Z3A, weeks of gestation, to identify the specific week of the pregnancy, if known.

4. A 32-year-old female presents with an ectopic pregnancy. The physician performs a laparoscopic salpingectomy. Select the appropriate CPT and ICD-10-CM codes for this encounter: Ans: D 59151, O00.90 Feedback: 59151 is for the laparoscopic treatment of an ectopic pregnancy with salpingectomy. CPT code 58943 indicates an oophorectomy, whereas CPT code 59120 indicates the salpingectomy, and these codes are not laparoscopic codes. Ectopic pregnancy without more information codes to O00.90.

5. Total obstetrical care does not include: Ans: C Diagnostic procedures such as ultrasounds Feedback: Total obstetrical care does not include diagnostic procedures such as ultrasounds. Antepartum care is the care prior to the baby’s birth, and postpartum care is the care after the birth of the baby. Total obstetrical care includes antepartum, delivery, and postpartum care.

6. The term salpingo-oophorectomy describes: Ans: D The removal of a fallopian tube and ovary Feedback: Salping/o refers to the fallopian tube, ooph/o refers to the ovary, and –ectomy is an excision or removal.

7. The patient had a cesarean section delivery 2 years ago and presented today for an attempted vaginal delivery, which resulted in a repeat cesarean section delivery. Select the appropriate CPT code for the delivery only: Ans: C 59620

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227

Feedback: CPT code 59620 represents the cesarean delivery only following attempted vaginal delivery.

59612 and 59614 represent vaginal deliveries after cesarean delivery, and 59618 is for routine obstetric care including antepartum, cesarean delivery, and postpartum.

8. Hernia repair is often included in the code description for several genitourinary services and is not reported separately. However, if a hernia repair is performed at a different site, it can be separately reported. Which of the following modifiers is used to indicate that the service occurred at a different site (via a different incision)?

Ans: B Modifier 59 Feedback: Modifier 59 will inform the payer that a separate distinct procedure which is often bundled into the primary procedure was performed at the same encounter.

9. Menopause consists of four stages. Which one of the following stages is actually the stage of menopause?

Ans: D This stage begins with a woman’s final period and continued lack of a menstrual period, for 1 year.

Feedback: Menopause is the third stage; it begins with a woman’s final period and lack of menstrual period for one year. The other stages are premenopause, perimenopause, and postmenopause.

10. A perineotomy, when performed, is considered part of the normal delivery ICD-10-CM code, O80. Which one of the following terms is the more common term for this procedure?

Ans: A Episiotomy Feedback: An episiotomy is another term for perineotomy; it is an incision on the perineum and posterior vaginal wall during labor. Conization is the removal of cone-shaped tissue of the cervix. Cerclage is suturing of the opening of the cervix. Dilation and curettage is the widening and surgical removal of part of the lining of the uterus.

Applying Your Knowledge Case 1 Maternal labor and delivery note: Patient is a 38-year-old female with estimated date of conception 10/09 and estimated gestational age of +41 weeks. Her prolonged labor began with uterine contractions for the past 2 days, mild this a.m. and increasingly more severe this evening, with contractions now every 2 to 4 minutes. Cervix is 1 cm/20 percent/_1 station, EFW3, 500 g, 7/21. Patient did progress to 7 cm; however, she was exhausted due to labor and loss of sleep for the past 2 nights due to her labor pain.

Delivery of a single viable female infant was performed vaginally with vacuum assistance. Episiotomy with fourth-degree laceration was repaired with 2-0 and 3-0 Vicryl.

Process 1: CPT 1. What is the procedure?

Ans: Vaginal delivery, vacuum assistance

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228 Feedback: Vaginal delivery, vacuum assistance is the procedure.

2. Locate the main term in the index.

Ans: Vaginal delivery Feedback: Main term is vaginal delivery.

3. What additional questions or set of questions can be determined?

Ans: Was it delivery only? Was there a previous cesarean delivery?

Feedback: Other questions to ask from the index include the following: Was it delivery only? Was there a previous cesarean delivery?

4. Upon review of all the code choices identified in the index, what additional questions can be determined?

Ans: Was there antepartum care and/or postpartum care documented? Was an external cephalic version performed?

Feedback: Upon review of all the code choices identified in the index, the additional questions are as follows: Was there antepartum care and/or postpartum care documented? Was an external cephalic version performed?

5. Based on the documentation, what is the correct code for this case?

Ans: A 59409 Feedback: Based upon the documentation, the correct code for this case is 59409, vaginal delivery only (with or without episiotomy and/or forceps).

Process 2: ICD ICD-10-CM 1. Based on the operative report header, what is the preoperative diagnosis?

Ans: Delivery, prolonged labor Feedback: Per the operative report header, the preoperative diagnosis is delivery, prolonged labor.

2. Is the postoperative diagnosis the same as or different from the preoperative diagnosis?

Ans: Different: delivery, prolonged labor, vacuum assisted Feedback: The postoperative diagnosis is different from the preoperative diagnosis: delivery, prolonged labor, vacuum assisted.

3. Is the postoperative diagnosis supported?

Ans: Yes Feedback: Yes, the postoperative diagnosis is confirmed the same as preoperative diagnosis.

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229 4. What is the main term for this condition?

Ans: Delivery Feedback: The main term for this condition is delivery.

5. Based on the subterm choices, what question(s) can be developed for this condition?

Ans: Vacuum extractor; did this affect fetus or newborn?

Feedback: Based upon the subterm choices, the following question(s) can be developed for this condition: vacuum extractor; did this affect fetus or newborn?

6. Based on the information in the Tabular List, is additional information needed to determine the appropriate diagnosis code?

Ans: No Feedback: Based upon the information in the Tabular List, no additional information is needed to determine the appropriate diagnosis code.

7. Is any sign, symptom, or additional condition documented?

Ans: Yes; exhaustion due to prolonged labor Feedback: Yes, there were signs, symptoms, or additional conditions documented: exhaustion due to prolonged labor.

8. Is the additional condition, sign, or symptom an integral part of the primary (or other) condition coded?

Ans: Yes; the exhaustion is part of the prolonged labor (dystocia code) Feedback: Yes, the additional condition, sign, or symptom is an integral part of the primary (or other) condition coded: the exhaustion is part of the prolonged labor (dystocia code).

9. Does the additional condition require or affect patient care, treatment, or management?

Ans: Yes Feedback: Yes, the additional condition does require or affect patient care, treatment, or management.

10. Based on the documentation, what are the correct ICD-10-CM codes for this case?

Ans: D O66.5, O62.0, O70.3, Z37.0 Feedback: Based upon the documentation, the correct ICD-10-CM codes for this case are O66.5, O62.0, O70.3, and Z37.0.

Process 3: Modifiers 1. Was the procedure performed different from that described by the nomenclature of the code?

Ans: No

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230 Feedback: The procedure performed was not different from that described by the nomenclature of the code.

2. Was the procedure performed at an anatomical site that has laterality?

Ans: No Feedback: The procedure was not performed at an anatomical site that has laterality.

3. Was the procedure performed in the global period of another procedure?

Ans: No Feedback: The procedure performed was not in the global period of another procedure.

4. Were additional procedures performed during the operative session, and does the documentation support them?

Ans: No Feedback: There were no additional procedures performed during the operative session.

5. Did the surgeon have help from another surgeon or another appropriate person?

Ans: No Feedback: The surgeon did not have help from another surgeon or other appropriate person.

6. Did a physician different from the surgeon provide the preoperative or postoperative portion of the procedure?

Ans: No Feedback: There was no physician different from the surgeon providing the pre- or postoperative portion of the procedure.

7. What modifier should be appended to the CPT code for this case?

Ans: B no modifier Feedback: No modifier should be appended to the CPT code for this case.

Case 2 Preoperative diagnosis: Uterine fibroids and menometrorrhagia Postoperative diagnosis: Same

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231 Operation: Total abdominal hysterectomy Pathology specimen: Uterus, approximately 240 grams; tubes and ovaries Approach and surgical procedure: The patient was placed in the dorsal supine position, prepped, and draped in the routine fashion. A lower abdominal midline incision was made through the skin, subcutaneous tissue, and anterior rectus fascia.

The retractor was placed, and the bowel retracted laterally. Kelly clamps were placed on the round the anterior peritoneum was entered. The contents of the abdomen were explored; the liver, gallbladder, kidneys, and aorta were noted as grossly normal in appearance. The appendix was in place. The bladder was retracted anteriorly. Clamps were placed across the adnexa, and the pedicles were sutured with figure-of-eight #1 chromic and a free tie of #1 chromic. The infundibulopelvic ligament, broad ligament, and cardinal ligament were clamped, transected, and ligated bilaterally.

The posterior peritoneum was entered, and the uterine vessels were grasped with an Allis clamp and sutured with #1 chromic. Clamps were placed on either side of the ligature; the vessels were divided and again suture-ligated with #1 chromic. The vagina was entered anteriorly, and the cervix was removed.

Figure-of-eight #1 chromic sutures were placed to the lateral vaginal cuff. The cuff was then reefed using continuous interlocking #1 chromic. Hemostasis was noted as good, and the posterior peritoneum was closed with continuous catgut. The retractor and packs were removed. Sponge and instrument counts were correct. The abdominal peritoneum was closed with continuous 0 chromic gut.

The fascia was closed with continuous interlocking 0 Vicryl. The fat was closed with continuous #2-0 plain and the skin closed with staples. The patient tolerated the procedure well and left the operating suite in satisfactory condition.

Process 1: CPT 1. What is the procedure?

Ans: Total abdominal hysterectomy Feedback: Total abdominal hysterectomy is the procedure.

2. Locate the main term in the index.

Ans: Hysterectomy Feedback: Hysterectomy is the main term in the index.

3. What additional questions or set of questions can be determined?

Ans: What is the approach?

Feedback: What is the approach? (Answer: open abdominal) 4. Upon review of all the code choices identified in the index, what additional questions can be determined?

Ans: Was it radical or total, and were additional procedures performed?

Feedback: Upon review of all the code choices identified in the index, the additional questions are as follows: Was it radical or total, and were additional procedures performed? (Answer: This procedure

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232 was total without the tubes and ovaries. [Note: total hysterectomy is the removal of the uterus and cervix.])

5. Based on the documentation, what is the correct code for this case?

Ans: A 58150 Feedback: Based upon the documentation, the correct code for this case is 58150.

Process 2: ICD ICD-10-CM 1. Based on the operative report header, what is the preoperative diagnosis?

Ans: Uterine fibroid Feedback: Per the operative report header, the preoperative diagnosis is uterine fibroid.

2. Is the postoperative diagnosis the same as or different from the preoperative diagnosis?

Ans: Same Feedback: The postoperative diagnosis is the same as the preoperative diagnosis.

3. Is the postoperative diagnosis supported?

Ans: Yes Feedback: The postoperative diagnosis is supported.

4. What is the main term for this condition?

Ans: Fibroid Feedback: Fibroid is the main term for this condition.

5. Based upon the subterm choices, what question(s) can be developed for this condition?

Ans: What is the anatomical site?

Feedback: Based upon the subterm choices, the following question can be developed for this condition: What is the anatomical site? (Answer: uterus)

6. Based on the information in the Tabular List, is additional information needed to determine the appropriate diagnosis code?

Ans: No

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233 Feedback: Based upon the information in the Tabular List, no additional information is needed to determine the appropriate diagnosis code.

7. Is any sign, symptom, or additional condition documented?

Ans: Yes, menometrorrhagia Feedback: Yes, menometrorrhagia was documented as a sign, symptom, or additional condition.

8. Is the additional condition, sign, or symptom an integral part of the primary (or other) condition coded?

Ans: No Feedback: The additional condition, sign, or symptom is not an integral part of the primary (or other) condition coded.

9. Does the additional condition require or affect patient care, treatment, or management?

Ans: No Feedback: The additional condition does not require or affect patient care, treatment, or management.

10. Based on the documentation, what are the correct ICD-10-CM codes for this case?

Ans: C D25.9, N92.1 Feedback: Based upon the documentation, the correct ICD-10-CM codes for this case are D25.9 and N92.1.

Process 3: Modifiers 1. Was the procedure performed different from that described by the nomenclature of the code?

Ans: No Feedback: The procedure performed was not different from that described by the nomenclature of the code.

2. Was the procedure performed at an anatomical site that has laterality?

Ans: No Feedback: The procedure performed was not on an anatomical site which has laterality.

3. Was the procedure performed in the global period of another procedure?

Ans: No Feedback: The procedure performed was not in the global period of another procedure.

4. Were additional procedures performed during the operative session, and does the documentation support them?

Ans: No

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234 Feedback: There were no additional procedures performed during the operative session.

5. Did the surgeon have help from another surgeon or another appropriate person?

Ans: No Feedback: The surgeon did not have help from another surgeon or other appropriate person.

6. Did a physician different from the surgeon provide the preoperative or postoperative portion of the procedure?

Ans: No Feedback: There was no physician different from the surgeon providing the pre- or postoperative portion of the procedure.

7. What modifier should be appended to the CPT code for this case?

Ans: B None Feedback: No modifier should be appended to the CPT code for this case.

Chapter 15 – Surgery Section: Nervous System LESSON PLANS Class Preparation: Teaching Focus and Resources Chapter 15 examines the anatomy and functions of the nervous system, which is one of the most complex systems of the body. This complexity can make coding for this system challenging.

This chapter reviews both the ICD and CPT guidelines that exist for the nervous system. Medical and procedural terms as well as commonly applied modifiers are identified in this chapter as well.

Learning Outcomes After completing Chapter 15, students will be able to: LO 15.1 Review the anatomy of the nervous system.

LO15.2 Understand chapter-specific ICD guidelinesand format for the nervous system.

LO 15.3 Identify the guidelines and format of theNervous System subsection of CPT. LO 15.4 Apply the modifiers most commonly used withcodes in the Nervous System subsection.

LO 15.5 Examine the common medical and proceduralterms used in operative reports.

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235

Class Presentation LO 15.1: Review the anatomy of the nervous system Slides 15-1 through 15-4



Chapter introduction and key terms

Slide 15-5



Anatomy of the Nervous System – Introduction

Slide 15-6



Anatomy of the Nervous System – divisions and flow - Introducation - continued

Slide 15-7



Anatomy of the Nervous System – continued - Central nervous system (CNS) - Peripheral nervous system (PNS) - Flow of the nervous system

Slide 15-8



Anatomy of the Nervous System – continued - Central Nervous System

LO 15.2: Understand chapter-specific ICD guidelines and format for the nervous system.

Slide 15-9



ICD Guidelines and Format for the Nervous system chapter – Introduction

Slide 15-10



ICD Guidelines and Format for the Nervous system chapter – continued - Inflammatory Diseases of the Central Nervous system

Slide 15-11



ICD Guidelines and Format for the Nervous system chapter – continued - Systemic Atrophies Primarily Affecting the Central Nervous System (G10-G14); Extrapyramidal and Movement Disorders (G20-G26); Other Degenerative Diseases of the Nervous System (G30–G32)

Slide 15-12



ICD Guidelines and Format for the Nervous system chapter – continued - Demylelinating diseases of the central nervous system

Slide 15-13



ICD Guidelines and Format for the Nervous system chapter – continued - episodic and paroxysmal disorders

Slide 15-14



ICD Guidelines and Format for the Nervous system chapter – continued - Nerve, Nerve Root, and Plexus Disorders (G50-G59); Polyneuropathies and Other Disorders of the Peripheral Nervous System (G60-G65); Diseases of Myoneural Junction and Muscle (G70–G73)

Slide 15-15



ICD Guidelines and Format for the Nervous system chapter – continued - Nerve, Nerve Root, and Plexus Disorders (G50-G59); Polyneuropathies

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236 and Other Disorders of the Peripheral Nervous System (G60-G65); Diseases of Myoneural Junction and Muscle (G70–G73) - continued Slide 15-16



ICD Guidelines and Format for the Nervous system chapter – continued - Cerebral Palsy and other paralytic sydromes

Slide 15-17



ICD Guidelines and Format for the Nervous system chapter – continued - Other Disorders of the Central Nervous system

LO 15.3: Identify the guidelines and format of theNervous System subsection of CPT. Slide 15-18



CPT General guidelines for the nervous System subsection - Coding questions

Slide 15-19



CPT guidelines for the Nervous System subsection - introduction (6100064999) - Subheading divisions

Slide 15-20



CPT guidelines for the Nervous System subsection – continued - Skull, Meninges, and Brain (6100-62258) Craniectomy procedures

Slide 15-21



CPT guidelines for the Nervous System subsection – continued - Skull, Meninges, and Brain Surgery of Skull Base (61580-61619) Approach procedures Definitive procedures Repair and or reconstruction

Slide 15-22



CPT guidelines for the Nervous System subsection – continued - Skull, Meninges, and Brain – (continued) Endovascular therapy (61623-61651) Surgery for Aneurysm, Arteriovenous Malformations, or Vascular Disease (61680-61711)

Slide 15-23



CPT guidelines for the Nervous System subsection – continued - Skull, Meninges, and Brain – continued Stereotaxis (61720-61791)

Slide 15-24



CPT guidelines for the Nervous System subsection – continued - Skull, Meninges, and Brain – continued Stereotactic Radiosurgery (61796-61800) Neurostimulators (61850-61888) Neuroendoscopy (62160-62165)

Slide 15-25



CPT guidelines for the Nervous System subsection – continued - Skull, Meninges, and Brain – continued

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237 Cerebrospinal fluid Shunt (CSF) (62180-62258) Slide 15-26



CPT guidelines for the Nervous System subsection – continued - Spine and Spinal Cord (62263-63746) Injection, Drainage, or Aspiration (62263-62327) Catheter Implantation (62350-62355) Reservoir/Pump Implantation (62360-62370)

Slide 15-27



CPT guidelines for the Nervous System subsection – continued - Spine and Spinal Cord – continued Decompressive Spine Procedures (63001–63615)

Slide 15-28



CPT guidelines for the Nervous System subsection – continued - Spine and Spinal Cord – continued Incision (63170-63200) Excision

Slide 15-29



CPT guidelines for the Nervous System subsection – continued - Spine and Spinal Cord – continued Implantation of Neurostimulator Electrodes (63655-63688) Repair (63700-63710) Shunt, Spinal CSF (63740-63746)

Slide 15-30



CPT guidelines for the Nervous System subsection – continued - Extracranial Nerves, Peripheral Nerves, and Autonomic Nervous System (64400-64999) - Introduction/Injection of Anesthetic Agent, Diagnostic or Therapeutic (64400-64530) Neurostimulators (64550-64595) Destruction by Neurolytic Agent (64600-64681) Neuroplasty (64702-64727) Neurorrhaphy (64831-64911)

LO 15.4: Apply the modifiers most commonly used withcodes in the Nervous System subsection.

Slide 15-31



Modifiers commonly used with codes from the Nervous system subsection of CPT - 50 - 51 - 59 - 62 - RT - LT

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238 -

Table 15.5

LO 15.5: Examine the common medical and procedural terms used in operative reports.

Slide 15-32



Common medical and procedural terms used with the Nervous system - table 15.6 and 15.7

Summary Slides Slides 15-33 through 15-36



Synopsis of chapter

Teaching Tips LO 15.1:  The primary function of the nervous system is to send and receive messages via nerve pathways made up of neurons.  The nervous system is divided into two major systems: the central nervous system (CNS), which includes the brain and spinal cord, and the peripheral nervous system (PNS) which connects all body parts to the central nervous system.  Flow of the nervous system: Stimuli: external, from peripheral nerves orsense organs, or internal, at the cellular level (endocrine system) to the sensory neuron, then the nerve pathway to the nerve root and finally the brain or spinal cord (reflex arc) then back to the nerve root on to the motor neuron and finally to the muscle or organ.

LO 15.2:  ICD provides only limited guidelines regarding the use of diagnosis codes in the nervous system These guidelines focus around pain.  ICD-10-CM: Diseases of the Nervous System is Chapter 6 of the ICD-10-CM manual, with the code range G01–G99.0.

Coding Tips and Guidelines o There are multiple code first sequencing notes within the Nervous System chapter.

Highlight and review each of these directional notes to aid incorrect coding sequence. o When coding for drug-induced headaches, G44.4-, be sure to code also for the drug when it is stated in the provider’s documentation. A use additional code note does appear at the G44.4 code level, so coders should highlight this note as a reminder. o If the type of headache is not stated in the provider’s documentation, it is coded as a symptom from Chapter 18 of the ICD-10-CM manual: R51, headache. o When coding hemiplegia and hemiparesis (category G81), the fifth digit for ambidextrous patients is always considered the right dominant side, or a 1. o To aid in accurate selection of the required fifth digit when coding for migraines, coders should highlight the term with in the description of each fifth digit. As the term without equates to ―not stated,‖ coders would not find this information documented. Targeting in

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239 on only what is documented when selecting a code speeds up the coding process during the exam.

LO 15.3:  The following questions will help a coder, when reading through an space operative report, to understand what actually was done and how thespace procedure should be translated and coded: • At which anatomical site was the procedure performed?

• Was the treatment for a traumatic injury (acute) or a medical condition(chronic)?

• What was the approach (e.g., open, closed, epidural, subdural,supratentorial, infratentorial, with or without laminectomy)?

• Was the procedure primary or a reexploration of a surgical site?

• Was the procedure done at a single site or multiple sites?

Coding Tips and Guidelines o When coding for surgery of the skull base (61580-61619) the anatomical sites for the approach and the definitive procedure should match up, many coders find that identifying the correct definitive procedure first also identifies the correct approach grouping and allows for an easier process of elimination and selection of the approach code. o The subheading guidelines for stereotactic radiosurgery (61796-61800) provide clarification of complex versus simple cranial lesions. Be sure to locate, read, and highlight these guidelines prior to the exam. o The procedures in the CSF shunt code range (62180-62258) include the work of programming the shunt, and initial programming is not coded separately. However, there is a parenthetical note in CPT that guides the coder tosee code 62252 for reprogramming of a programmable CSF shunt. Locate and highlight this note. o CPT includes detailed guidelines and parenthetical notes regarding the correct use of the codes within the Injection, Drainage, or Aspiration subheading (62263-62319). Many of these codes are component codes and require the radiological supervision and interpretation code to completely report the procedure. Coders need to be aware of this pairing and watch for cases on the exam in which both codes are needed to complete the coding sequence. o The surgeon’s documentation will identify whether the procedure was performed on a vertebra or a vertebral interspace. Typically, this information is provided by identifying the anatomical site as L2 or as L2–3. These notations mean two very different things: • L2 identifies the second lumbar vertebra, the vertebral segment.

• L2–3 is used to identify the interspace between the second and third lumbar vertebrae. o Think of the dash between the two vertebrae as the intervertebral disc. This association will also help when trying to determine the number of interspaces treated. o Several parenthetical notes inform the coder that daily hospital management of an epidural or subarachnoid pain catheter (01996) is not reportable on the same day as placement of the catheter. Writing the description of code 01996 on this page of your manual will speed coding of these services.

LO 15.4:  Modifiers are used in the Nervous System subsection to continue or modify the story of the patient’s encounter. In this subsection, modifiers 50, 51, 59, 62, RT, and LT are most commonly used.

LO 15.5:  Corpectomy: removal or resection of the anterior portion of the vertebra (spinal column)

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240       

Discectomy: removal of all or a part of the intervertebral disc Foraminotomy: enlargement of the foramen or hole through which the nerve root exits Facetectomy: removal of the facet or bony overgrowth from the facet to decompress the nerve root Laminectomy: removal of the lamina of a vertebral Hemilaminectomy/Laminotomy: removal of the superior or inferior half of the lamina Craniectomy: Bone flap is removed without return to the original site Craniotomy: Bone flap is removed with return to the original site

Chapter 15 Answer Key Exercise 15.1 1. The CNS consists of what anatomical parts?

Ans: Brain and spinal cord Feedback: The CNS is comprised of the brain and spinal cord.

2. What are the location and function of the brainstem?

Ans: The brainstem is located at the base of the brain and continues on with the spinal cord. It regulates basic involuntary functions necessary for survival such as breathing, heart rate, blood pressure, and swallowing.

Feedback: N/A 3. Name the four lobes of the brain, and explain the function of one.

Ans: Frontal lobe, parietal lobe, temporal lobe, and occipital lobe. Answers may vary as far as which lobe is chosen for function description.

Feedback: The four lobes of the brain are: Frontal lobe: involved in planning, organizing, problem solving, memory, impulse control, decision making, selective attention, and control of behavior and emotions.

Parietal lobe: integrates sensory information from various parts of the body, and maps objects perceived visually into body coordinate positions, telling us which way is up and helping to keep us from bumping into things when we walk. It also allows for knowledge of numbers and their relations.

Temporal lobe: involved in auditory perception and contains the primary auditory cortex. Allows for processing of semantics in both speech and vision, recognizing and processing sound, and understanding and producing speech, as well as various aspects of memory, comprehension, naming, verbal memory, and other language functions.

Occipital lobe: located at the lower back of the head; contains the primary visual cortex, which receives and processes visual information such as color and motion, and contains areas that help in perceiving and interpreting shapes and colors.

4. Name the structure that divides the left and right hemispheres of the cerebrum.

Ans: Corpus callosum

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241

Feedback: The corpus callosum is the structure that divides the left and right hemispheres of the cerebrum.

5. What is the function of the spinal cord?

Ans: The spinal cord carries sensory information from the peripheral nerves to the brain and from the brain to the peripheral nerves.

Feedback: The spinal cord is divided into four regions (cervical, thoracic, lumbar, and sacral) and carries information from the peripheral nerves to the brain and back to the peripheral nerves.

Exercise 15.2 1. Define bruxism.

Ans: Bruxism is a movement disorder which results in clenching of the jaw or grinding of teeth.

2. How does the encephalitis, myelitis, and encephalomyelitis category differ from the meningitis category?

Ans: The encephalitis, myelitis, and encephalomyelitis category G04-G05.4 ICD-10CM differs from the meningitis category as most of the underlying conditions listed here are the result of viral or parasitic diseases or due to a complication of immunizations or previous systemic infections.

Feedback: N/A 3. Define mononeuritis and mononeuritis multiplex, and explain how these conditions are further defined in ICD. Ans: Mononeuritis is the inflammation of a single nerve and may affect the body along the entire nerve path. Mononeuritis multiplex is the inflammation of at least two unrelated nerves and is coded to G56G57. Coding of mononeuritis is categorized anatomically by upper limb (G56.-) and lower limb (G57.-).

Each of these categories is subdivided based upon the nerve affected. A very common condition included in these categories is carpal tunnel syndrome (G56.0-).

Feedback: N/A

4. Six months after insertion of a neurostimulator, the patient is experiencing uncomfortable stimulation of the original pain site. What is the correct code?

Ans: T85.840A Feedback: T85.840A pain due to nervous system prosthetic devices, implants and grafts, initial encounter Exercise 15.3

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242 1. Burr holes are commonly used to begin a craniotomy or craniectomy. Is this procedure coded in addition to the more extensive approach when it is performed for this purpose?

Ans: No Feedback: Burr holes are commonly used to begin a craniotomy or craniectomy and are not coded in addition to the more extensive approach when performed for this purpose.

2. Regional nerve blockades or nerve blocks involve the injection of an anesthetic agent along a nerve pathway for temporary control or alleviation of pain. Discuss the further differentiation of code choices in this range.

Ans: This range of codes is first categorized by the type of nerves affected: somatic, paravertebral spinal nerves and branches, and autonomic. The procedures within each of these categories is then further defined by the nerve treated and the method of treatment (via single injection or infusion by catheter).

Feedback: Regional nerve blockades or nerve blocks involve the injection of an anesthetic agent along a nerve pathway for temporary control of pain or to alleviate pain. These ranges of codes are first categorized by the type of nerves affected: somatic, paravertebral spinal nerves and branches, and autonomic. The procedures within each of these categories are then further defined by the nerve treated and the method of treatment.

3. What is the commonly used code for carpal tunnel surgery?

Ans: 64721 Feedback: N/A 4. Excision of intraspinal lesions is divided into two groupings by approach. List these approaches and their code ranges.

Ans: Posteriorly by laminectomy (63250-63295) and anteriorly by vertebral corpectomy (63300-63308).

Feedback: N/A 5. Laminotomy is also known as_________.

Ans: hemilaminectomy Feedback: Laminotomy is the removal of the superior or inferior half of the lamina (multiple levels are counted by interspace). It is also called hemilaminectomy.

Exercise 15.4 1. Which modifier is used to identify that a procedure normally bundled into another procedure is actually a separate procedure and is medically necessary?

Ans: Modifier 59

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243

Feedback: Modifier 59 indicates a distinct procedural service.

2. The approach to the spinal column was performed by a thoracic surgeon, and decompression was completed by a neurosurgeon. What modifier is appended to both surgeons’ codes?

Ans: Modifier 62 Feedback: Modifier 62 indicates two surgeons, cosurgeons: each surgeon performed their portion of the same procedure.

3. Which modifier identifies that a procedure was performed bilaterally?

Ans: 50 or RT; LT depending on the payer.

Feedback: N/A Exercise 15.5 1. The patient record documents diagnosis of vertigo. Would the ICD code for syncope be the appropriate code to report? If not, why?

Ans: No. Syncope is for fainting or loss of consciousness and vertigo is lightheadedness.

Feedback: N/A 2. Werndig-Hoffman disease is a _________ disease that affects communication between the CNS and the ___________.

Ans: anterior horn cell, motor neurons Feedback: Werndig-Hoffman disease is an anterior horn cell disease that affects communication between the central nervous system and the motor neurons.

3. What test is performed to record electrical activity of the brain?

Ans: Electroencephalography Feedback: Electroencephalography is a test performed to record electrical activity of the brain.

Chapter 15 Review Using Terminology 1. E

Alzheimer’s disease

8. C

Meninges

2. A

Central nervous system (CNS)

9. H

Meningitis

3. G

Encephalitis

10. D

Parkinson’s disease

4. K

Facetectomy

11. B

Peripheral nervous system

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244 5. L

Hemiparesis

12. J

Stereotactic

6. I

Hemiplegia

13. N

Vertebral interspace

7. F

Hydrocephalus

14. M

Vertebral segment

Checking Your Understanding 1. The name of the entire motor nervous system is: Ans: A Autonomic nervous system Feedback: The name of the entire motor nervous system is the autonomic nervous system. The peripheral nervous system connects the brain and the spinal cord to the body. The parasympathetic nervous system brings all systems back to normal. The sympathetic nervous system is responsible for the fight or flight response.

2. Which type of hydrocephalus occurs when another condition prevents the absorption of CSF through the normal ventricular channels?

Ans: B Communicating Feedback: Obstructive hydrocephalus is caused by a blockage within the CSF channels. Idiopathic normal pressure hydrocephalus is an increase in the volume of CSF within the ventricles.

3. Callie has been a medical transcriptionist for 25 years and has been complaining of a tingling sensation in her right arm. She was diagnosed with carpal tunnel syndrome and underwent an open procedure that included neuroplasty and transposition of the median nerve at the carpal tunnel.

Select the appropriate ICD and CPT codes from the following: Ans: A 64721-RT, G56.01 Feedback: CPT code 64721 is the correct code to identify carpal tunnel surgery. ICD-10-CM code G56.00 describes carpal tunnel syndrome of an unspecified limb. The documentation states right arm, so G56.01, carpal tunnel syndrome of right upper limb would be the appropriate code.

4. A patient has a cranial bone flap removed and placed under fatty tissue in the abdomen for return to the original site later. This procedure is a(n): Ans: B Craniotomy Feedback: This will also require the use of code 61316 (incision and subcutaneous placement of cranial bone graft). A craniectomy involves the removal of the bone flap without return to the original site.

5. A patient presents to the operating room for enlargement of the foramen, or hole, through which the nerve root exits the spinal canal. This type of procedure would be identified on an operative report as a: Ans: B Foraminotomy Feedback: Corpectomy is the removal or resection of the anterior portion of the vertebra (spinal column).

Facetectomy is the removal of the facet or bone overgrowth from the facet which leads to compression of the nerve root. Laminectomy is the removal of the lamina of a vertebral segment.

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245 6. A patient’s CT scan shows inflammation of the meninges of the brain and spinal cord. The diagnosis on the report would be: Ans: A Meningitis Feedback: Encephalitis and myelitis are defined as inflammation of the brain tissue and spinal cord. The statement did not identify pneumonia as the infectious organism so pneumococcal meningitis would not be reported.

7. A patient presents for reprogramming of a programmable CSF shunt. Select the appropriate CPT code: Ans: C 62252 Feedback: The description of code 62252 is reprogramming of programmable cerebrospinal shunt, and there is an instructional note which informs the coder to use code 62252 for reprogramming of programmable CSF shunt. CPT code 62256 is for removal of complete cerebrospinal fluid shunt system without replacement. CPT code 62230 is for replacement or revision of cerebrospinal fluid shunt, obstructed valve, or distal catheter in shunt system. CPT code 61070 is for percutaneous irrigation or aspiration of shunt reservoir.

8. The patient is diagnosed with peripheral neuropathy in diabetes. Select the appropriate ICD-10CM code(s): Ans: D E11.42 Feedback: The Alphabetic Index directs the coder to the proper coding of diabetes with peripheral neuropathy.

9. In an anterior C2–3 discectomy for decompression of the spinal cord, the approach to the spinal column was performed by a thoracic surgeon and decompression was completed by a neurosurgeon. Select the appropriate CPT code with the appropriate modifier, if needed, for both surgeons: Ans: C 63075-62 Feedback: 63077 is for the thoracic spine. The guidelines with this section in the CPT manual instruct the coder on the use modifier 62 with code 63076.

10. A patient’s diagnosis in the medical record is hemicrania continua. Which of the following also identifies this diagnosis?

Ans: D Complicated headache syndrome and continual primary unilateral headache Feedback: Hemicrania continua is assigned ICD-10 code G44.51, which is in the G44.5 subcategory, complicated headache syndrome.

Applying Your Knowledge

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246 Case 1 Preoperative diagnosis: Herniated disk left L4–5 interspace, with sequestered fragment, left L5 radiculopathy Postoperative diagnosis: Herniated disk left L4–5 interspace, with sequestered fragment, left L5 radiculopathy Procedure: Left L4–5 partial hemilaminectomy, medial facetectomy, removal of herniated disk and sequestered far lateral disk Anesthesia: General anesthesia Estimated blood loss: 30 ml Endotracheal anesthesia was administered, and the back was prepped and draped in the usual fashion. We used intraoperative x-ray to approximate the location of the L4–5 interspace such that we could center the incision over this area. An incisionwas made over the L4–5 interspace, and the incision carried down through the subcutaneous tissues, which in this lady were quite considerable.

The lumbosacral fascia was opened on the left side only, and the paraspinal muscles were stripped subperiosteally to expose the spinous processes and laminae of L4 and L5. We obtained an x-ray with our marker at the L5 lamina. Once this was done, the L4–5 interspace was identified and a left L4–5 partial hemilaminectomy and medial facetectomy were performed. Verifying that was inferior enough sufficiently to be able to reach the L5 nerve root and sequestered fragment. Partially, the bony removal was accomplished also, in addition to the Midas Rex drill. It was performed using curettes and Kerrisons. The yellow ligament was removed, exposing the common dural sac, and I was able toidentify the L4–5 interspace, which appeared to be indurated and consistent with a previous disc herniation.The L5 nerve root was identified and was gently mobilized medially, and I was able to identify the sequestered disc, which was actually in three large fragments. These were mobilized with a blunt hook and then delivered with a small pituitary punch. Perhaps the largest of the fragments actually appeared to extend out the foramina along with the L5 nerve root. After the fragments were released, the dura and nerve root appeared to be much more relaxed and I probed out the foramina using both a blunt hook and then a Woodson. No additional fragments were uncovered. I inspected the L4–5 disk with an Epstein curette. There were no additional rents that appeared to be scarred, and rather than risk a second disc herniation through an area that appeared to be already healed, this was left alone. The common dural sac was well decompressed en route. The area was irrigated with an antibiotic saline solution. A small autologous fat graft was harvested and placed over the root and dura and then covered with a Gelfoam thrombin slurry.

The wound was infiltrated with25 percent Marcaine with epinephrine, and the wound was closed by reapproximating the muscles and fascia with O Vicryl: a 2-0 Vicryl subcutaneous closure and a running 4-0 subcuticular stitch in the skin. The wound was reinforced with Steri-Strips. A sterile dressing was applied. Throughout the case the patient remained hemodynamically stable.

Process 1: CPT 1. What is the procedure?

Ans: Hemilaminectomy Feedback: Hemilaminectomy is the procedure.

2. Locate the main term in the index.

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247 Ans: Hemilaminectomy Feedback: Hemilaminectomy is the main term.

3. What additional questions or set of questions can be determined?

Ans: None Feedback: No additional questions or set of questions can be determined.

4. Upon review of all the code choices identified in the index, what additional questions can be determined?

Ans: What level is the hemilaminectomy performed on, cervical or lumbar? How many interspaces were decompressed? Was this a new procedure at this level or a reexploration of a previous hemilaminectomy (laminotomy)?

Feedback: Upon review of all the code choices identified in the index, the following additional questions can be determined: What level is the hemilaminectomy performed on, cervical or lumbar? How many interspaces were decompressed? Was this a new procedure at this level or a reexploration of a previous hemilaminectomy (laminotomy)?

5. Based on the documentation, what is (are) the correct code(s) for this case?

Ans: D 63042 Feedback: Based upon the documentation, the correct code for this case is 63042, Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc, reexploration, single interspace; lumbar. The documentation states, ―the L4-5 interspaces…appeared to be indurated and consistent with a previous disk herniation‖ indicating the procedure is a reexploration at the same level of a previous hemilaminectomy.

Process 2: ICD ICD-10-CM 1. Based on the operative report header, what is the preoperative diagnosis?

Ans: Herniated disk left L4-5 interspace, with sequestered fragment, left L5 radiculopathy Feedback: Per the operative report header, the preoperative diagnosis is herniated disk left L4-5 interspace, with sequestered fragment, left L5 radiculopathy.

2. Is the postoperative diagnosis the same as or different from the preoperative diagnosis?

Ans: Same Feedback: The postoperative diagnosis is the same as the preoperative diagnosis.

3. Is the postoperative diagnosis supported?

Ans: Yes

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248 Feedback: The postoperative diagnosis is supported. The surgeon was able to identify the herniated disc fragments: ―…and I was able to identify the sequestered disk which was actually in 3 large fragments‖.

4. What is the main term for this condition?

Ans: Displacement Feedback: Displacement is the main term for this condition.

5. Based on the subterm choices, what question(s) can be developed for this condition?

Ans: What is the anatomical site (intervertebral) and spinal level of the displacement? Due to trauma? Is another condition (myelopathy) present with the condition?

Feedback: Based upon the subterm choices, the following questions can be developed for this condition: What is the anatomic site (intervertebral) and spinal level of the displacement? Due to trauma? Is another condition (myelopathy) present with the condition?

6. Based on the information in the Tabular List, is additional information needed to determine the appropriate diagnosis code?

Ans: Yes, the presence of other conditions such as radiculopathy or myelopathy Feedback: Based upon the information in the Tabular List, the following additional information is needed to determine the appropriate diagnosis code: the presence of other conditions such as radiculopathy or myelopathy.

7. Is any sign, symptom, or additional condition documented?

Ans: Yes, radiculopathy Feedback: Yes, radiculopathy is documented as a sign, symptom, or additional condition.

8. Is the additional condition, sign, or symptom an integral part of the primary (or other) condition coded?

Ans: No, a combination code is provided for the symptom and the condition.

Feedback: No, the additional condition, sign or symptom is not an integral part of the primary (or other) condition coded. A combination code is provided for the symptom and the condition.

9. Does the additional condition require or affect patient care, treatment, or management?

Ans: No Feedback: The additional condition does not require or affect patient care, treatment, or management.

10. Based on the documentation, what is (are) the correct ICD-10-CM code(s) for this case?

Ans: B M51.16 Feedback: Based upon the documentation, the correct ICD-10-CM code for this case M51.16 Intervertebral disc disorders with radiculopathy, lumbar region. M51.17 is incorrect as it indicates disc displacement with radiculopathy of the lumbosacral region. M51.06 reports disc displacement at the correct level; however, the documentation does not indicate myelopathy as is included in this ICD-10-CM

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249 code. M51.26 does report lumbar disc displacement and M54.16 radiculopathy of the lumbar region; however, ICD-10-CM provides a combination code of M51.16 to report lumbar disc displacement with radiculopathy, and when available to fully report a condition, combination codes should be used in place of separate codes for each condition or condition and symptom.

Process 3: Modifiers 1. Was the procedure performed different from that described by the nomenclature of the code?

Ans: No Feedback: The procedure performed was not different from that described by the nomenclature of the code.

2. Was the procedure performed at an anatomical site that has laterality?

Ans: Yes, procedure was performed unilaterally on the left side.

Feedback: Yes, the site has laterality; the procedure was performed unilaterally on the left side.

3. Was the procedure performed in the global period of another procedure?

Ans: No Feedback: The procedure performed was not in the global period of another procedure.

4. Were additional procedures performed during the operative session, and does the documentation support them?

Ans: No Feedback: There were no additional procedures performed during the operative session.

5. Did the surgeon have help from another surgeon or another appropriate person?

Ans: No Feedback: The surgeon did not have help from another surgeon or other appropriate person.

6. Did a physician different from the surgeon provide the preoperative or postoperative portion of the procedure?

Ans: No Feedback: There was no physician different from the surgeon providing the pre- or postoperative portion of the procedure.

7. What modifier should be appended to the CPT code for this case?

Ans: C LT Feedback: The modifier LT should be appended to the CPT for this case. As this procedure can be performed bilaterally or unilaterally, an anatomical site modifier should be appended to the procedure code. Modifier 78 is incorrect; although this is a reexploration of a previous laminectomy, there is no indication that the procedure is being performed in the global (post-op) period of the previous

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250 laminectomy. This is confirmed by the surgeon’s statement, ―and rather than risk a second disk herniation through an area that appeared to be already healed this was left alone.‖ Modifier 58 is also incorrect as a procedure of this nature would not be planned or considered during the previous procedure.

Case 2 Preoperative diagnosis: Acute/chronic subduralhematoma, headaches, and right-sided weakness Postoperative diagnosis: Acute/chronic subduralhematoma, headaches, and right-sided weakness Procedure: Left-sided burr hole evacuation of subdural hematoma Anesthesia: General anesthesia Estimated blood loss: Less than 10 ml Description of procedure: Following a thorough discussion of the risk, benefits, and alternative treatments with the patient and verifying that she has sufficient information to make an informed decision, we proceeded. The patient received preoperative antibiotics and had sequential compression devices that were operating prior to the induction of the general anesthetic. Under general endotracheal anesthesia, the patient was placed supine on the operating table and prepped and draped in the usual fashion. The CT scan of the head was verified. Following our last time-out, two incisions were made over the left convexity, one anteriorly and one posteriorly. These were approximated at 2.5 to 3 cm in length. The incision was carried down through the scalp, using unipolar cautery for homeostasis. The wound was retracted using a small Weitlaner, and the soft tissue was cleared from the periosteum. Using the perforator, 2 burr holes were made, again one anteriorly and one posteriorly. The bony edges were waxed for homeostasis. The discoloration through the dura was visible, consistent with the subdural hematoma. We first opened the anterior burr hole, opening the dura. The dura was coagulated using bipolar cautery and a 15-blade knife.

From here there was aflow of straw-colored fluid consistent with a chronic subdural hematoma. We irrigated from one burr hole to the other until the fluid cleared. Once the fluid was cleared, we then left a 1-French drain in the subdural space. The drain was brought out through a separate trocar incision. The burr holes were covered with Gelfoam, and then the wound was closed by reapproximating the galea with 2-0 Vicryl and staples in the skin. Postoperatively a full head dressing was applied. The patient tolerated the procedure well and remained hemodynamically stable throughout the case.

Process 1: CPT 1. What is the procedure?

Ans: Burr hole Feedback: Burr hole is the procedure.

2. Locate the main term in the index.

Ans: Evacuation of a subdural hematoma Feedback: The main term is evacuation of a subdural hematoma.

3. What additional questions or set of questions can be determined?

Ans: What is the procedure or condition?

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251 Feedback: After locating the main term in the index, the additional question determined is, ―What is the procedure or condition?‖ 4. Upon review of all the code choices identified in the index, what additional questions can be determined?

Ans: Was the hematoma extradural/subdural or intracerebral? Was the hematoma evacuated or aspirated?

Feedback: Upon review of all the code choices identified in the index, these additional questions can be determined: Was the hematoma extradural/subdural or intracerebral? Was the hematoma evacuated or aspirated?

5. Based on the documentation, what is the correct code for this case?

Ans: D 61154 Feedback: Based upon the documentation, the correct code for this case is 61154, which correctly reports the evacuation of a subdural hematoma through a burr hole. 61312 reports the evacuation of a hematoma through a craniectomy or craniotomy, not a burr hole. 61150 reports the correct approach, burr hole, but for the drainage of an abscess or cyst, not a hematoma. 61314 reports the evacuation of a hematoma; however, the approach is craniectomy or craniotomy, not burr hole, and the site is infratentorial (below the tentorium) and we know the site is supratentorial by the location of the burr holes, ―left convexity‖ (skull vault or dome).

Process 2: ICD ICD-10-CM 1. Based on the operative report header, what is the preoperative diagnosis?

Ans: Subdural hematoma acute over chronic Feedback: Per the operative report header, the preoperative diagnosis is subdural hematoma acute over chronic.

2. Is the postoperative diagnosis the same as or different from the preoperative diagnosis?

Ans: Same Feedback: The postoperative diagnosis the same as the preoperative diagnosis.

3. Is the postoperative diagnosis supported?

Ans: Yes Feedback: The following statement in the report supports the postoperative diagnosis: ―The discoloration through the dura was visible, consistent with the subdural hematoma‖ 4. What is the main term for this condition?

Ans: Hematoma Feedback: Hematoma is the main term for this condition.

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252 5. Based on the subterm choices, what question(s) can be developed for this condition?

Ans: What is the anatomical site? Is the condition traumatic or nontraumatic?

Feedback: Based upon the subterm choices, questions developed for this condition are as follows: What is the anatomical site? Is the condition traumatic or nontraumatic? Note: Under the terms non-traumatic hematoma, the coder is instructed to see hemorrhage, intracranial.

6. Based on the information in the Tabular List, is additional information needed to determine the appropriate diagnosis code?

Ans: Yes. Is the condition acute, subacute, or chronic?

Feedback: Based upon the information in the Tabular List, the following additional information is needed to determine the appropriate diagnosis code: Is the condition acute, subacute, or chronic?

7. Is any sign, symptom, or additional condition documented?

Ans: Yes, headaches and right-sided weakness Feedback: Yes; signs, symptoms, or additional conditions—headaches and right-sided weakness—are documented.

8. Is the additional condition, sign, or symptom an integral part of the primary (or other) condition coded?

Ans: Yes Feedback: Yes, the additional condition, sign, or symptom is an integral part of the primary (or other) condition coded.

9. Does the additional condition require or affect patient care, treatment, or management?

Ans: No Feedback: The additional condition does not require or affect patient care, treatment, or management.

10. Based on the documentation, what is (are) the correct ICD-10-CM code(s) for this case?

Ans: D I62.01, I62.03 Feedback: Based upon the documentation, the correct ICD-10-CM codes for this case are I62.01, I62.03.

This choice reports both the acute and chronic subdural nontraumatic hematoma (hemorrhage). I61.4 reports a nontraumatic hematoma, but of the cerebellum and not subdural. S06.5X0A reports a traumatic subdural hematoma, and the condition is nontraumatic as this patient had a chronic subdural hematoma which has become acute. I62.01 correctly reports the acute subdural hematoma, but also needed is I62.03 to report the chronic subdural hematoma as is documented for this case.

Process 3: Modifiers 1. Was the procedure performed different from that described by the nomenclature of the code?

Ans: No

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253 Feedback: No, the procedure performed was not different than that described by the nomenclature of the code.

2. Was the procedure performed at an anatomical site that has laterality?

Ans: No Feedback: The procedure was not performed on an anatomical site that has laterality.

3. Was the procedure performed in the global period of another procedure?

Ans: No Feedback: The procedure performed was not in the global period of another procedure.

4. Were additional procedures performed during the operative session, and does the documentation support them?

Ans: No Feedback: There were no additional procedures performed during the operative session.

5. Did the surgeon have help from another surgeon or another appropriate person?

Ans: No Feedback: The surgeon did not have help from another surgeon or other appropriate person.

6. Did a physician different from the surgeon provide the preoperative or postoperative portion of the procedure?

Ans: No Feedback: There was no physician different from the surgeon providing the pre- or postoperative portion of the procedure.

7. What modifier should be appended to the CPT code for this case?

Ans: D None Feedback: No modifier should be appended to the CPT code for this case. LT would be used to report a site with laterality and although the skull has a right and left side, it is considered one structure. As the skull is not considered a site with laterality, modifier 50 would be inappropriate. There is no indication in the documentation to support a substantial increase in the work, time, intensity, or technical of the procedure or severity of patient’s condition warranting appending modifier 22.

Chapter 16 – Surgery Section: Eyes, Ears, and Endocrine System LESSON PLANS Class Preparation: Teaching Focus and Resources

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254

The anatomy of the eyes, ears, and endocrine system is reviewed in Chapter 16. The coding guidelines for CPT and ICD, medical and procedural terms, and modifiers needed to assign the appropriate codes for the eyes, ears, and endocrine system are identified and applied in this chapter.

Learning Outcomes After completing Chapter 16, students will be able to: LO 16.1 Review the anatomy of the eyes, ears, and endocrine system.

LO 16.2 Understand the chapter-specific ICD guidelines and format for the eyes.

LO 16.3 Comprehend the chapter-specific ICD guidelines and format for the ears.

LO 16.4 Identify the guidelines and format of the eyes and ocular adnexa sections of CPT. LO 16.5 Recognize the guidelines and format of the ears and endocrine sections of CPT. LO 16.6 Apply the modifiers most commonly used with codes in the eyes, ears, and endocrine sections of CPT. LO 16.7 Examine the common medical and procedural terms used in operative reports.

Class Presentation LO 16.1: Review the anatomy of the eyes, ears, and endocrine system.

Slides 16-1 through 16-4



Chapter introduction and key terms

Slide 16-5



Introduction

Slide 16-6



Anatomy of the eyes, ears, and endocrine system

Slide 16-7



Anatomy of the eyes, ears, and endocrine system- continued - Ears

Slide 16-8



Anatomy of the eyes, ears, and endocrine system- continued - Endocrine system

LO 16.2: Understand the chapter-specific ICD guidelines and format for the eyes.

Slide 16-9



ICD Guidelines and Format for the Eye and Adnexa chapter - Disorders of the eyelid, lacrimal system, and orbit

Slide 16-10



ICD Guidelines and Format for the Eye and Adnexa chapter - continued - Disorders of the eyelid, lacrimal system, and orbit - continued

Slide 16-11



ICD Guidelines and Format for the Eye and Adnexa chapter - continued

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255 -

Disorders of conjuctive

Slide 16-12



ICD Guidelines and Format for the Eye and Adnexa chapter - continued - Disorders of the sclera: cornea, iris, and ciliary body

Slide 16-13



ICD Guidelines and Format for the Eye and Adnexa chapter - continued - Disorders of lens

Slide 16-14



ICD Guidelines and Format for the Eye and Adnexa chapter - continued - disorders of choroid and retina

Slide 16-15



ICD Guidelines and Format for the Eye and Adnexa chapter - continued - Glaucoma - Disorders of vitreous body and globe

Slide 16-16



ICD Guidelines and Format for the Eye and Adnexa chapter - continued - disorders of optic nerve and visual pathways - Disorders of ocular muscles, binocular movement, accommodation, and refraction

Slide 16-17



ICD Guidelines and Format for the Eye and Adnexa chapter - continued - Visual disturbance and blindness - Intraoperative and postprocedural complications and disorders of eye and adnexa

LO 16.3: Comprehend the chapter-specific ICD guidelines and format for the ears Slide 16-18



ICD Guidelines and Format for the Ear chapter - Diseases of the ear and masoid process

Slide 16-19



ICD Guidelines and Format for the Ear chapter – continued - Diseases of external ear

Slide 16-20



ICD Guidelines and Format for the Ear chapter – continued - diseases of middle ear and mastoid

Slide 16-21



ICD Guidelines and Format for the Ear chapter – continued - diseases of inner ear - Other disorders of ear ICD Guidelines and Format for the Ear chapter – continued - Intraoperative and postprocedural complications and disorders of ear and mastoid process (H95)

 Slide 16-22

LO 16.4: Identify the guidelines and format of the eyes and ocular adnexa sections of CPT.

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256 Slide 16-23



CPT General Headings of the Eyes and Ocular Adnexa Subsection - Eyes and ocular adnexa (65091-68899)

Slide 16-24



CPT Guidelines for the Eye and Ocular Adnexa Subsection - Removal of Eye (65091-65114) Evisceration Enucleation Exenteration

Slide 16-25



CPT Guidelines for the Eye and Ocular Adnexa Subsection – continued - Secondary implants (65125-65175) - Removal of Foreign Body (65205-65265) - Repair of Laceration (65270-65290)

Slide 16-26



CPT Guidelines for the Eye and Ocular Adnexa Subsection - Anterior Segment Cornea (65400-65782) Anterior Chamber (65800-66030) Lens (66820-66940) Intraocular Lens Procedures (66982-66986)

Slide 16-27



CPT Guidelines for the Eye and Ocular Adnexa Subsection - Posterior segment (67005-67255)

Slide 16-28



CPT Guidelines for the Eye and Ocular Adnexa Subsection - Ocular Adnexa Extraocular muscles (67311-67346) Orbit (67400-67599) Eyelids (67700-67999) Conjunctiva (68020-68899)

LO 16.5: Recognize the guidelines and format of the ears and endocrine sections of CPT. Slide 16-29



CPT General Headings for the Auditory System subsection - Auditory system (69000-69979)

Slide 16-30



CPT Guidelines for the Auditory System Subsection - External ear Excision (69100-69155) Removal (69200-69222) Repair (69300-69320)

Slide 16-31



CPT Guidelines for the Auditory System Subsection – continued - Middle ear

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257 Incision (69420-69450) Excision (69501-69544) Repair (69601-69676) Slide 16-32



CPT Guidelines for the Auditory System Subsection – continued - Inner ear Incision and/or Destruction (69801-69806) Introduction (69930) Operating Microscope (69990)

Slide 16-33



CPT General Headings for the Endocrine System Subsection -endocrine system (60000-60281)

Slide 16-34



CPT Guidelines for the Endocrine System Subsection - Thyroid gland Incision/Excision (60000-60281)

Slide 16-35



CPT Guidelines for the Endocrine System Subsection – continued - Parathyroid, Thymus, Adrenal Glands, Pancreas, and Carotid Body Excision (60500-60605)

LO 16.6: Apply the modifiers most commonly used with codes in the eyes, ears, and endocrine sections of CPT. Slide 16-36



Modifiers commonly used with codes from the Eyes, Auditory, and Endocrine system subsection of CPT - 50 - 51 - 62 - Table 16.9

LO 16.7 Examine the common medical and procedural terms used in operative reports.

Slide 16-37



Common medical and procedural terms used with the Eyes, Auditory, and Endocrine system - Table 16.10, 16.11, and 16.12

Summary Slides Slide 16-38 through 16-43



Synopsis of chapter

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258

Teaching Tips LO 16.1:  Eyes o o 



The functions of the eyes are to receive and reflect light rays, which generate nerve impulses that are then transmitted to the brain to become images or sight.

Path of light: cornea through aqueous humor of anterior chamber through the pupil and vitreous humor of posterior chamber to the retina which produces electrical signal or impulse traveling via optic nerve to brain.

Ears o o

The main functions of the ear are balance and hearing.

Path of sound waves: sound waves enter the outer ear travel to the tympanic membrane to middle ear and inner ear producing an electrical impulse which travels along the acoustic nerve to brain and finally the cerebral cortex.

Endocrine system o The main function of the endocrine system is to release hormones (chemicals) into the body through the bloodstream. o The structures of the endocrine system are the: • Pituitary gland • Pineal gland • Thyroid gland • Parathyroid gland • Thymus

LO 16.2: o

ICD-10-CM codes for conditions related to the eye and its supporting structures are listed in Chapter 7 – Diseases of the Eye and Adnexa H00–H59

Coding Tips and Guidelines o To help the student select the appropriate code when using the H54 category, have students add the right-side column of table 17.5 to the visual acuity table in ICD-10-CM o Not all categories in this chapter provided a bilateral code choice. When a condition affects both eyes and a bilateral choice is not available, a code for each side should be reported.

LO 16.3:  Categories within this section are subdivided by the anatomical sites of the ear, beginning with the external ear and ending with the hearing loss due to sensorineural or conductive disorders. o ICD-10-CM: Diseases of the Ear, H60-H95 Coding Tips and Guidelines o Highlight the instructional note at the beginning of the chapter regarding the use of an external cause codes when conditions of the ear are due to injury, exposure, or contact with an irritant or agent leading to a condition of the ear.

LO 16.4:  The codes in these sections are defined by the following general headings: • Eyeball • Anterior Segment • Posterior Segment • Ocular Adnexa

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259



• Conjunctiva These general headings are then further defined by the following subclassifications: • Incision • Excision • Removal • Repair • Destruction

Coding Tips and Guidelines o Highlight the instructional note at the beginning of this subsection that directs the use of CPT code 65205 if a foreign body is removed.

LO 16.5:  The codes in the ear section are defined by the following general headings: • External Ear • Inner Ear • Middle Ear • Temporal Bone, Middle Fossa  The codes in the endocrine section are defined by the following general headings: • Thyroid Gland • Parathyroid Gland, Thymus, Adrenal Glands, Pancreas, and Carotid Body These general headings can then be further defined by the following subclassifications: • Incision • Excision • Removal • Repair • Destruction Coding Tips and Guidelines o Highlight the instructional note below code 69120 that directs the coder to use 15120 for reconstruction of the ear. o An instructional note after code 69604 directs the use of 69631 or 69632 for planned secondary tympanoplasty after mastoidectomy. o Many coders find it useful to highlight the list of codes and code ranges located beneath CPT code 69990 as a reminder of the codes that include the use of an operating microscope in their description.

LO 16.6:  Modifiers are used in the Eyes, Ears, and Endocrine sections to continue or modify the story of the patient’s encounter. Some of the more common modifiers used in these sections are: • Bilateral services, 50 • Multiple procedures, 51 • Two surgeons, 62  Several instructional notes throughout these sections direct the use of modifier 50 if the procedure described was performed bilaterally.

LO 16.7:  The Eyes, Ears, and Endocrine sections include medical terms and procedural terms that are specific to the systems involved. Tables 16.11 through 16.13 list some of these terms and identify

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260 some key terms that could appear in a provider’s documentation concerning the eyes, ears, and endocrine system.

Chapter 16 Answer Key Exercise 16.1 1. Explain the pathway of light.

Ans: Cornea, aqueous humor of anterior chamber, pupil, vitreous humor of posterior chamber, retina, electrical signal, optic nerve, brain, and then the image Feedback: Pathway of light: cornea  aqueous humor of anterior chamber  pupil  vitreous humor of posterior chamber  retina  electrical signal or impulse  optic nerve  brain 2. Explain the path of sound waves.

Ans: Sound waves, outer ear, tympanic membrane, middle ear, inner ear, electrical impulse, acoustic nerve, brain, cerebral cortex, sound Feedback: Path of sound waves: sound waves  outer ear  tympanic membrane  middle ear  inner ear  electrical impulse  acoustic nerve  brain  cerebral cortex  sound 3. List the structures of the endocrine system.

Ans: Pituitary gland, pineal gland, thyroid gland, parathyroid gland, and thymus Feedback: The structures of the endocrine system include the pituitary gland, pineal gland, thyroid gland, parathyroid gland, and thymus.

4. Identify the location of the tympanic membrane, and explain its function.

Ans: Also known as the ear drum, the tympanic membrane divides the external and middle ear and converts sound to vibration.

Feedback: The tympanic membrane is also known as the ear drum. It divides the external and middle ear.

The tympanic membrane converts sound to vibration.

5. Which endocrine gland produces the hormone melatonin?

Ans: The pineal gland Feedback: The pineal gland produces the hormone melatonin.

Exercise 16.2 1. List the types of cataracts.

Ans: Congenital: Occurs at or prior to birth and may or may not affect vision significantly enough to require surgery.

Age-related or senile: Typically occurs in patients over 70 years of age, but may develop as early as 40 or 50 years of age.

Secondary: May develop after surgical procedures on the eye, or due to an underlying condition such as diabetes or the prolonged use of medications such as steroids.

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261 Traumatic: Develops due to a direct injury to the eye, typically from blunt trauma or exposure to certain chemicals.

Feedback: N/A 2. Define the two main types of glaucoma.

Ans: Open-angle: Fluid does not flow through the trabecular meshwork properly.

Closed-angle: The angle between the iris and the cornea is too narrow or the iris dilates too widely, closing the angle. This may be documented as narrow-angle glaucoma.

Feedback: N/A 3. What is the subclassification for acute/subacute iridocyclitis based on?

Ans: Acute/subacute iridocyclitis is subclassified based upon the type of iridocyclitis: primary, recurrent, secondary due to infection or not due to infection.

Feedback: N/A Exercise 16.3 1. Identify the further differentiations of nonsuppurative and suppurative conditions of otitis media.

Ans: Nonsuppurative conditions are further classified based upon the type as serous, mucoid, or sanguinous; acute or chronic; and laterality. Suppurative conditions are classified as acute or chronic.

Acute suppurative codes are further defined based on a rupture of the eardrum. Chronic suppurative codes are further defined based upon the structures affected or the location of the condition in relation to the tympanic membrane as well as laterality.

Feedback: Otitis media is coded to categories H65 and H66. ICD categorizes otitis media as nonsuppurative (H65) and suppurative (H66). Each of these categories is further divided based on acuity of the condition as acute or chronic. Nonsuppurative conditions are further classified based on the type: serous, mucoid, or sanguinous. Suppurative conditions are classified as acute or chronic. Acute suppurative codes are further defined based on a rupture of the eardrum, and chronic suppurative codes are further defined based on the structures affected or the location of the condition in relation to the tympanic membrane.

2. Hearing loss is coded to category H90 and H91. Define the further subclassifications of hearing loss.

Ans: The conditions of hearing loss are subdivided based upon the type of loss as conductive, sensorineural, or a combination of sensorineural and conductive. Further specificity is reported by unilateral or bilateral and right or left ear involvement.

Feedback: Hearing loss is coded to category H90, H91. The conditions of hearing loss are subdivided based on the type of loss: conductive, sensorineural, or a combination of sensorineural and conductive.

Further specificity is reported by unilateral or bilateral and right or left ear involvement.

3. Further define the subcategories used to assign codes for otitis externa.

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262 Ans: Category H60: these subcategories are primarily broken down into infective and noninfectious forms of otitis externa. Conditions included in each of these subcategories are classified by the underlying cause or nature of the condition.

Feedback: Otitis externa is an infection or inflammation that extends into the cartilage of the ear, and ICD subcategories are primarily divided into infectious and noninfectious forms of otitis externa. Conditions included in each of these subcategories are classified by the underlying cause or nature of the condition.

Exercise 16.4 1. Removal of the eyeball is coded based upon how much of the eyeball and orbital structures is removed with the eye. Define the terms evisceration, enucleation, and exenteration.

Ans: Evisceration: Removal of the contents within the eye, leaving the scleral shell intact.

Enucleation: Removal of the eyeball in total by cutting it free of the extraocular muscles and the optic nerve.

Exenteration: Removal of the eyeball and orbital support structure, with or without orbital bone.

2. Under the subheading for laceration repairs of the eyeball, the codes are first divided based on the anatomical site of the lacerations. What are these anatomical sites, and how are the laceration repair codes further defined?

Ans: These sites include the conjunctiva, cornea, and extraocular muscle, tendon, or Tenon’s capsule.

Conjunctival laceration repair codes are further defined by type of repair and hospitalization of the patient (65270-65273).

Feedback: Under the subheading for laceration repairs of the eyeball, the codes are first divided based on the anatomical site of the laceration. The sites include the conjunctiva, cornea, and extraocular muscle, tendon, or Tenon’s capsule. Conjunctival laceration repair codes are further defined by type of repair and hospitalization of the patient (65270–65273).

3. To accurately code a keratoplasty, what must the coder be able to determine from the medical record.

Ans: Keratoplasty, also known as corneal transplants, is divided in CPT based upon the thickness of the donor graft or the portion of the cornea grafted to the donor’s eye such as the endothelial disc (65756).

Penetrating keratoplasties are further specified by CPT by the presence of a natural lens.

Feedback: Keratoplasty, also known as a corneal transplant, is divided by CPT based on the thickness of the donor graft or the portion of the cornea grafted to the donor’s eye, such as the endothelial disc (65756). Penetrating keratoplasties are further specified by CPT by the presence of a natural lens (65730), the absence of a lens (65750), and an artificial lens (65755).

4. Describe a monotony. How else might it be described in a provider’s documentation?

Ans: Monotony (65820), which may also be documented as a divinities or barman’s operation, involves the use of a gonio-knife to open the angle of the trabecular meshwork.

Feedback: Many of the procedures performed to reduce intraocular pressure or improve the flow of vitreous fluid within the eye are listed under the subheadings Anterior Chamber, Anterior Sclera, or Iris,

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263 Ciliary Body. Included under the Anterior Chamber subheading is monotony (65820), which may also be documented as a divinities or barman’s operation, involves the use of a gonio-knife to open the angle of the trabecular meshwork.

Exercise 16.5 1. Would it be appropriate to append modifier 50 to CPT code 69210 when impacted cerumen is removed from both ears?

Ans: Yes, the code CPT guidance for code 69210 indicates for bilateral procedure, report 69210 with modifier 50‖ .

2. What must a coder be able to determine from the provider documentation in order to assign the correct code for a thyroidectomy?

Ans: It is very important for a coder to be able to read the operative report and decide from the documentation exactly what procedure was accomplished, the approach, and why it was performed in order to assign the accurate code from this code range.

Feedback: To assign the accurate code from this code range, coders must be able to read the operative report and decide from the documentation exactly what procedure was accomplished, what the approach was, and why the procedure was performed.

3. Explain the difference between a modified radical mastoidectomy and a radical mastoidectomy.

Ans: In a modified radical mastoidectomy, some middle ear bones are left in place and the eardrum is rebuilt. In a radical mastoidectomy, most of the bone is removed.

Feedback: The mastoidectomy codes, 69502-69511, are further defined as complete, modified radical (some middle ear bones are left in place and the eardrum is rebuilt), or radical (most of the bone is removed).

Exercise 16.6 1. Debridement, mastoidectomy cavity, complex is performed bilaterally. Assign the appropriate CPT code with the appropriate modifier appended.

Ans: 69222-50 Feedback: There is an instructional note beneath code 69222 instructing the use of modifier 50 for bilateral procedures 2. In order to append modifier 62, what must both surgeons document?

Ans: Each performed distinct parts of the same procedure Feedback: Modifier 62 is appended when two surgeons perform distinct parts of a procedure on the eye or ear. Each surgeon would report his or her distinct portion of the procedure, appending modifier 62 to the appropriate procedure code.

3. Which modifier is not to be used with CPT code 65820?

Ans: Modifier 63

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264 Feedback: Modifier 63 may not be appended to code 65820 Goniotomy, also known as a DeVincintus or Barken’s operation.

Exercise 16.7 1. What is the difference between a Rinne test and a Weber test?

Ans: A Weber test is used to determine hearing deficit as conductive or sensorineural. A Rinne test is used for bone air conduction of sound wave.

Feedback: N/A 2. List the two abbreviations most commonly seen in cataract operative reports.

Ans: ECCE and IOL Feedback: ECCE stands for extra capsular cataract extraction. IOL stands for intraocular lens.

3. How might an excessive secretion of thyroid hormone be described in a medical record?

Ans: Graves’ disease, hyperthyroidism, toxic diffuse goiter Feedback: N/A

Chapter 16 Review Using Terminology 1. L

AU

9. K

Otitis Externa

2. H

Audiometry

10. E

Presbyopia

3. N

Cushing’s syndrome

11. C

Sclera

4. M

Graves’ disease

12. A

Thymus

5. G

Hyperopia

13. O

Thyroid storm

6. D

Hypotony

14. I

Tinnitus

7. J

Impacted cerumen

15. F

Tympanic membrane

8. B

Myopia

Checking Your Understanding 1. A 25-year-old patient has been diagnosed with noise-induced hearing loss due to the exposure of continuous music. Select the appropriate ICD-10-CM code: Ans: B. H83.3X9 Feedback: H83.3X9 is assigned for noise effects on inner ear, unspecified ear, as the documentation does not specify which ear or ears are involved. The documentation does specify the hearing loss as noiseinduced.

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265 2. A 23-year-old female presents to the ophthalmologist with type 2 diabetes mellitus with a cataract on her left eye. The patient has also been diagnosed with benign essential hypertension.

Select the appropriate ICD-10-CM codes: Ans: C. E11.36, I10 Feedback: The description for E11.36 is type 2 diabetic mellitus with diabetic cataract. Index: diabetes, type 2 with cataract = E11.36. I10 reports the hypertension.

3. The clear part of the eye that covers the pupil and iris and controls and focuses light entering the eye is the: Ans: A. Cornea Feedback: The sclera forms the visible white of the eye and surrounds the optic nerve. The conjunctiva is the mucous membrane lining the supporting structures of the eye and inner eyelids. The lens is located directly behind the cornea and focuses light rays onto the retina.

4. The patient presented for removal of foreign object from the cornea. This was performed without a slip lamp. Choose the appropriate CPT code for this procedure: Ans: C. 65220 Feedback: 65220 correctly describes removal of foreign body, external eye; corneal, without slip lamp.

Code 65222 is with slit lamp; 65235 is intraocular; and 65210 is conjunctival embedded or sclera no perforating, which the documentation does not state.

5. A patient who had previous eye surgery that did not involve the extraocular muscle presented for strabismus surgery on two horizontal muscles. Select the appropriate CPT code(s): Ans: B. 67312, 67331 Feedback: 67331 is an add-on code for the previous eye surgery and would not be the primary procedure code. 67316 is for 2 vertical muscles.

6. A tympanostomy (requiring insertion of a ventilating tube), with local or topical anesthesia, that is performed on both ears is assigned CPT code: Ans: D. 69433-50 Feedback: CPT instructs the use of modifier 50 with 69433 for a bilateral procedure. 69436 requires general anesthesia, and 69450 is for a tympanolysis.

7. A procedure was performed on the ocular sinister. Which of the following modifiers should be appended to the code?

Ans: B. OS Feedback: OS is oculus sinister - left eye. OD is oculus dexter - right eye. OU is oculus uterque - each eye. AS is auris sinistra - left ear.

8. A 20-year-old female patient presented to the office for a test to determine whether her hearing deficit as conductive or sensorineural. This type of test is called: Ans: C. the Weber test

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266 Feedback: The Weber test is done for auditory acuity. The Rinne test is done with a vibrating tuning fork and is used for bone air conduction of sound wave. Audiometry is a measurement of sound.

9. A 52-year-old male presents with tachycardia, weight loss, and nervousness. The physician is concerned the patient’s heart rate is high. Stat labs are run, and the physician determines that the patient is experiencing hyperthyroidism with thyroid storm. The patient is admitted. Select the appropriate ICD-10-CM code: Ans: B. E05.91 Feedback: E05.91 correctly describes hyperthyroidism with mention of thyrotoxic crisis or storm. E05.01 is hyperthyroidism with diffuse goiter; E05.90 is without mention of thyrotoxic storm; and E03.9 is hyperthyroidism, unspecified.

10. Robert, a 64-year-old male, presents to the office with early stage of low-tension glaucoma of the right eye. Select the appropriate ICD-10-CM code(s): Ans: A. H40.1211 Feedback: H40.1211 identifies the low-tension glaucoma of the right eye, mild stage. The specificity here is the type of glaucoma, laterality and stage.

Appling Your Knowledge Case 1 Procedure performed: Bilateral tympanostomy Preoperative diagnosis: Bilateral recurrent otitis media with effusion Postoperative diagnosis: Left recurrent otitis media with effusion Procedure: The patient was placed in the supine position and under the adequate general anesthesia; the patient was prepped and draped in the usual manner. Using the operating microscope, the left tympanic membrane was visualized. The canal was cleaned of cerumen and a radial incision was made in the anteroinferior quadrant of the membrane. A 0.40 tube was placed in the previously created myringotomy. Suspension drops were instilled, and a cotton ball was placed at the meatus.

Process 1: CPT 1. What is the procedure?

Ans: Tympanostomy Feedback: Tympanostomy is the procedure.

2. Locate the main term in the index.

Ans: Tympanostomy

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267 Feedback: Tympanostomy is the main term.

3. What additional questions or set of questions can be determined?

Ans: None Feedback: There are no additional questions or set of questions.

4. Upon review of all the code choices identified in the index, what additional questions can be determined?

Ans: Under what type of anesthesia was the procedure performed?

Feedback: Upon review of all the code choices identified in the index, the additional question is, ―Under what type of anesthesia was the procedure performed?‖ 5. Based on the documentation, what is the correct code for this case?

Ans: B 69436 Feedback: Based upon the documentation, the correct code for this case is 69436, which correctly reports tympanostomy with tube insertion under general anesthesia. 69421 reports an incision of the tympanic membrane for aspiration of the middle ear and/or Eustachian tube. 69433 does report a tympanostomy with tube insertion, but performed with local anesthesia, and the procedure was documented as completed under general anesthesia. 69424 reports the removal of ventilating tubes; the procedure performed is insertion of tubes.

Process 2: ICD ICD-10-CM 1. Based on the operative report header, what is the preoperative diagnosis?

Ans: Otitis media with effusion, recurrent Feedback: Per the operative report header, the preoperative diagnosis is otitis media with effusion, recurrent.

2. Is the postoperative diagnosis the same as or different from the preoperative diagnosis?

Ans: Same Feedback: The postoperative diagnosis is the same as the preoperative diagnosis.

3. Is the postoperative diagnosis supported?

Ans: Yes Feedback: Yes, the postoperative diagnosis is supported.

4. What is the main term for this condition?

Ans: Otitis Feedback: Otitis is the main term for this condition.

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268 5. Based on the subterm choices, what question(s) can be developed for this condition?

Ans: Is the condition chronic, acute, or recurrent? Is effusion present, or what other conditions are present?

Feedback: Based upon the subterm choices, the following questions can be developed for this condition: Is the condition chronic, acute, or recurrent? Is effusion present, or what other conditions are present?

6. Based on the information in the Tabular List, is additional information needed to determine the appropriate diagnosis code?

Ans: Laterality of the condition Feedback: Based upon the information in the Tabular List, laterality of the condition is necessary to determine the appropriate diagnosis code.

7. Is any sign, symptom, or additional condition documented?

Ans: No Feedback: There were no signs, symptoms, or additional conditions documented.

8. Is the additional condition, sign, or symptom an integral part of the primary (or other) condition coded?

Ans: N/A Feedback: N/A 9. Does the additional condition require or affect patient care, treatment, or management?

Ans: N/A Feedback: N/A 10. Based on the documentation, what is the correct ICD-10-CM code for this case?

Ans: A H65.196 Feedback: Based upon the documentation, the correct ICD-10-CM code for this case is H65.196, which correctly reports bilateral recurrent nonsuppurative (effusion) otitis media. H65.193 does report bilateral nonsuppurative otitis media; however, this code is incorrect as ICD-10-CM does provide a code choice for recurrent. H65.493 reports chronic nonsuppurative otitis media; however, this condition is not documented as chronic, and the ICD-10-CM index provides direction through the subterm listed to code the recurrent condition as acute. H65.19 is an incomplete (truncated) code and not reportable.

Process 3: Modifiers 1. Was the procedure performed different from that described by the nomenclature of the code?

Ans: No Feedback: The procedure performed was not different from that described by the nomenclature of the code.

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269 2. Was the procedure performed at an anatomical site that has laterality?

Ans: Yes Feedback: Yes, the procedure was performed at an anatomical site that has laterality.

3. Was the procedure performed in the global period of another procedure?

Ans: No Feedback: The procedure performed was not in the global period of another procedure.

4. Were additional procedures performed during the operative session, and does the documentation support them?

Ans: No Feedback: There were no additional procedures performed during the operative session.

5. Did the surgeon have help from another surgeon or another appropriate person?

Ans: No Feedback: The surgeon did not have help from another surgeon or other appropriate person.

6. Did a physician different from the surgeon provide the preoperative or postoperative portion of the procedure?

Ans: No Feedback: There was no physician different from the surgeon providing the pre- or postoperative portion of the procedure.

7. What modifier should be appended to the CPT code for this case?

Ans: D none Feedback: The modifier 50 should not be appended to the CPT for this case to identify that the procedure was performed bilaterally since the code description is bilateral. 51 is incorrect because although the procedure was performed multiple times, it was the same procedure performed on a bilateral site. 59 is reported in cases where a separate distinct procedure is performed in addition to another procedure.

However, the 59 modifier is the modifier of last resort and should not be reported if another more appropriate modifier is available.

Case 2 Procedure performed: Extracapsular cataract extraction with intraocular lens insertion, right eye.

Ophthalmic microscope was used.

Preoperative diagnosis: Senile subcapsular polar cataract, posterior Postoperative diagnosis: Senile sub capsular polar cataract, posterior

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270 Local anesthesia was administered with lidocaine 2 percent with epinephrine for a lid block.

Retrobulbar anesthesia was administered using marcaine 0.75 percent with epinephrine and lidocaine 4 percent. Patient was prepped and draped in the usual sterile ophthalmic fashion.

The eye was stabilized with a 4-0 black silk superior rectus traction suture and was subsequently deflected downward. A scleral incision was made 2 mm superior to the superior limbus and approximately 12 mm in length. The dissection was then carried posteriorly from the base of the incision into clear cornea. A stab wound was made into clear cornea at 1 o’clock to provide an access, and a keratome was utilized to enter the anterior chamber through the base of the corneoscleral wound at 10 o’clock.

Healon was injected into the anterior chamber through a cystitome needle. The needle was subsequently used to create an anterior capsulotomy, and capsule forceps were utilized to affect a circular tear capsulorrhexis capsulotomy. Balanced salt solution was injected underneath the capsule to dissect the nucleus free from the capsule.

Using a lens loop and Colibri forceps, the nucleus was expressed through the wound. Two interrupted 10-0 nylon sutures were then inserted through the corneoscleral wound, dividing the wound into equal thirds.

Lens cortical material was irrigated and aspirated from the wound. Following this, the posterior capsule was noted to be intact, and Healon was injected into the anterior chamber.

The previously selected intraocular lens was soaked in balanced salt solution. The lens was flushed with fresh balanced salt solution and coated with Healon. Angled forceps were then used to insert the lens through the scleral incision, with the inferior foot of the haptic passing beneath the anterior capsule at 6 o’clock. Long-angled tying forceps were then used to place the superior foot of the haptic through the pupil behind the anterior capsule at 12 o’clock. The lens was rotated to ensure stability. 10-0 nylon interrupted sutures were placed to close the corneoscleral wound.

Process 1: CPT 1. What is the procedure?

Ans: Cataract extraction with intraocular lens insertion, extracapsular Feedback: Cataract extraction with intraocular lens insertion, extracapsular, is the procedure.

2. Locate the main term in the index.

Ans: Cataract Feedback: The main term is cataract.

3. What additional questions or set of questions can be determined?

Ans: What is the method of removal?

Feedback: The additional question that can be determined is, ―What is the method of removal?‖ 4. Upon review of all the code choices identified in the index, what additional questions can be determined?

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271 Ans: Was the procedure extra- or intracapsular? Was the IOL inserted at the same time or later?

Feedback: Upon review of all the code choices identified in the index, the following additional questions can be determined: Was the procedure extra- or intracapsular? Was the IOL inserted at the same time or later?

5. Based on the documentation, what is the correct code for this case?

Ans: B 66984 Feedback: Based upon the documentation, the correct code for this case is 66984, which describes the extracapsular extraction of a cataractous lens with concurrent insertion of an IOL. 66982 describes a complex cataract extraction which requires additional work or devices to open the iris, such as expansion devices or sutures to enlarge and maintain the pupil’s opening during the procedure, which was not documented in this case. 66983 describes an intracapsular cataract extraction, and the documentation indicates an extracapsular extraction was performed. 66985 describes a secondary implant of an IOL, not an extraction and concurrent implant of the IOL as is documented.

Process 2: ICD ICD-10-CM 1. Based on the operative report header, what is the preoperative diagnosis?

Ans: Senile subcapsular polar cataract, posterior Feedback: Per the operative report header, the preoperative diagnosis is senile subcapsular polar cataract, posterior.

2. Is the postoperative diagnosis the same as or different from the preoperative diagnosis?

Ans: Same Feedback: The postoperative diagnosis is the same as the preoperative diagnosis.

3. Is the postoperative diagnosis supported?

Ans: Yes Feedback: Yes, the body of the report supports the postoperative diagnosis .

4. What is the main term for this condition?

Ans: Cataract Feedback: Cataract is the main term for this condition.

5. Based on the subterm choices, what question(s) can be developed for this condition?

Ans: What is the underlying cause or type of the cataract? Where is the cataract located within the lens?

Feedback: Based upon the subterm choices, the following questions can be developed for this condition: What is the underlying cause or type of the cataract? Where is the cataract located within the lens?

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272 6. Based on the information in the Tabular List, is additional information needed to determine the appropriate diagnosis code?

Ans: Yes, laterality Feedback: Based upon the information in the Tabular List, the additional information needed to determine the appropriate diagnosis code is laterality.

7. Is any sign, symptom, or additional condition documented?

Ans: No Feedback: No signs, symptoms, or additional conditions were documented.

8. Is the additional condition, sign, or symptom an integral part of the primary (or other) condition coded?

Ans: N/A Feedback: N/A 9. Does the additional condition require or affect patient care, treatment, or management?

Ans: N/A Feedback: N/A 10. Based on the documentation, what is the correct ICD-10-CM code for this case?

Ans: B H25.041 Feedback: Based upon the documentation, the correct ICD-10-CM code for this case is H25.041, which correctly reports an age-related (senile) posterior subcapsular polar cataract of the right eye. The eye was identified in the header of the documentation: “Extracapsular cataract extraction with intraocular lens insertion, right eye.” H25.039 reports an age-related cataract, anterior portion of the lens and of an unspecified eye. The documentation states the cataract was located in the posterior portion of the lens.

H25.049 does report an age-related posterior subcapsular polar cataract but of an unspecified eye, and the documentation stated it was the right eye. H26.05 reports a cataract of an infant or child.

Process 3: Modifiers 1. Was the procedure performed different from that described by the nomenclature of the code?

Ans: No Feedback: The procedure performed was not different from that described by the nomenclature of the code.

2. Was the procedure performed at an anatomical site that has laterality?

Ans: Yes, right eye Feedback: The procedure was performed on an anatomical site that has laterality; it was performed on the right eye.

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273 3. Was the procedure performed in the global period of another procedure?

Ans: No Feedback: The procedure performed was not in the global period of another procedure.

4. Were additional procedures performed during the operative session, and does the documentation support them?

Ans: No; N/A Feedback: No; N/A 5. Did the surgeon have help from another surgeon or another appropriate person?

Ans: No Feedback: The surgeon did not have help from another surgeon or other appropriate person.

6. Did a physician different from the surgeon provide the preoperative or postoperative portion of the procedure?

Ans: No Feedback: There was no physician different from the surgeon providing the pre- or postoperative portion of the procedure.

7. What modifier should be appended to the CPT code for this case?

Ans: D. Either RT or OD Feedback: Either of the modifiers RT or OD should be appended to the CPT for this case. Both RT and OD correctly identify the right eye. Reporting would depend upon payer discretion. 50 reports a bilateral procedure; although the anatomical site has laterality, the procedure was performed only on the right side.

Unit 4 Exam Answer Key 1. A patient is seen in the outpatient clinic for colonoscopy due to a family history of colon cancer.

The patient has no personal history of gastrointestinal disease and is currently without signs and symptoms. The colonoscopy revealed a colonic polyp that was removed by hot biopsy forceps. What should the CPT and diagnosis codes for this case be?

Ans: C. 45384, Z12.11, Z80.0, K63.5 Feedback: Assign code Z12.11, Encounter for screening for malignant neoplasm of colon (encounter for screening colonoscopy NOS), as the first-listed diagnosis because this was a screening colonoscopy. Code Z80.0, Family history of malignant neoplasm of digestive organs, may be assigned as an additional diagnosis. Assign code K63.5, polyp of colon, as an additional diagnosis. Because the polyp was removed, 45384 is reported to identify the definitive procedure performed.

2. A 23-year-old patient is seen by Dr. Johnson for a cough with wheezing and green-colored mucus for the past four days, as well as four days of external bleeding hemorrhoids and diarrhea. Dr. Johnson gives her Augmentin for acute viral bronchitis, instructions on the care of external

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274 hemorrhoids, and a diet plan to assist with the diarrhea. What diagnoses should Dr. Johnson use for this encounter?

Ans: A. J20.8, K64.4, R19.7 Feedback: J20.8, Acute bronchitis, unspecified; K64.4, residual hemorrhoid skin tags (external hemorrhoids, NOS); and R19.7 Diarrhea, unspecified. Hemorrhoids are external, and the bronchitis is not specific to the type of virus.

3. A 35-year-old patient is brought to the operating room for an outpatient surgery for a hiatal hernia repair. The surgeon is able to repair the hernia laparoscopically by placing sutures in the crus diaphragmatic muscles below the esophagus and bringing them together to close the hiatal hernia. The anterior and posterior walls of the fundus are wrapped and stitched around the esophagus to complete the procedure. Select the appropriate CPT and ICD-10-CM codes for this procedure: Ans: C. 43281, K44.9 Feedback: 43281 correctly reports a laparoscopic hernia repair with fundoplasty and without implantation of mesh, as described in the CPT manual, and K44.9 reports a hiatal hernia without mention of gangrene or obstruction.

4. Operative Report Preoperative Diagnosis: Internal hemorrhoids Postoperative Diagnosis: Internal hemorrhoids, anal fistula Procedure Performed: Hemorroidectomy and repair of anal fistula Operative Note: The patient presented today for an inpatient procedure to repair an anal fistula and remove internal hemorrhoids. The patient was put under general anesthesia, prepped, and draped. The physician entered the anus using an endoscope to determine placement of internal hemorrhoids, and upon entering, identified an intersphincteric anal fistula that had occurred since the last visit by the patient. The procedure was initiated, and removal of two columns of internal hemorrhoids was performed using rubber band ligation. Once that procedure was performed, an endoscopic repair of the anal fistula took place, using fibrin glue to seal the fistula. With this accomplished, the patient was awakened from anesthesia and taken to an inpatient room for an overnight stay. Select the appropriate CPT and ICD-10-CM codes: Ans: C. 46221, 46706-59, K64.8, K60.3 Feedback: 46221 correctly identifies a hemorroidectomy, internal, by rubber band ligation, and 46706 correctly identifies the repair of the anal fistula with fibrin glue as indicated in the operative report. A modifier -59 needs to be appended to identify that this is a separate procedure in addition to the primary procedure of the hemorroidectomy. K64.8 reports the internal hemorrhoids without mention of degree, and K60.3 reports the anal fistula not being congenital; we know it is not congenital from the verbiage ―upon entering identified an intersphinteric anal fistula that had occurred since the last visit.‖ 5. Preoperative Diagnosis: 1) Cholelithiasis, 2) acute cholecystitis Preoperative Diagnosis: 1) Cholelithiasis, 2) acute cholecystitis Name of operation: Laparoscopic cholecystectomy

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275 Anesthesia: General Findings: The gallbladder was thickened and showed evidence of chronic cholecystitis. There was a great deal of inflammatory reaction around the cystic duct. The cystic duct was slightly larger.

There were nine stones impacted in the cystic duct. The gallbladder contained numerous stones, which were small. With the stones impacted in the cystic duct, it was felt that probably none were within the common duct. Other than rather marked obesity, no other significant findings were noted on limited exploration of the abdomen.

Procedure: Under general anesthesia after routine prepping and draping, the abdomen was insufflated with the Veress needle and the standard four trocars were inserted uneventfully.

Inspection was made for any entry problems, and none were encountered.

After limited exploration, the gallbladder was then retracted superiorly and laterally, and the cystic duct was dissected out. This was done with some difficulty due to the fibrosis around the cystic duct, but care was taken to avoid injury to the duct and to the common duct. In this manner, the cystic duct and cystic artery were dissected out. Care was taken to be sure that the duct that was identified went into the gallbladder and was the cystic duct. The cystic duct and cystic artery were then doubly clipped and divided, taking care to avoid injury to the common duct. The gallbladder was then dissected free from the gallbladder bed. Again, the gallbladder was somewhat adherent to the gallbladder bed due to previous inflammatory reaction. The gallbladder was dissected free from the gallbladder bed utilizing the endo shears and the cautery to control bleeding. The gallbladder was extracted through the operating trocar site, and the trocar was reinserted. Inspection was made of the gallbladder bed. One or two bleeding areas were fulgurated, and bleeding was well controlled.

Select the appropriate CPT and ICD-10-CM codes: Ans: A. 47562, K80.00 Feedback: 47562 correctly identifies laparoscopic cholecystectomy, and ICD-10-CM code K80.00 correctly identifies cholelithiasis with acute cholecystitis and without mention of obstruction.

6. An endoscopy procedure was started on a patient who was scheduled and prepped for a total colonoscopy. The physician was unable to advance the scope beyond the splenic flexure due to unforeseen circumstances. Which of the following modifiers is appended to the colonoscopy code?

Ans: C. 53 Feedback: Modifier 53 is a discontinued procedure. CPT gives the guidance on the use of this modifier with this particular type of scenario.

7. Which of the following terms refers to an abnormal accumulation of fluid in the peritoneal cavity that is often a complication of a malignancy?

Ans: C. Ascites Feedback: Ascites is an abnormal accumulation of fluid in the peritoneal cavity. Peritonitis is the inflammation of the lining of the abdominal cavity. Crohn’s disease is a chronic inflammatory disease primarily of the bowel. Volvulus is twisting or turning.

8. A 55-year-old male patient is coming to the hospital for an outpatient service for a prostate biopsy. The patient has a family history of prostate cancer, and had recent blood work showing

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276 elevated PSA levels, and has problems urinating. The patient presents and is placed under anesthesia and prepped and draped. Ultrasonic guidance is used for needle placement, and a needle biopsy is taken. The biopsy is sent to pathology, and the patient is awaiting the results. Select the appropriate CPT and ICD-10-CM codes: Ans: D. 55700, 76942, R97.20, Z80.42 Feedback: 55700 correctly reports a prostate biopsy using needle, any approach, and the approach is not specified. Imaging guidance was used, so CPT 76942 should be used in addition to the primary procedure. R97.20 correctly reports elevated PSA levels, and Z80.42 correctly reports family history, not personal history, of neoplasm of the prostate.

9. The patient is a female transgender patient who has undergone hormonal therapy, along with other services, to prepare her for her sex change to a male. The patient is counseled on the adverse effects of surgery, as well as complications that may occur. The patient signs the consent for surgery and is taken back to the operating room, prepped for surgery, and placed under general anesthesia. The patient successfully comes through surgery. Select the appropriate CPT code: Ans: C. 55980 Feedback: CPT code 55980 correctly reports an intersex surgery from female to male; it is indicated in the procedure note that patient was previously a female and is now changing to a male.

10. Preoperative Diagnosis: Bladder tumor, 3.4 cm Postoperative Diagnosis: Bladder tumor, 4.2 cm Procedure: The patient was placed in the lithotomy position after receiving IV sedation. He was prepped and draped. A 21- French cystoscopy was passed into the bladder; a previous CT scan of the bladder indicated a tumor of approximately 3.4 cm. After inspection of the bladder with the cystoscope, the findings were consistent with a bladder tumor but the size was inconsistent; the actual finding was a size of 4.2 cm. A biopsy was taken, and laser surgery was performed with fulguration on the removal of the tumor. The patient tolerated the procedure well. Code only the procedure: Ans: A. 52235 Feedback: CPT code 52235 correctly reports cystourethroscopy with fulguration or treatment of a medium bladder tumor size 2.0 to 5.0 cm, and the actual size reported was 4.2 cm.

11. An elderly gentleman has worsening bilateral hydronephrosis. He did not have much of a postvoid residual on bladder scan. He is taken to the OR to have a bilateral cystoscopy and retrograde pyelogram. The results come back as gross prostatic hyperplasia. Select the appropriate CPT and ICD-10-CM codes: Ans: C. 52005-50, N40.0, N13.30 Feedback: 52005-50: the scenario states that the patient had a bilateral procedure performed, so modifier 50 is appropriate. ICD-10-CM N40.0 represents benign prostatic hyperplasia without LUTS (lower urinary tract infection) and N13.30 reports the hydronephrosis, unspecified.

12. A 25-year-old male patient presents for outpatient surgery today on penile genital warts that previously were treated with medication and have not subsided. The patient is having the genital warts removed using a cryosurgery technique. What are the correct CPT and ICD-10-CM codes?

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277 Ans: B. 54056, A63.0 Feedback: The CPT code 54056 correctly codes destruction of a lesion(s) penis using cryosurgery, and the ICD-10-CM code A63.0 correctly reports genital warts.

13. Postoperative Diagnosis: Ovarian cyst, right Anesthesia: General Name of operation: Open drainage of cyst Procedure: The patient was taken to the operating room, prepped and draped in the usual manner, and adequate anesthesia was induced. An infraumbilical incision was made, and abdominal entrance was made. Gas was entered into the abdomen at two liters. The abdomen was visualized.

The cyst was noted on the right, a 4-cm ovarian cyst. This was needled, and a hole was cut in it with the scissors. Hemostasis was intact. The instruments were removed. The patient was awakened and taken to the recovery room in good condition. Select the appropriate CPT and ICD-10-CM codes: Ans: B. 58805, N83.201 Feedback: CPT code 58805 correctly identifies drainage of an ovarian cyst using an abdominal approach; this was indicated by an incision being made into the abdomen. Diagnosis code N83.201 correctly identifies an ovarian cyst, right side.

14. Preoperative Diagnosis: Right eustachian tube dysfunction Postoperative Diagnosis: Right eustachian tube dysfunction Anesthesia: General mask Name of operation: Eustachian tube catheterization Procedure: The patient was taken to the operating room and placed in the supine position. After general anesthesia was given, the operating microscope with brought in for full use throughout the case. The right tympanic membrane was approached using a transnasal approach. An anteriorinferior radial incision was made in the right tympanic membrane. Suction revealed a substantial amount of mucopurulent drainage. A Sheehy pressure equalization tube was placed in the site.

Floxin drops were added. The patient tolerated the procedure well and returned to the recovery room awake and in stable condition.

Select the appropriate CPT and ICD-10-CM codes: Ans: A. 69799, H69.81 Feedback: The correct CPT code is 69799, unlisted procedure middle ear. CPT code 69400 had previously been reported for this procedure. CPT now instructs the use of the unlisted procedure. H69.81, other specified disorders of Eustachian tube identifies the Eustachian tube dysfunction 15. Operation: LEEP procedure Diagnosis: Cervical polyp

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278 Procedure: With the patient in the supine position, general anesthesia was administered. The patient was put in the dorsal lithotomy position and prepped and draped for dilatation and curettage in a routine fashion.

An insulated posterior weighted retractor was put in. Using the LEEP tenaculum, we were able to grasp the anterior lip of the cervix with a large wire loop at 35 cutting, 30 coagulation. The cervical polyp on the posterior lip of the cervix was excised.

Then changing to a 40 of coagulation and 4 cutting, the base of the polyp was electrocoagulated, which controlled all the bleeding and then it was closed with figure-of-eight 3-0 Vicryl sutures.

Rechecking the cervix, no bleeding was noted. The patient was laid flat on the table, awakened, and moved to the recovery room bed and sent to the recovery room in satisfactory condition.

Select the appropriate CPT and ICD-10-CM codes: Ans: D. 57460, N84.1 Feedback: CPT code 57460 correctly reports colposcopy of the cervix including upper and adjacent vagina with loop electrode biopsy of the cervix, which is what the LEEP procedure is. Diagnosis code N84.1 correctly reports cervical polyp.

16. The patient is a 35-year-old female who been having prolonged and heavy bleeding during menstruation. After other testing, the patient opted to have an elective uterine ablation using NovaSure.

Procedure: After the patient was put under general anesthesia, the patient was placed in the dorsolithotomy position, after which the perineum and the vagina were prepped, the bladder was straight catheterized, and the patient was draped. After a bimanual exam was performed, a speculum was placed and the cavity integrity assessment performed. The NovaSure system uses a small amount of CO2 to verify cavity integrity prior to performing the procedure. The NovaSure thermal endometrial ablation procedure them delivered radiofrequency energy until tissue impedance reaches 50 ohms; the electrode array was retracted for easy removal, leaving the uterine lining desiccated down to the superficial myometrium. The patient was awakened from anesthesia and sent home to recover.

Select the appropriate CPT and ICD-10-CM codes: Ans: C. 58353, N92.0 Feedback: CPT code 58353 correctly reports endometrial ablation, thermal without hysterscopic guidance, and diagnosis code N92.0 identifies menorrhagia.

17. A 39-year-old female presents with an ectopic pregnancy. Due to previous abdominal surgeries, the surgeon is unable to perform a laparoscopic fallopian tube removal and must use an open procedure to successfully perform the removal. The physician elects to surgically treat this patient by using an open approach to her abdomen to remove her left fallopian tube and ovary, along with the products of conception. Select the appropriate CPT and ICD-10-CM codes: Ans: C. 59120-LT, O00.90 Feedback: CPT code 59120 correctly identifies surgical treatment of an ectopic pregnancy, requiring salpingectomy and/or oophorectomy, abdominal or vaginal approach. Note the physician removed both the fallopian tube and ovary. The code O00.90 is the correct diagnosis for ectopic pregnancy without

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279 intrauterine pregnancy, and since the location was not specified in the report, the coder must assign the unspecified code.

18. The medical term that can be used for pain in the head is: Ans: B. Cephalgia Feedback: Agraphia refers to impairment or loss of ability to write. Neuralgia refers to nerve pain.

Paraplegia refers to loss of feeling in two limbs.

19. The term salpingo- oophorectomy refers to: Ans: D. The removal of the fallopian tube and ovary Feedback: Salping/o refers to the fallopian tube, and oophor/o refers to the ovary.

20. Which of the following is the gland that secretes a factor that causes T cells to mature and is larger in infants?

Ans: C. Thymus Feedback: The thymus gland is located in the mediastinum, just behind the upper portion of the sternum, and helps to produce and develop T cells.

21. Select the appropriate CPT and ICD-10-CM codes to report the removal of 35 percent of the left thyroid lobe through isthmusectomy. The patient’s diagnosis is benign thyroid neoplasm.

Ans: D. 60210, D34 Feedback: CPT code 60210 represents partial thyroid lobectomy, with or without isthmusectomy, and D34 refers to a benign neoplasm of the thyroid gland.

22. There are two main types of glaucoma. Which type of glaucoma describes when fluid does not flow through the orbicular meshwork properly?

Ans: A. Open angle Feedback: Closed angle is when the angle between the iris and the cornea is too narrow or the iris dilates too widely, closing the angle.

23. The nervous system is divided into two major systems. Which system includes the brain and the spinal cord?

Ans: D. Central nervous system Feedback: The central nervous system (CNS) includes the brain and spinal cord. The peripheral nervous system (PNS) connects all body parts to the central nervous system. The peripheral nervous system is subdivided into two systems: the autonomic and somatic nervous systems.

24. To accurately identify that a procedure was performed on the second lumbar vertebra, which of the following would be documented in the operative report?

Ans: A. L2

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280 Feedback: L2 identifies the second lumbar vertebra the vertebral segment. L2-3 is used to identify the interspace between the second and third lumbar vertebra. C2 and C2-3 designate the cervical vertebra.

25. When multiple surgeons perform the complete skull base procedure (approach procedure, definitive procedure, reconstruction/repair), each surgeon reports only the code for the specific procedure each performed. If one surgeon performs all of the procedures, then all the applicable codes are reported and a modifier is added to the secondary procedure code(s). Which modifier is added?

Ans: C. 51 Feedback: Modifier 51 represents multiple procedures. Since one surgeon performed all of the procedures, modifier 51 would be appropriate. If multiple surgeons had performed and reported the specified procedure(s) they performed, modifier 62 would be appropriate.

Chapter 17 – Radiology Section LESSON PLANS Class Preparation: Teaching Focus and Resources Chapter 17, Radiology, examines and reviews guidelines, modifiers, and common medical and procedural terms pertaining to diagnostic imaging, diagnostic ultrasound, mammography, bone and joint studies, radiation oncology and nuclear medicine.

Learning Outcomes After completing Chapter 17, students will be able to: LO 17.1 Review the general ICD and CPT guidelines for radiology coding.

LO 17.2 Identify the CPT guidelines and format of the Diagnostic Imaging subsection of CPT. LO 17.3 Understand the CPT guidelines and format of the Diagnostic Ultrasound and Breast, Mammography subsections of CPT. LO 17.4 Apply the CPT guidelines and format of the Bone/Joint Studies and Radiation Oncology subsections of CPT. LO 17.5 Recognize the CPT guidelines and format of the Nuclear Medicine subsection of CPT.

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281 LO 17.6 Evaluate the modifiers most commonly used with codes in the Radiology section of CPT. LO 17.7 Examine the common medical and procedural terms used in operative reports.

Class Presentation LO 17.1: Review the general ICD and CPT guidelines for radiology coding.

Slides 17-1 through 17-5



Chapter introduction and key terms

Slide 17-6



General ICD guidelines - Signs and Symptoms - Abnormal findings - Encounter for radiation therapy

Slide 17-7



General ICD guidelines – continued - Fractures - Other common categories used when reporting radiology procedures

Slide 17-8



General CPT guidelines - Contrast material

Slide 17-9



General CPT guidelines - continued - Number of views - Fluoroscopy

Slide 17-10



General CPT guidelines – continued - Component Coding

Slide 17-11



General CPT guidelines – continued - Coding questions

LO 17.2 Identify the CPT guidelines and format of the Diagnostic Imaging subsection of CPT. Slide 17-12



CPT Guidelines and format of Diagnostic imaging Subsections - Diagnostic imaging

Slide 17-13



CPT Guidelines and format of Diagnostic imaging Subsections – continued - Number of views/ type of view Computed tomography Magnetic resonance imaging

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282

LO 17.3: Understand the CPT guidelines and format of the Diagnostic Ultrasound and Breast, Mammography subsections of CPT. Slide 17-14



CPT Guidelines and format of Diagnostic Ultrasound and Breast Mammography Subsections - Diagnostic ultrasound (76506 – 76999) Head and neck Chest Abdomen and retroperitoneum

Slide 17-15



CPT Guidelines and format of Diagnostic Ultrasound and Breast Mammography Subsections – continued - Diagnostic ultrasound – continued Abdomen and retroperitoneum – continued Pelvis Extremities Ultrasonic guidance

Slide 17-16



CPT Guidelines and format of Diagnostic Ultrasound and Breast Mammography Subsections – continued - Breast, mammography (77053-77067)

LO 17.4: Apply the CPT guidelines and format of the Bone/Joint Studies and Radiation Oncology subsections of CPT. Slide 17-17



CPT Guidelines and format of Bone/Joint Studies and Radiation Oncology Subsections - Bone/Joint studies (77071 – 77092) - Dual- energy x-ray absorptiometry ( D X A)

Slide 17-18



CPT Guidelines and format of Bone/Joint Studies and Radiation Oncology Subsections - continued - Radiation oncology (77261 – 77799) Clinical Treatment Planning and Simulation-Aided Field Setting (77261–77299)

Slide 17-19



CPT Guidelines and format of Bone/Joint Studies and Radiation Oncology Subsections - continued - Radiation oncology - continued

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283 Radiation Treatment Delivery (77401–77425) Radiation Treatment Management (77427–77499) Proton Beam Treatment Delivery (77520–77525) Clinical Brachytherapy (77750–77799)

LO 17.5: Recognize the CPT guidelines and format of the Nuclear Medicine subsection of CPT. Slide 17-20



CPT Guidelines and format of Nuclear Medicine subsections - Nuclear medicine Diagnostic (78012-78999)

Slide 17-21



CPT Guidelines and format of Nuclear Medicine subsections - Diagnostic studies Endocrine System (78012–78099) Gastrointestinal System (78201–78299)

Slide 17-22



CPT Guidelines and format of Nuclear Medicine subsections - Diagnostic studies – continued Musculoskeletal System (78300–78399)

Slide 17-23



CPT Guidelines and format of Nuclear Medicine subsections - Diagnostic Studies – continued Cardiovascular System (78414–78499) Respiratory System (78579–78599)

Slide 17-24



CPT Guidelines and format of Nuclear Medicine subsections - Therapeutic Studies (79005–79999)

LO 17.6: Evaluate the modifiers most commonly used with codes in the Radiology section of CPT. Slide 17-25



Modifiers commonly used with the Radiology section - 26 - 52 - 59 - 76 - 77 - Table 17.2

LO 17.7: Examine the common medical and procedural terms used in operative reports.

Slide 17-26



Common medical and procedural terms used with the Radiology section - Coronal Plane - Sagittal Plane

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284 -

Axial Plane Median Plane

Slide 17-27



Common medical and procedural terms used with the Radiology section – continued - Anterior - Posterior - Superior/cephalic - Inferior/caudal - Proximal - Distal

Slide 17-28



Common medical and procedural terms used with the Radiology section – continued - Ascites - Dual-energy x-ray absorptiometry - Extension - Flexion - Pronation - Radiopharmaceutical - Single-photon emission computed tomography - Supination

Summary Slides Slides 17-29 through 17-35



Synopsis of chapter

Teaching Tips LO 17.1:  ICD Guidelines • When a diagnosis has not been confirmed or the radiology report is documented as normal, signs and symptoms should be reported.

• ICD abnormal-findings codes may be used when additional testing is required and the test results are negative.

• A patient encounter for radiation therapy has definite sequencing guidelines.

• Multiple fractures are sequenced in the order of severity, with the most severe first.

• There is a differentiation between a traumatic fracture and a pathologic fracture.  CPT guidelines • Contrast material: With contrast means that contrast is administered intravascularly, intraparticularly, or intrathecally. Oral and/or rectal contact is not with contrast.

• Number of views: Many of the code descriptions within the Radiology subsection specify a minimum number of views.

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285 • Fluoroscopy: Fluoroscopy is inherent in many radiological procedures. Unless specifically instructed otherwise, fluoroscopy used to complete a procedure and obtain a permanent record is included in the code description and is not reported separately.

Coding Tips and Guidelines o To locate a definitive or confirmed diagnosis within the provider documentation, coders should look for terms such as impression, finding, reported as, and conclusion o Highlight the guideline at the beginning of the Radiology section regarding the use of contrast material in your CPT manual.

LO 17.2:  Codes under this subheading are further defined by the following: • Anatomical site • Number of views/type of view • Computed tomography (CT) or computed tomography angiography (CTA) • Magnetic resonance imaging (MRI) or magnetic resonance angiography (MRA), with or without contrast 17.3 Understand the CPT guidelines and format of the Diagnostic Ultrasound and Breast, Mammography subsections of CPT.  Diagnostic Ultrasound: Ultrasound imaging, or sonography, is a noninvasive test that uses highfrequency sound waves to produce images that are captured in real time and show structure, movement, and the flow of blood through blood vessels. The code ranges in this subsection are divided by anatomical site, complete or limited, and obstetrical or nonobstetrical for pelvic ultrasounds.  Breast, Mammography: Diagnostic and screening mammograms are assigned codes within this subsection. Computer-aided detection (CAD) analysis should be reported as an additional code if it is performed with the mammogram.

Coding Tips and Guidelines o When a code description states the minimum number of views and more than the specified number is taken the code is still be correct. The minimum number of views must be met but may be exceed. o KUB stands for ―kidney, ureters, and bladder.‖ It is reported with code 74018 and is often included in the code descriptions for codes within the abdomen and gastrointestinal tract subsections. o CT scans are used to visualize and study the structure of organs, whereas CTA is used to visualize and study the vessels (arteries and veins). o Instructional notes below the CT code ranges for each anatomical site direct the coder to codes 76376 and 76377 to report 3-D rendering (reconstruction). The provider documentation must be clear that there was concurrent physician supervision of the image postprocessing and must state whether or not the image postprocessing was done at an independent workstation. o MRI scans are used to visualize and study the structure of organs, whereas MRA is used to visualize and study the vessels (arteries and veins). o Nonselective and selective procedures, along with first-, second-, and third-order coding of vascular families, are discussed in the Cardiology chapter of this book. The specific guidelines for the reporting of diagnostic angiography and venography supervision and interpretation codes are located at the beginning of the specific code ranges and should be reviewed and understood by the coder before assigning these codes.

LO 17.3:

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286 



Diagnostic Ultrasound: Ultrasound imaging, or sonography, is a noninvasive test that uses highfrequency sound waves to produce images that are captured in real time and show structure, movement, and the flow of blood through blood vessels. The code ranges in this subsection are divided by anatomical site, complete or limited, and obstetrical or nonobstetrical for pelvic ultrasounds.

Breast, Mammography: Diagnostic and screening mammograms are assigned codes within this subsection. Computer-aided detection (CAD) analysis should be reported as an additional code if it is performed with the mammogram.

Coding Tips and Guidelines o Ultrasound procedures are defined as A-mode, M-mode, B-scan, and real-time scan. The definitions are located in the guidelines before the code ranges for this subsection. o The definitions for complete and limited ultrasounds would be good definitions to highlight in your CPT manual. o Be sure to match the diagnostic mammogram to the diagnostic CAD (codes 77055 or 77056 with 77051) and the screening mammogram to the screening CAD (code 77057 with 77052). Delete this bullet point n/a

LO17.4:  Bone/Joint Studies: Bone age studies, bone length studies (orthoroentgenograms or scan grams), and dual-energy x-ray absorptiometry (DEXA) studies are assigned codes under this subheading.

Bone age studies (77072) are used to estimate the stage of development of a child. DXA scans (77080–77081) are performed to measure bone mass density.  Radiation Oncology: Codes under this subheading describe therapeutic treatment that is often performed in addition to surgery and chemotherapy.

These codes are further defined by the following subheadings: • Clinical Treatment Planning and Simulation-Aided Field Setting • Radiation Treatment Delivery • Radiation Treatment Management • Proton Beam Treatment Delivery • Clinical Brachytherapy Coding Tips and Guidelines o Ultrasound procedures are defined as A-mode, M-mode, B-scan, and real-time scan. The definitions are located in the guidelines before the code ranges for this subsection. o The definitions for complete and limited ultrasounds would be good definitions to highlight in your CPT manual. o Be sure to match the diagnostic mammogram to the diagnostic CAD (codes 77055 or 77056 with 77051) and the screening mammogram to the screening CAD (code 77057 with 77052) LO17.5:  Nuclear medicine studies involve the diagnostic and therapeutic use of radioactive materials.  Thyroid studies typically are uptakes or imaging scans, and they are reported using codes from this subsection. These studies can include a vascular flow study. Scans produce an image of the thyroid, while an uptake study produces a value or percentage.  Bone scans are often done to diagnose malignancies or inflammatory diseases such as osteomyelitis or cellulitis. These codes are further defined by: • Limited area or localized area, such as the knee • Multiple areas, defined as two or more anatomical sites

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287 • Whole body, defined as from the head to as least the level of the knees • Three-phase study, which consists of initial vascular flow, blood pool images, and delayed static images Coding Tips and Guidelines o There are terms used in provider documentation that are specific to nuclear medicine studies. Radionuclide, radiopharmaceutical, millicures, and microcuries are the most common. Being aware of these terms helps coders to identify services as nuclear medicine.

LO17.6:  In the Radiology section the modifiers most commonly used are 26, professional component; 52, reduced service; 59, distinct procedure; 76, repeat procedure or service by the same physician or other qualified healthcare professional; and 77, repeat procedure or service by another physician or another qualified healthcare professional.

LO17.7:  Body planes: coronal, axial, sagittal, medial  Body directions: anterior/posterior, ventral/dorsal, superior/inferior, proximal/distal

Chapter 17 Answer Key Exercise 17.1 1. The documentation states that the patient ingested the contrast material before the CT study was performed. Would this CT study be reported as with or without contrast?

Ans: Without contrast, since the guidelines state oral contact is not considered with contrast.

Feedback: The guidelines state that oral and/or rectal contact is not with contrast, so this would be reported as without contrast.

2. List some of the common procedures assigned codes from the Radiology section of CPT. Ans: Answers will vary but may include CT, MRI, plain film x-rays, nuclear medicine studies, and radiation oncology treatment.

Feedback: Radiology involves establishing diagnoses and treating diseases and injuries. Several different methods are used to arrive at a diagnosis or to treat a condition. X-rays, computed tomography (CT), magnetic resonance imaging (MRI), ultrasound, positron emission tomography (PET), and interventional procedures are the most common methods used to perform these functions.

3. Why is it important that the medical documentation state the number of views?

Ans: Many of the codes are very specific as to the minimum number of views needed to be performed and documented in order to assign the code.

Feedback: Many of the code descriptions within the Radiology subsection specify a minimum number of views. For example: 71046 Chest x-ray, two views.

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288 4. A patient with a diagnosis of lung cancer presents today for radiation therapy and experiences severe nausea and vomiting during the encounter. Code this encounter in the appropriate sequence.

Ans: Z51.0 Encounter for antineoplastic radiation therapy would be the first listed code per the coding guidelines. Then C34.90 for malignant neoplasm of unspecified part of unspecified bronchus or lung and R11.2 for nausea with vomiting, unspecified.

5. When the findings on a chest x-ray are normal, what should the coder look for in the report to use as the diagnosis for ICD coding?

Ans: Any signs or symptoms that are indications for the ordering of the chest x-ray Feedback: When a diagnosis has not been confirmed or the radiology report is documented as normal, signs and symptoms should be reported.

Exercise 17.2 1. What is the difference between a CT scan and a CTA? Ans: CT scans are used to visualize and study the structure of an organ, whereas a CTA is used to visualize and study the vessels (arteries or veins).

Feedback: CT scans are used to visualize and study the structure of an organ, whereas a CTA is used to visualize and study the vessels (arteries or veins).

2. Define KUB. Ans: KUB is kidney, ureters, and bladder and is reported with code 74018.

Feedback: KUB is kidney, ureters, and bladder and is reported with code 74018. It is often included in the code description for codes within the abdomen and gastrointestinal tract subsection.

3. What range of codes would be appropriate for cardiac computed tomography of the heart?

Ans: 75571-75574 Feedback: Computed tomography, thorax, 71250–71260. (An instructional note below this code range directs the coder to code range 75571–75574 for cardiac CT of the heart.)

4. What specifically needs to be in the provider documentation to justify the use of the 3-D rendering codes, 76376 and 76377?

Ans: The provider documentation must be clear that there was concurrent physician supervision of image post-processing and whether or not the image post-processing was on an independent work station.

Feedback: To justify the use of the 3-D rendering codes 76376 and 73677, the provider documentation must be clear that there was concurrent physician supervision of the image post-processing and must state whether or not the image post-processing was done at an independent workstation.

Exercise 17.3 1. What is the definition of a real-time scan?

Ans: A real-time scan is a two-dimensional ultrasonic scanning procedure with display of both twodimensional structure and motion with time.

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289 Feedback: Ultrasound procedures are defined as A-mode, M-mode, B-scan, and real-time scan. The definitions are located in the guidelines before the code ranges for this subsection, Diagnostic Ultrasound (76506–76999).

2. The radiology report documents that a patient with gallstones received an ultrasound scan, realtime, with image documentation of the gallbladder only. Which CPT would be appropriate to assign?

Ans: 76705 for limited exam, which is one organ or one quadrant 3. How does the CPT manual define a complete ultrasound of an extremity?

Ans: Real time scan of a specific joint that includes examination of the muscles, tendons, joint, other soft tissue structures, and any identifiable abnormality Feedback: The guidelines before this code range define a complete ultrasound of an extremity and a limited ultrasound of an extremity.

4. A bilateral diagnostic mammogram with a diagnostic computer-aided detection analysis was documented. What code(s) would be reported?

Ans: 77066 diagnostic mammography, including computer-aided detection (CAD) when performed; bilateral. The CAD is included in the code description for the bilateral diagnostic mammogram.

5. What would be the appropriate code for an MRI of both breasts with contrast?

Ans: 77049 Exercise 17.4 1. A dual-energy x-ray absorptiometry (DXA) is documented as being performed on the hips and spine. Which skeleton is being examined, and what is the appropriate code?

Ans: Axial; CPT code 77080 2. What instruction does the subheading guideline for Clinical Brachytherapy give the coder about the reporting of hospital admission and daily visits with codes in this section?

Ans: Clinical Brachytherapy codes include hospital admission and daily visits.

Feedback: The codes in this range are assigned for brachytherapy, which is the application of radioactive isotopes for internal radiation. The hospital admission and subsequent visits are included in the code description and are not coded separately.

3. What is the appropriate CPT code for intraoperative radiation treatment management?

Ans: 77469 Exercise 17.5 1. How can radioactive materials be administered to a patient?

Ans: Ingestion, injection, or inhalation

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290 Feedback: Nuclear medicine studies involve the diagnostic and therapeutic use of radioactive materials.

Examples of radioactive materials used to perform these studies are Xenon, DTP, technetium, iodine, cardiolite, and thallium. These materials are administered by ingestion, injection, or inhalation.

2. What is included in a nuclear medicine three-phase bone scan, code 78315?

Ans: Initial vascular flow, blood pool images, and delayed static images Feedback: Code 78315 is a three-phase study, which consists of initial vascular flow, blood pool images, and delayed static images.

3. Explain the difference between diagnostic and therapeutic nuclear medicine studies.

Ans: Diagnostic nuclear medicine studies establish or confirm a diagnosis. Therapeutic nuclear medicine studies provide relief by the use of a radioactive material.

Feedback: Diagnostic nuclear medicine studies establish or confirm a diagnosis. Some examples of diagnostic nuclear medicine studies are bone scans, lung scans, thyroid scans and uptakes, renal imaging, SPECT, and PET studies. Therapeutic nuclear medicine studies provide relief by the use of a radioactive material. Two examples are radioactive iodine for patients with hyperthyroidism (Graves’ disease) and strontium (Metastron) for cancer patients.

Exercise 17.6 1. What is the appropriate modifier to use when less than the minimum number of views is taken and a specific code does not exist for the lower number of views?

Ans: 52 Feedback: Modifier 52 indicates reduced services; less than the minimum number of views was performed.

2. If a scenario on the CPC exam instructs the test taker to code for the professional component only, which modifier would be attached to the appropriate radiology code?

Ans: 26 Feedback: Modifier 26 indicates professional component; only the professional component or supervision and interpretation is being reported.

3. If a one view chest x-ray, CPT code 71045, is performed twice on the same day by the same physician, which modifier would be attached to the second x-ray?

Ans: 76 Feedback: Modifier 76 indicates repeat procedure or service by the same physician or other qualified health care professional. Example: A two-view chest x-ray (71046) is interpreted by physician A at 8 a.m., and another two-view chest x-ray (71046) is interpreted by the same physician later the same day.

Exercise 17.7 1. The radiology report finding states that there is an excess of fluid in the peritoneal cavity. What term would the coder look for in the Alphabetic Index of ICD? Ans: Ascites

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291 Feedback: An accumulation of excess fluid in the peritoneal cavity is signified by the term ascites.

2. Define axial plane, which is also called transverse plane.

Ans: A horizontal plane which divides the body into upper and lower portions Feedback: Axial or transverse plane is defined as a horizontal plane which divides the body into upper and lower portions.

3. Describe a SPECT study?

Ans: SPECT = single photon emission computed tomography. It is a nuclear medicine study in which images are produced in multiple dimensions in order to diagnose an abnormality within an area.

Feedback: A SPECT (single photon emission computed tomography) study is a nuclear medicine study in which images are produced in multiple dimensions in order to diagnose an abnormality within the area.

Chapter 17 Review Using Terminology 1.

A

Computed tomography

8. D

Magnetic resonance imaging

2.

C

Contrast material

9. E

3.

G

Diagnostic study

10. M Pronation

4.

L

Dual-energy x-ray absorptiometry

11. I

5.

K

Extension

12. F Sagittal plane

6.

N

Flexion

13. J

Supination

7.

B

Fluoroscopy

14. H

Ultrasound

Nuclear medicine

Radiopharmaceutical

Checking your Understanding 1. George Smith was admitted to the hospital for three days for intracavitary radiation source application of 10 radioelement solution ribbons for treatment of his prostate cancer by the therapeutic radiologist, who also saw the patient each day of his admission. Select the appropriate CPT and ICD-10-CM codes: Ans: D. 77762, C61 Feedback: 77762 is intracavitary radiation source application, intermediate. The CPT manual defines intermediate as five to ten sources/ribbons. This is brachytherapy and the guidelines inform the coder that the hospital admission and daily visits are included in the code and not reported separately. ICD-10-CM code C61 is the correct code for malignant neoplasm of prostate. Note: There are instructional notes with C61 to use additional code to identify hormone sensitivity status or rising PSA following treatment for malignant neoplasm of prostate.

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292 2. Amanda Jones presented to the ED with acute GI bleeding from the rectum as a result of her diverticulitis. The physician ordered a nuclear medicine study of the abdomen to determine the rate of blood loss and the status of her current disease. Select the appropriate CPT and ICD-10-CM codes: Ans: B. 78278, K57.33 Feedback: 78278 is acute gastrointestinal blood loss imaging and would be the correct code; it would not be CT scan of the abdomen and pelvis as the patient is currently experiencing blood loss, and this procedure monitors the rate and amount of the blood loss allowing the physician to accurately pinpoint the area and decide on a treatment plan. K57.33 is for diverticulitis of the large intestine with bleeding while K57.30 and K57.31 are for diverticulosis with or without bleeding.

3. Betty presented for biopsy of two breast masses with placement of localization clip under ultrasound guidance. Select the appropriate codes.

Ans: A. 19083, 19084, N63.0 Feedback: 19083, biopsy, breast with placement of breast localization device(s) (e.g., clip, metallic pellet), when performed, and imaging of the breast specimen, when performed, percutaneous; first lesion, including ultrasound guidance; 19084 reports each additional lesion. Since the code description includes ultrasound guidance, CPT code 76942 would not be reported separately. The breast mass locations have not been specified. therefore, billing for the unspecific breast mass is the most appropriate.

4. Don presents to the nuclear medicine department for a myocardial perfusion imaging (SPECT) with quantitative wall motion, ejection fraction, single study at rest. Code for the professional services for this study.

Ans: B. 78451-26 Feedback: 78451 represents myocardial perfusion imaging, tomographic (SPECT) including attenuation correction, qualitative or quantitative wall motion; ejection fraction by first pass or gated technique, additional quantification when performed; single study, at rest or stress. Modifier 26 represents the professional services.

5. A morbidly obese male, age 46, is seen for increasing pain in his knees, which is affecting his mobility. The physician orders a bilateral x-ray of the knees, with the patient standing as part of the workup. The x-ray report indicates bilateral osteoarthritis which is felt to be secondary to his morbid obesity. Select the appropriate CPT and ICD-10-CM codes: Ans: D. 73565, M17.4. E66.01 Feedback: Code 73565 description is radiologic, examination, knee; both knees standing, anteroposterior.

ICD-10-CM code M17.4 is the correct code since the report indicated osteoarthritis of the knees secondary to his morbid obesity. The knee pain would not be reported since it is an integral part of the osteoarthritis. E66.01 reports the morbid obesity since the documentation states the OA is secondary to the morbid obesity.

6. A 45-year-old female presents with a significant history of cardiovascular disease. The physician orders a study to determine the right ventricular ejection fraction by the first-pass technique at rest. Select the appropriate CPT code(s) for this procedure: Ans: C. 78472, 78496

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293 Feedback: CPT instructs the use of add-on code 78496 with code 78472.

7. An ultrasound of a pregnant uterus, real time with image documentation, fetal and maternal evaluation, second trimester, in a female carrying twins was performed. Select the appropriate code(s) for this procedure: Ans: C. 76805, 76810 Feedback: Both codes are needed: 76805 for the first gestation and 76810 for the second. As this is the second trimester, the pairing is correct.

8. John, a 20-year-old male, presented to his physician for evaluation of nonpainful masses on the left side of the neck. As part of the workup, the physician ordered a CT of the neck with and without contrast to aid in the diagnosis. Select the appropriate code(s): Ans: B. 70492 Feedback: Code 70492 is the correct code; the description of the code is computed tomography, soft tissue neck; without contrast material followed by contrast material(s) and further sections. Only one code is need to report the scan being performed without contrast and then with contrast. Using two codes to report this would be considered unbundling.

9. A 30-year-old male presents with flank pain and gross hematuria. The physician orders a CT of the abdomen and pelvis without contrast followed by contrast in the pelvis. Select the appropriate CPT code for the radiologist’s supervision and interpretation.

Ans: C. 74178-26 Feedback: Codes 72194 and 72193 are incorrect since the question said to code for the supervision and interpretation, which means the code would need a modifier 26 appended. The description for 74178 is computed tomography, abdomen and pelvis, without contrast material in one or both body regions, followed by contrast material(s) and further sections in one or both body regions.

10. An 18-year-old patient presents today for an x-ray of his right knee and an MRI to rule out a torn ACL of the knee due to an injury sustained when checked into boards during a hockey game.

After the testing is complete, the interpretation and report verify a torn ACL ligament, right knee, complete. Select the appropriate CPT and ICD-10-CM codes: Ans: D 73721, 73562-RT, S83.511A Feedback: 73721 reports an MRI, any joint of lower extremity, without contrast material while 73720 reports MRI of lower extremity other than a joint. 73562 reports the x-ray of the knee, 1 or 2 views. ICD10-CM code S83.511A identifies the tear (sprain) ACL ligament, right knee, initial encounter.

Applying your Knowledge Case Study Indication: Right upper-quadrant abdominal pain Procedure: Gallbladder ultrasound There is a cyst in the left hepatic lobe. The liver is otherwise unremarkable. There is no biliary ductal dilation. There is no abdominal ascites. There are multiple gallstones noted within the

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294 gallbladder. There are no abnormalities in the visualized portions of the abdominal aorta or pancreas. The spleen does not appear enlarged. The right kidney contains a 4-cm cyst. The left kidney appears normal.

Impression: 1. Hepatic cyst 2. 4-cm kidney cyst 3. Cholelithiasis Process 1: CPT 1. What is the procedure?

Ans: Gallbladder ultrasound Feedback: Gallbladder ultrasound is the procedure.

2. Locate the main term in the index.

Ans: Ultrasound Feedback: The main term is ultrasound.

3. What additional questions or set of questions can be determined?

Ans: Anatomic site Feedback: The additional question topic is anatomic site (answer: abdomen).

4. Upon review of all the code choices identified in the index, what additional questions can be determined?

Ans: Was the ultrasound complete or limited?

Feedback: Upon review of all the code choices identified in the index, the following question can be determined: Was the ultrasound complete or limited?

5. Based on the documentation, what is the correct code for this case?

Ans: A 76700-26 Feedback: Based upon the documentation, the correct code for this case is 76700-26, Complete abdominal ultrasound. Everything that needed to be documented for a complete abdominal ultrasound is in the report. 76770 and 76775 are codes for retroperitoneal ultrasounds.

Process 2: ICD ICD-10-CM 1. Based on the operative report header, what is the preexamination diagnosis?

Ans: Right upper quadrant pain

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295 Feedback: Per the operative report header, the preoperative diagnosis is right upper quadrant pain.

2. Is the postexamination diagnosis the same as or different from the preexamination diagnosis?

Ans: Different: hepatic cyst, 4-cm kidney cyst, and cholelithiasis Feedback: The postexamination diagnosis is different from the preexamination diagnosis: hepatic cyst, 4cm kidney cyst, and cholelithiasis.

3. Is the postexamination diagnosis supported?

Ans: Yes Feedback: Yes, the postexamination diagnosis is supported.

4. What is the main term for this condition?

Ans: Cyst, cholelithiasis Feedback: The main term for this condition is cyst, cholelithiasis. (Coder must know that hepatic is liver.)

5. Based on the subterm choices, what question(s) can be developed for this condition?

Ans: Cysts: Are they congenital or acquired, multiple or single? Cholelithiasis: Is it with or without cholecystitis? Acute or chronic?

Feedback: Based upon the subterm choices, the following questions can be developed for this condition: Cysts: Are they congenital or acquired, multiple or single? Cholelithiasis: Is it with or without cholecystitis? Acute or chronic?

6. Based on the information in the Tabular List, is additional information needed to determine the appropriate diagnosis code?

Ans: No Feedback: Based on the information in the Tabular List, no additional information is needed to determine the appropriate diagnosis code.

7. Is any sign, symptom, or additional condition documented?

Ans: Yes, abdominal pain Feedback: Yes, the signs, symptoms, or additional conditions (abdominal pain) are documented.

8. Is the additional condition, sign, or symptom an integral part of the primary (or other) condition coded?

Ans: Yes Feedback: Yes, the additional condition, sign, or symptom is an integral part of the primary (or other) condition coded.

9. Does the additional condition require or affect patient care, treatment, or management?

Ans: No

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296 Feedback: The additional condition does not require or affect patient care, treatment, or management.

10. Based on the documentation, what are the correct ICD-10-CM code(s) for this case?

Ans: C K76.89, N28.1, K80.20 Feedback: Based upon the documentation, the correct ICD-10-CM codes for this case are K76.89, N28.1, and K80.20.

Process 3: Modifiers 1. Was the procedure performed different from that described by the nomenclature of the code?

Ans: No Feedback: The procedure performed was not different from that described by the nomenclature of the code.

2. Was the procedure performed at an anatomical site that has laterality?

Ans: No Feedback: The procedure performed was not on an anatomical site that has laterality.

3. Was the procedure performed in the global period of another procedure?

Ans: No Feedback: The procedure performed was not in the global period of another procedure.

4. Were additional procedures performed during the examination, and does the documentation support them?

Ans: No Feedback: No additional procedures were performed during the examination.

5. Did the surgeon have help from another surgeon or other appropriate person?

Ans: No Feedback: The surgeon did not have help from another surgeon or other appropriate person.

6. Did a physician different from the surgeon provide the preexamination or postexamination portion of the procedure?

Ans: No Feedback: There was no physician different from the surgeon providing the preexamination or postexamination portion of the procedure.

7. What modifier should be appended to the CPT code for this case?

Ans: B -26 Feedback: The modifier 26 (professional component) should be appended to the CPT code for this case.

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297

Chapter 18 – Pathology/Laboratory LESSON PLANS Class Preparation: Teaching Focus and Resources The CPT and ICD guidelines are reviewed for the codes used in chapter 18, Pathology/Laboratory, to reflect services provided to give additional diagnostic and treatment management data to the treating physician. Modifiers and common medical and procedural terms specific to Pathology/Laboratory are also identified and examined in this chapter.

Learning Outcomes After completing Chapter 18, students will be able to: LO 18.1 Review the general ICD and CPT guidelines for pathology/laboratory coding.

LO 18.2 Identify the CPT guidelines and format of the Organ or Disease-Oriented Panels, Drug Testing, Therapeutic Drug Assays, Evocative/Suppression Testing, Consultations, and Urinalysis subsections of CPT. LO 18.3 Understand the CPT guidelines and format of the Molecular Pathology, Chemistry, Hematology, Immunology, Transfusion Medicine, and Microbiology subsections of CPT. LO 18.4 Apply the CPT guidelines and format of the Anatomic Pathology, Cytopathology, Cytogenic Studies, Surgical Pathology, Other Procedures, and Reproductive Medicine Procedures subsections of CPT. LO 18.5: Evaluate the modifiers most commonly used with codes in the Pathology/Laboratory section of CPT LO 18.6: Examine the common medical and procedural terms used in operative reports.

Class Presentation LO 18.1: Review the general ICD and CPT guidelines for pathology/laboratory coding.

Slides 18-1 through 18-5



Chapter introduction and key terms

Slide 18-6



General ICD and CPT guidelines for Pathology and Laboratory coding - Signs and Symptoms - Abnormal findings

Slide 18-7



General ICD and CPT guidelines for Pathology and Laboratory coding - continued - Neoplasms

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298 Slide 18-8



General ICD and CPT guidelines for Pathology and Laboratory coding – continued - Additional testing

Slide 18-9



General ICD and CPT guidelines for Pathology and Laboratory coding – continued - Coding questions

LO 18.2: Identify the CPT guidelines and format of the Organ or Disease-Oriented Panels, Drug Testing, Therapeutic Drug Assays, Evocative/Suppression Testing, Consultations, and Urinalysis subsections of CPT. Slide 18-10



CPT guidelines and format of the Organ or Disease-Oriented Panels, Drug Testing, Therapeutic Drug Assays, Evocative/Suppression Testing, Consultations, and Urinalysis subsections of CPT - Organ or Disease-Oriented Panels (80047–80081) - Drug Assay (80305–84830)

Slide 18-11



CPT guidelines and format of the Organ or Disease-Oriented Panels, Drug Testing, Therapeutic Drug Assays, Evocative/Suppression Testing, Consultations, and Urinalysis subsections of CPT - continued - Evocative/Suppression Testing (80400–80439)

Slide 18-12



CPT guidelines and format of the Organ or Disease-Oriented Panels, Drug Testing, Therapeutic Drug Assays, Evocative/Suppression Testing, Consultations, and Urinalysis subsections of CPT – continued - Consultations (80500-80502)

Slide 18-13



CPT guidelines and format of the Organ or Disease-Oriented Panels, Drug Testing, Therapeutic Drug Assays, Evocative/Suppression Testing, Consultations, and Urinalysis subsections of CPT – continued - Urinalysis (81000-81099)

LO 18.3: Understand the CPT guidelines and format of the Molecular Pathology, Chemistry, Hematology, Immunology, Transfusion Medicine, and Microbiology subsections of CPT. Slide 18-14



 Slide 18-15



CPT guidelines and format of the Molecular Pathology, Chemistry, Hematology, Immunology, Transfusion Medicine, and Microbiology subsections of CPT Molecular Pathology (81161–81479) CPT guidelines and format of the Molecular Pathology, Chemistry, Hematology, Immunology, Transfusion Medicine, and Microbiology

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299 subsections of CPT – continued - Molecular pathology – continued - Chemistry (82000-84999) - Genomic Sequencing Procedures and Other Molecular Multianalyte Assays (81410-81471) Slide 18-16



CPT guidelines and format of the Molecular Pathology, Chemistry, Hematology, Immunology, Transfusion Medicine, and Microbiology subsections of CPT – continued - Multianalyte Assays with Algorithmic Analyses (81490-81599)

Slide 18-17



CPT guidelines and format of the Molecular Pathology, Chemistry, Hematology, Immunology, Transfusion Medicine, and Microbiology subsections of CPT – continued - Multianalyte Assays with Algorithmic Analyses - continued

Slide 18-18



CPT guidelines and format of the Molecular Pathology, Chemistry, Hematology, Immunology, Transfusion Medicine, and Microbiology subsections of CPT – continued - Hematology and Coagulation (85002–85999)

Slide 18-19



CPT guidelines and format of the Molecular Pathology, Chemistry, Hematology, Immunology, Transfusion Medicine, and Microbiology subsections of CPT – continued - Immunology (86000–86849) - Transfusion Medicine (86850–86999)

Slide 18-20



Microbiology (87003–87999)

LO 18.4: Apply the CPT guidelines and format of the Anatomic Pathology, Cytopathology, Cytogenic Studies, Surgical Pathology, Other Procedures, and Reproductive Medicine Procedures subsections of CPT. Slide 18-21



CPT guidelines and format of the Anatomic Pathology, Cytopathology, Cytogenic Studies, Surgical Pathology, Other Procedures, and Reproductive Medicine Procedures subsections - Anatomic Pathology (88000-88099) - Cytopathology (88104-88199)

Slide 18-22



CPT guidelines and format of the Anatomic Pathology, Cytopathology, Cytogenic Studies, Surgical Pathology, Other Procedures, and Reproductive Medicine Procedures subsections – continued - Cytogenic Studies (880230-88299) - Surgical Pathology (88300-88399)

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300 LO 18.5: Evaluate the modifiers most commonly used with codes in the Pathology/Laboratory section of CPT Slide 18-23



Modifiers commonly used with codes from the Pathology and Laboratory section of CPT - 26 - 90 - 91 - QW - Table 18.2

LO 18.6: Examine the common medical and procedural terms used in operative reports.

Slide 18-24



Common medical and procedural terms used with Pathology and Laboratory coding - Table 18.3

Summary Slides Slides 18-25 through 18-33

-

Synopsis of chapter

Teaching Tips LO 18.1:  ICD guidelines • When a diagnosis has not been confirmed or the pathology is documented as normal, signs and symptoms should be reported.

• ICD abnormal-findings codes may be used when additional testing is required and the test results are negative.

• Neoplasms: The Alphabetic Index of ICD and the neoplasm table enable the coder to select the appropriate neoplasm code based on the type of neoplasm and the site.  CPT guidelines: The following questions will help a coder, when reading through an operative report, to understand what actually was done and how the procedure should be translated and coded: • At which anatomical site was the study performed (if applicable)?

• Was the study qualitative or quantitative?

• What are all of the laboratory studies that were performed during the present encounter (e.g., organ panel, surgical pathology)?

• What type of equipment was used (e.g., automated, nonautomated, microscope)?

• Which type of consultation was involved: clinical pathology or surgical pathology?

• How many tests were performed?

Coding Tips and Guidelines o To locate a definitive or confirmed diagnosis within the provider documentation, coders should look for terms such as impression, finding, reported as, or conclusion.

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301 o

Uncertain behavior means that the neoplasm exhibits both benign and malignant behavior and the direction of its continued growth is uncertain, and unspecified behavior means that the type of neoplasm was not documented.

LO 18.2:  Organ or Disease-Oriented Panels (80047–80076): All of the tests listed within the code description must be performed in order to assign the code.  Drug Assay(80305–80377): The codes in this code range are used to report drug screening, drug confirmation, and tissue preparation services. These codes are used to identify the presence of a drug, which is a qualitative analysis.  Therapeutic Drug Assays (80143–80299), Evocative/Suppression Testing (80400–80440): The administration of pharmaceutical agents is used to measure a patient’s response to those agents.

The codes within this range are used for the laboratory portions of the testing.  Consultations (Clinical Pathology) (80503–80506): The codes are further defined as to the level based on either medical decision making or time.  Urinalysis (81000–81099): This code range is used to report tests on urine.

Coding Tips and Guidelines o Highlight in your CPT manual that codes 80047 and 80048 are alike except for the calcium test: 80047 is described as ―calcium, ionized,‖ whereas 80048 is described as ―calcium, total.‖ Total calcium tests both ionized calcium (which is free-flowing calcium, not attached to proteins) and calcium attached to proteins. o Code the number of procedures, not the number of drugs tested. o The CPT guidelines at the beginning of the code range direct the coder to use codes 96365–96368; 96372–96376 for physician administration of the evocative or suppressive agents. o The reporting of only the test results is not enough to justify the use of a clinical pathology code.

LO 18.3:  Molecular Pathology (81170–81479): Codes in this range are used to report laboratory testing involving genes. The appropriate code is based on the specific gene or genes being analyzed.  Chemistry (82000–84999): Specific tests on any bodily substance, such as urine, blood, breath, and feces, are reported using codes under this subheading.  Samples from different sources may be reported separately.  Hematology and Coagulation (85002–85999): Hematology is the study of disorders of the blood, while coagulation is the process of blood clotting. Studies under this subheading include blood counts and are differentiated as to the following: CBC, RBC, WBC, automated or manual, microscopic.  Immunology (86015–86849): Immunology is the study of the immune study. Codes within this code range report tests used to identify immune system conditions caused by antibodies and antigens.  Microbiology (87003–87999): The codes under this subheading are further differentiated by the type of study.

Coding Tips and Guidelines o The molecular pathology codes include all analytical services performed in the test, such as cell lysis, nucleic acid stabilization, and amplification. o Several editions of the CPT manual have a section in the guidelines before code range 81170-81479 that lists definitions that apply to this category.

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302 o

Coders will find it helpful to read over this section and highlight any definitions that are new to them.

LO 18.4:    

Anatomic Pathology (88000–88099): An instructional note with this range of codes states that these codes represent physician services only. It also instructs the use of modifier 90 for outside laboratory services.

These codes are for reporting postmortem examinations, that is, necropsies (autopsies).

Cytopathology (88104–88199): Cytopathology is the study of cells, and the codes under this subheading are used to report laboratory tests performed to identify cellular changes. The codes are divided by type of procedure and technique.

Surgical Pathology (88300–88399): The codes in this range are defined by the following: • Number of specimens (each specimen is a unit) • Anatomical site • Gross examination only • Gross and microscopic examination Coding Tips and Guidelines o Gross examination means that the specimen is examined with the naked eye and is not prepared for examination by microscope. o CPT codes 88150 to 88154 are used to report Pap smears using non-Bethesda reporting.

Codes 88164 to 88167 are used to report Pap smears using the Bethesda system of reporting. o The same anatomical site may be found within several codes (levels), so it is important to read the documentation and the code description carefully. For example: Joint, loose body 88304 (level III) Joint, resection 88305 (level IV) o A specimen is the unit submitted for evaluation, the block is a piece cut from the specimen to be frozen, and a section is a further division of the block.

LO 18.5:  Modifiers commonly used include: • 26, professional component: When only the interpretation and report are performed, such as for a molecular pathology test, modifier 26 is reported with the appropriate molecular pathology code.

• 90, outside laboratory: This modifier is used when a lab test is performed at an outside lab and the outside lab bills the physician office and the office, in turn, bills the insurer.

• 91, repeat clinical diagnostic lab test: If a patient has two total bilirubin tests performed on the same day, one in the morning and one in the afternoon, the tests would be reported as 82247 and 82247-91.

• QW: This modifier is used when the service provided is a CLIA-waived test.

LO 18.6:  Chromatography: combination of methods or phases used to analyze a drug class or classes  Cytopathology: study of cells; used to identify cellular changes

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303  

Mutations: variants associated with altered gene function that lead to functional deficits or disease Necropsy (autopsy): a postmortem exam

Chapter 18 Answer Key Exercise 18.1 1. What are the four sections of the neoplasm table?

Ans: Malignant (primary, secondary, carcinoma in situ), Benign, Uncertain Behavior, Unspecified Behavior Feedback: The neoplasm table in the ICD is divided into four sections: Malignant (primary, secondary, carcinoma in situ), Benign, Uncertain Behavior, and Unspecified Behavior.

2. What are some key words to look for in provider documentation to help identify a definitive diagnosis?

Ans: Impression, finding, reported as, or conclusion Feedback: To locate a definitive or confirmed diagnosis within the provider documentation, coders should look for terms such as impression, finding, reported as, or conclusion.

3. What is an indicator?

Ans: An indicator is a laboratory test in which, if a positive result occurs, an additional test would be then be done as a follow-up.

Feedback: With some laboratory tests, if a positive result occurs, an additional test is then done as a follow-up. These tests are called indicators and allow for additional tests without the written order of a physician. This additional testing is reported separately since the initial results need additional testing to add to the clinical value of the results.

Exercise 18.2 1. Explain the difference between qualitative and quantitative analyses.

Ans: Qualitative analysis measures the presence of a drug. Quantitative analysis measures the amount of the drug present.

Feedback: Qualitative analysis is the laboratory procedure that identifies the presence of a drug.

Quantitative analysis is the laboratory procedure that measures the amount of a drug present.

2. How are the codes in the urinalysis subheading further defined?

Ans: Method of testing, constituents being tested, equipment being used, and reason for test Feedback: The Urinalysis (81000–81099) code range is used to report tests on urine. The codes are further defined by the method of testing (reagent or dipstick); the constituents being tested; and the equipment used (automated or nonautomated, with or without microscope).

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304 3. What is the difference between a limited clinical pathology consultation and a comprehensive one?

Ans: Limited: without review of patient’s history and medical record. Comprehensive: complex diagnostic problem with review of history and medical record.

Feedback: The reporting of only the test results is not enough to justify the use of a clinical pathology code. The codes are further defined as to the level based on medical decision making and time: 80503 80506 4. Identify the appropriate CPT code range to be used to identify possible use or non-use of a drug or drug class.

Ans: 80305-80307 Feedback: CPT code range 80305-80307 is the range used for presumptive drug class screening.

Exercise 18.3 1. Which code range and subheading include codes for reporting blood banking?

Ans: Codes used to report blood banking, CPT codes 86077-86079, are found in the Immunology subheading.

2. Identify how the codes under the Microbiology subheading are further differentiated.

Ans: The codes within this subheading are further differentiated by the type of study, such as bacteriology (bacteria), mycology (fungus), parasitology (parasites), and virology (viruses). The code descriptions also include the method of identification as presumptive or definitive.

Feedback: The codes within the Microbiology subheading are further differentiated by the type of study, such as bacteriology (bacteria), mycology (fungi), parasitology (parasites), and virology (viruses). The code descriptions also include the method of identification, described by CPT as presumptive (identification of a microorganism by colony morphology growth on selective media, Gram stains, or up to three tests such as catalase, oxidase, indole, or urease) or definitive (identification to the genus or species level that requires additional tests such as biochemical panels or slide cultures).

3. Which type of laboratory tests is reported with codes from the range 86015-86849?

Ans: Immunology, which is the study of the immune system. Codes within this code range report tests used to identify immune system conditions caused by antibodies and antigens.

Feedback: Codes in the range of 86015-86849 are used to report immunology tests. Immunology is the study of the immune system. Codes within this code range report tests used to identify immune system conditions caused by antibodies and antigens. An antigen is a foreign substance that produces antibodies that fight infection and disease. The tests in this section are mostly qualitative or semiquantitative unless otherwise indicated.

4. What are the gene names in the codes descriptions in the Molecular Pathology section based upon?

Ans: The gene names are based on HUGO (Human Genome Organization) approved names.

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305 Feedback: Codes under the Molecular Pathology subheading are used to report laboratory testing involving genes. The appropriate code selected is based on the specific gene or genes being analyzed. The gene name may be described in the code description as an abbreviation followed by the gene name. The gene names are based on Human Genome Organization (HUGO) approved names.

Exercise 18.4 1. Codes within the anatomic pathology range are used to report postmortem examinations—that is, necropsies (autopsies). How are they further defined?

Ans: They are further defined based on the following: - The extent and type of exam, gross versus gross and microscopic - Whether the examination is without the CNS, with the brain, or with brain and spinal cord - Whether the exam is a forensic examination, which is used for legal evidence Feedback: An instructional note with the range of Anatomic Pathology codes (88000-88099) states that these codes represent physician services only. It also instructs the use of modifier 90 for outside laboratory services. These codes are for reporting postmortem examinations, that is, necropsies (autopsies). They are further divided as to the extent and type of exam (gross versus gross and microscopic); whether the examination is without the CNS, with the brain, or with the brain and spinal cord; and whether the exam is a forensic examination (used for legal evidence).

2. What is the difference between cytopathology studies and cytogenic studies?

Ans: Cytopathology is the study of cells, and studies performed identify cellular change. Cytogenic studies identify cellular structure and function related to genetics.

Feedback: Cytopathology is the study of cells, and the codes under this subheading are used to report laboratory tests performed to identify cellular changes. The codes are divided by type of procedure and technique. Cytogenic studies are concerned with cellular abnormalities and pathologic conditions related to genetics.

3. Gross and microscopic evaluation of a pituitary tumor with first tissue block, frozen tissue, is documented. What would be the appropriate code(s)?

Ans: 88305, 88331 Exercise 18.5 1. The patient has two tests performed on the same day that were ordered by the physician and not performed because of equipment malfunction. Which modifier would be appropriate to use?

Ans: Modifier 91 Feedback: Modifier 91, which indicates repeat clinical diagnostic laboratory test 2. When only the interpretation and report are performed, which modifier should be reported with the appropriate pathology/laboratory code?

Ans: Modifier 26 Feedback: Modifier 26, which indicates professional component Exercise 18.6

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306 1. Define specimen, block, and section.

Ans: A specimen is the unit submitted for evaluation, the block is a piece cut from the specimen to be frozen, and a section is a further division of the block.

Feedback: Specimen is a unit submitted for evaluation, such as chemical, pathologic, or hematological.

Block is portion of a tissue obtained from a specimen. Section is a further division of the block.

2. In the Pathology/Laboratory section of most editions of the CPT manual, where can definitions of terms such as mutations, somatics, variants, and breakpoints be found?

Ans: The guidelines at the beginning of the Molecular Pathology subheading code range Feedback: The definitions of terms such as mutations, somatics, variants, and breakpoints can be found in the guidelines at the beginning of the Molecular Pathology subheading code range.

3. Pap smears are the most common test reported with codes under what subheading?

Ans: Cytopathology Feedback: Pap smears are the most common test reported with codes under the subheading Cytopathology.

Chapter 18 Review Using Terminology 1.

B

Block

8.

G

Ionized calcium

2.

M

Chromatography

9.

L

Molecular pathology

3.

C

Coagulation

10.

N

Mutations

4.

K

Cytogenic

11.

D

Organ Panel

5.

F

Cytopathology

12.

E

Quantitative

6.

H

Hematology

13.

A

Qualitative

7.

J

Immunology

14.

I

Specimen

Checking your Understanding 1. A patient has a family history of breast cancer. She presents for cancer gene analysis with molecular pathology testing. A full sequence analysis and full duplication/deletion variants in BRCA1, BRCA2 will be performed. What CPT code is reported for this molecular pathology procedure?

Ans: B. 81162 Feedback: CPT code 81162 is for BRCA 1 and BRCA 2 full sequence analysis and full duplication/deletion variants.

2. A lump is discovered in the breast of a young woman during a routine physical examination. A breast biopsy is performed and submitted for surgical pathology and microscopic pathology and microscopic evaluation of the surgical margins. A pathologic report is completed after a

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307 comprehensive examination of the breast specimen. Select the appropriate CPT code for the pathology procedure: Ans: A. 88307 Feedback: Surgical pathology services 88300 through 88308 include accession, examination, and reporting. This was a Level V surgical pathology requiring microscopic evaluation of the surgical margins; therefore, code 88307 is the correct code.

3. Clinical information: Cysts, right neck and chest Specimen submitted: 1. Cyst, right neck 2. Cyst, right chest Gross description: 1. Received, labeled with the patient’s name and ―right neck cyst‖ is a skin ellipse measuring 2.8 x 1.0 x 1.4 cm. The epithelial surface appears relatively unremarkable. A subepidermal soft white nodule is identified and sampled in one cassette.

2. Received, labeled with the patient’s name and ―right chest cyst‖ is an ellipse of skin and subcutaneous tissue measuring 2.8 x 1.8 x 1.5 cm. On cut section, there is subepidermal white nodular cystic structure present.

Microscopic and final diagnosis: 1. Cyst, right neck, excision. Epidermoid cyst.

2. Cyst, right chest, excision. Epidermoid cyst.

Select the appropriate CPT codes: Ans: B. 88304 x 2, L72.0 Feedback: Two separate specimens were submitted; therefore, 88304 would be reported twice, and the cysts are not coded as benign neoplasms.

4. Mrs. Jones underwent a modified mastectomy. The pathologist was unable to make a definitive diagnosis, and the oncologist requested a pathologic consultation of the slides as well as a review of the history and medical records. Select the appropriate CPT code for the consulting pathologist: Ans: C. 80503 Feedback: 88305 and 88309 are codes for surgical pathology gross and microscopic evaluation. 5.Sally had her first prenatal visit yesterday and presents at the laboratory today with an order for a CBC w/differential, blood typing, RH typing, antibody screen, syphilis, rubella antibody, hepatitis B surface antigen, alphafetoprotein, and urinalysis. Select the appropriate CPT code(s): Ans: C. 80055, 82105, 81000 Feedback: All tests with the exception of the alphafetoprotein and urinalysis are included in the obstetric panel 80055 and would not be coded separately.

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308 6. Mrs. Thomas went to her physician with symptoms of chronic and worsening fatigue, muscle weakness, loss of appetite, and weight loss, as well as hyperpigmentation. Her physician ordered an ACTH stimulation panel and a cortisol (performed twice) to confirm a diagnosis of adrenal insufficiency. Select the appropriate CPT code(s): Ans: D. 80400 Feedback: ACTH stimulation panel; for adrenal insufficiency, cortisol x 2.

7. Mr. Green was DOA of unknown causes in the ED. A complete autopsy, including brain and spinal cord, was performed, followed by the appropriate microscopic examinations of the tissue to determine his cause of death. Select the appropriate CPT code: Ans: B. 88027 Feedback: 88027 correctly describes necropsy (autopsy), gross and microscopic with brain and spinal cord. 88007 is for gross examination only. 88045 is for necropsy, forensic examination, coroner’s call.

88025 is for brain only, and this autopsy included the brain and spinal cord.

8. Susie Smith underwent a fine-needle aspiration of a breast mass, which was sent to the laboratory for cytology review for pathology with interpretation and report. Select the appropriate CPT code(s): Ans: D. 88173 Feedback: 88177 is an add-on code and cannot be used by itself; it is to be used in conjunction with 88172.

9. The patient presented in the ED complaining of nausea, vomiting, and diarrhea and is now demonstrating epigastria pain and dehydration. The ED physician ordered the following tests: basic metabolic panel with ionized calcium, CBC with automated differential, and urinalysis. Select the appropriate ICD-10-CM and CPT codes for this encounter: Ans: A. 80047, 85025, 81000, R11.2, R19.7, R10.13, E86.0 Feedback: 80047 is the basic metabolic panel, which included ionized calcium in the description; 85025 is for the complete automated CBC with automated differential; and 81000 is for the urinalysis. R11.2 reports the nausea with vomiting; R19.7 the unspecified diarrhea; R10.13 the epigastric pain; and E86.0 the dehydration.

10. A 35-year-old female underwent cystoscopy for hematuria, polyuria, and burning as well as abdominal pain. The physician found multiple papillary tumors in the trigone and sent them for gross and microscopic examination. Results of the examination revealed stage II transitional cell carcinoma. Select the appropriate codes: Ans: D. 88305, C67.0 Feedback: C67.0 malignant neoplasm of the trigone of the urinary bladder is the correct ICD-10-CM code. C67.1 is for the dome of the urinary bladder. 88305 is the correct CPT code. 88309 is for partial or total resection of the urinary bladder. 88304 does not list the urinary bladder.

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309

Applying your Knowledge Case Study Specimen: Cervix, uterus, bilateral tubes, and ovaries Gross: The specimen received consists of a pear-shaped uterus, attached ovaries, and fallopian tubes. The uterus weighs 130 g and measures 9 x 5 x 4.2 cm. The external surface is smooth.

There is a small nodule protruding through the serosal surface. On cut section, the ectocervix is smooth. The endocervical canal is patent. The endometrial cavity is pyramidal in shape and lined by 0.4-cm endometrium. Serial sectioning shows four additional nodules ranging in diameter from 0.2 to 0.3 cm.

Specimen: A. Cervix B. Endomyometrium and nodules C. Right ovary, measuring 5 x 1.7 x 1.3 cm. Several subcapsular cysts are present. Adjacent fallopian tube measures 7 cm in length by 0.5 cm in diameter. Sections of the fallopian tube are unremarkable.

D. Left ovary measuring 5.2 x 2.1 x 2 cm. There are also several small cysts present in the left ovary. The adjacent fallopian tube measures 8.2 cm in length and 0.6 in diameter. The section is unremarkable.

Microscopic: Chronic inflammation of the uterine cervix revealed in specimen A. Endometrium of proliferative histology revealed in sections of specimen B. Sections of specimens C and D show sections of ovaries with follicular cysts and serosal adhesions.

Sections of fallopian tubes are unremarkable Diagnoses: Endometrium of proliferative histology.

Follicular cysts and serosal adhesions of ovaries.

Fallopian tubes, unremarkable.

Chronic cervicitis.

Process 1: CPT 1. What is the procedure?

Ans: Surgical pathology, gross and microscopic Feedback: Surgical pathology, gross and microscopic is the procedure.

2. Locate the main term in the index.

Ans: Pathology Feedback: Pathology is the main term.

3. What additional questions or set of questions can be determined?

Ans: Was the pathology surgical or clinical? What is the type of surgical pathology exam?

Feedback: The additional questions are as follows: Was the pathology surgical or clinical? What is the type of surgical pathology exam?

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310 4. Upon review of all the code choices identified in the index, what additional questions can be determined?

Ans: Was the exam gross only or gross and microscopic? What is the anatomic/reason for submission?

Number of specimens?

Feedback: Upon review of all the code choices identified in the index, the following additional questions can be determined: Was the exam gross only or gross and microscopic? What is the anatomic/reason for submission? Number of specimens?

5. Based on the documentation, what is (are) the correct code(s) for this case?

Ans: C 88307 Feedback: Based upon the documentation, the correct code for this case is 88307, which correctly reports gross and microscopic pathologic examination of the female reproductive system for nonneoplastic or prolapse reasons. 88305 reports gross and microscopic pathologic exam of the female reproductive system, but for prolapse, which is not indicated in the documentation. Reporting 88305 for gross and microscopic pathologic exam of the cervix separately would be incorrect as the cervix removed with the uterus is consider part of the female reproductive system. Also, 88305 reports pathology for a biopsy of the cervix and not removal and examination of the entire cervix. 88307 reports gross and microscopic pathologic exam of the female reproductive system for neoplastic conditions.

Process 2: ICD ICD-10-CM 1. Based on the report header, what is the preexamination indication/diagnosis?

Ans: None listed Feedback: Per the report header, there is no preexamination indication/diagnosis.

2. Is the postexamination diagnosis the same as or different from the preexamination diagnosis?

Ans: N/A Feedback: N/A 3. Is the postexamination diagnosis supported?

Ans: Yes Feedback: Yes, the post-examination diagnosis is supported.

4. What is the main term for this condition?

Ans: Cervicitis; cyst Feedback: Cervicitis and cyst are the main terms for these conditions.

5. Based on the subterm choices, what question(s) can be developed for this condition?

Ans: Is the condition with or due to another condition? What is the anatomic location or type of cyst?

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311 Feedback: Based upon the subterm choices, the following questions can be developed for this condition: Is the condition with or due to another condition? What is the anatomic location or type of the cyst?

6. Based on the information in the Tabular List, is additional information needed to determine the appropriate diagnosis code?

Ans: A) None (additional code for infectious agent if known) B) None Feedback: Based upon the information in the Tabular List for cervicitis, an additional code for the infectious agent is needed if known. No additional information is needed to determine the appropriate diagnosis code for cyst.

7. Is any sign, symptom, or additional condition documented?

Ans: Yes: endometrium of proliferative histology Feedback: Yes, signs, symptoms, or additional conditions (endometrium of proliferative histology) were documented.

8. Is the additional condition, sign, or symptom an integral part of the primary (or other) condition coded?

Ans: No; however, as an incidental finding, the documentation does not support a specific diagnosis.

Feedback: The additional condition, sign, or symptom is not an integral part of the primary (or other) condition coded. However, as an incidental finding, the documentation does not support a specific diagnosis.

9. Does the additional condition require or affect patient care, treatment, or management?

Ans: No Feedback: The additional condition does not require or affect patient care, treatment, or management.

10. Based on the documentation, what are the correct ICD-10-CM codes for this case?

Ans: B N72, N83.00 Feedback: Based upon the documentation, the correct ICD-10-CM codes for this case are N72 and N83.00. This combination of codes reports both the cervicitis and the follicular cyst of the ovary.

Although an incidental finding, the statement of endometrial proliferative histology does not indicate endometriosis of the uterus; therefore, the other answer choices (which include N80.0 endometriosis of uterus) are incorrect.

Process 3: Modifiers 1. Was the procedure performed different from that described by the nomenclature of the code?

Ans: Yes: professional component only Feedback: Yes, the procedure performed was different from that described by the nomenclature of the code: professional component only.

2. Was the procedure performed at an anatomical site that has laterality?

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312 Ans: N/A Feedback: N/A 3. Was the procedure performed in the global period of another procedure?

Ans: N/A Feedback: N/A 4. Were additional procedures performed during the examination, and does the documentation support them?

Ans: No Feedback: No additional procedures were performed during the examination.

5. Did the surgeon have help from another surgeon or another appropriate person?

Ans: N/A Feedback: N/A 6. Did a physician different from the surgeon provide the preexamination or postexamination portion of the procedure?

Ans: No Feedback: There was no physician different from the surgeon providing the pre- or postexamination portion of the procedure.

7. What modifier should be appended to the CPT code for this case?

Ans: A 26 Feedback: Modifier 26 should be appended to the CPT code for this case (the services being reported are the professional component only). Modifier 58 reports a staged procedure or service, which is not reflected in the documentation and is not appropriate for this examination. Modifier 51 is not appropriate as multiple procedures were not performed during this examination.

Chapter 19 – Medicine Section LESSON PLANS Learning Outcomes After completing Chapter 19, students will be able to: LO 19.1 Identify the chapter-specific CPT guidelines and format of the Immunization Administration for Vaccines/Toxoids, Vaccines/Toxoids, Psychiatry, Dialysis, and End-Stage Renal Disease subsections of CPT.

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313 LO 19.2 Understand the chapter-specific CPT guidelines and format of the Gastroenterology, Ophthalmology, Special Otorhinolaryngologic Services, Cardiovascular Services, and Noninvasive Vascular Diagnostic Studies subsections of CPT. LO 19.3 Apply the chapter-specific CPT guidelines and format of the Pulmonary, Allergy and Clinical Immunology, and Neurology and Neuromuscular subsections of CPT. 19.4 Recognize the CPT guidelines and format of the Hydration/Chemotherapy and Physical Medicine and Rehabilitation subsections of CPT. LO 19.4 Recognize the CPT guidelines and format of the Hydration/Chemotherapy and Physical Medicine and Rehabilitation subsections of CPT. LO 19.5 Apply the modifiers most commonly used with codes in the Medicine section of CPT. LO 19.6 Examine the common medical and procedural terms used in operative reports.

Class Presentation LO 19.1: Identify the chapter-specific CPT guidelines and format of the Immunization Administration for Vaccines/Toxoids, Vaccines/Toxoids, Psychiatry, Dialysis, and End-Stage Renal Disease subsections of CPT. Slides 19-1 through 19-5



Chapter introduction and key terms

Slide 19-6



Format of the Immunization Administration for Vaccines/Toxoids, Psychiatry, Dialysis, and End-Stage Renal Disease subsections of CPT - Immunization Administration for Vaccines/Toxoids (90460– 90474) - Vaccines, Toxoids (90476–90749)

Slide 19-7



Format of the Immunization Administration for Vaccines/Toxoids, Psychiatry, Dialysis, and End-Stage Renal Disease subsections of CPT – continued - Psychiatry (90785–90899)

Slide 19-8



Guidelines of the Immunization Administration for Vaccines/Toxoids, Psychiatry, Dialysis, and End-Stage Renal Disease subsections of CPT - Other psychiatric services or procedures (90863-90899)

Slide 19-9



Guidelines of the Immunization Administration for Vaccines/Toxoids, Psychiatry, Dialysis, and End-Stage Renal Disease subsections of CPT – continued - Dialysis (90935-90947)

Slide 19-10



Guidelines of the Immunization Administration for Vaccines/Toxoids, Psychiatry, Dialysis, and End-Stage Renal

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314 Disease subsections of CPT – continued - End-stage renal disease services (90951-90970)

LO 19.2: Understand the chapter-specific CPT guidelines and format of the Gastroenterology, Ophthalmology, Special Otorhinolaryngologic Services, Cardiovascular Services, and Noninvasive Vascular Diagnostic Studies subsections of CPT. Slide 19-11



Guidelines of Gastroenterology, Ophthalmology, Special Otorhinolaryngologic Services, Cardiovascular Services, and Noninvasive Vascular Diagnostic Studies subsections of CPT - Gastroenterology (91010-91299) - Ophthalmology (92002-92499)

Slide 19-12



Guidelines of Gastroenterology, Ophthalmology, Special Otorhinolaryngologic Services, Cardiovascular Services, and Noninvasive Vascular Diagnostic Studies subsections of CPT – continued - Special otorhinolaryngologic services (92502-92700) - Audiologic function tests (92550-92597) - Evaluative and therapeutic services (92601-92700)

Slide 19-13



Guidelines of Gastroenterology, Ophthalmology, Special Otorhinolaryngologic Services, Cardiovascular Services, and Noninvasive Vascular Diagnostic Studies subsections of CPT – continued - Cardiovascular services (92920-93799) - Other therapeutic services and procedures

Slide 19-14



Guidelines of Gastroenterology, Ophthalmology, Special Otorhinolaryngologic Services, Cardiovascular Services, and Noninvasive Vascular Diagnostic Studies subsections of CPT – continued - Cardiovascular services – continued Coronary therapeutic services and procedures

Slide 19-15



Guidelines of Gastroenterology, Ophthalmology, Special Otorhinolaryngologic Services, Cardiovascular Services, and Noninvasive Vascular Diagnostic Studies subsections of CPT – continued - Cardiovascular services Cardiography

Slide 19-16



Guidelines of Gastroenterology, Ophthalmology, Special Otorhinolaryngologic Services, Cardiovascular Services, and Noninvasive Vascular Diagnostic Studies subsections of CPT – continued - Cardiovascular services – continued Cardiovascular monitoring services Implantable and wearable cardiac device evaluations

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315 Echocardiography Cardiac catheterization Slide 19-17



Guidelines of Gastroenterology, Ophthalmology, Special Otorhinolaryngologic Services, Cardiovascular Services, and Noninvasive Vascular Diagnostic Studies subsections of CPT – continued Noninvasive vascular diagnostic studies (93880-93998)

LO 19.3: Apply the chapter-specific CPT guidelines and format of the Pulmonary, Allergy and Clinical Immunology, and Neurology and Neuromuscular subsections of CPT. 19.4 Recognize the CPT guidelines and format of the Hydration/Chemotherapy and Physical Medicine and Rehabilitation subsections of CPT. Slide 19-18



Guidelines of the Pulmonary, Allergy and Clinical Immunology, and Neurology and Neuromuscular subsections of the CPT - Pulmonary (94002-94799) Ventilator management Pulmonary diagnostic testing and therapies

Slide 19-19



Guidelines of the Pulmonary, Allergy and Clinical Immunology, and Neurology and Neuromuscular subsections of the CPT – continued - Allergy and Clinical Immunology (95004-95199) Allergy testing Ingestion challenge testing Allergen immunotherapy

Slide 19-20



Guidelines of the Pulmonary, Allergy and Clinical Immunology, and Neurology and Neuromuscular subsections of the CPT - continued - Neurology and Neuromuscular procedures (95782-96020) Sleep medicine testing Routine Electroencephalography Electromyography

Slide 19-21



Guidelines of the Pulmonary, Allergy and Clinical Immunology, and Neurology and Neuromuscular subsections of the CPT - continued - Neurology and Neuromuscular procedures (95782-96020) – continued Nerve conduction test Neurostimulators Health and behavior assessment/intervention

LO 19.4: Recognize the CPT guidelines and format of the Hydration/Chemotherapy and Physical Medicine and Rehabilitation subsections of CPT.

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316

Slide 19-22



Guidelines of the Hydration/Chemotherapy and Physical Medicine and Rehabilitation subsections of CPT - Hydration, Therapeutic, Prophylactic, Diagnostic Injections and Infusions, and Chemotherapy and Other Highly Complex Drug or Highly Complex Biologic Agent Administration (96360–96549) Services included with infusion and injection procedures

Slide 19-23



Guidelines of the Hydration/Chemotherapy and Physical Medicine and Rehabilitation subsections of CPT – continued - Hydration, Therapeutic, Prophylactic, Diagnostic Injections and Infusions, and Chemotherapy and Other Highly Complex Drug or Highly Complex Biologic Agent Administration (96360–96549) continued Infusions

Slide 19-24



Guidelines of the Hydration/Chemotherapy and Physical Medicine and Rehabilitation subsections of CPT – continued - Hydration, Therapeutic, Prophylactic, Diagnostic Injections and Infusions, and Chemotherapy and Other Highly Complex Drug or Highly Complex Biologic Agent Administration (96360–96549) continued Hydration Therapeutic, Prophylactic, and Diagnostic injections and infusions Chemotherapy and other Highly Complex Drug or Highly Complex Biologic Agent administration

Slide 19-25



Guidelines of the Hydration/Chemotherapy and Physical Medicine and Rehabilitation subsections of CPT – continued - Physical Medicine and Rehabilitation (97010–97762) Modalities Therapeutic procedures Active wound care management

Slide 19-26



Moderate (Conscious) Sedation (99151–99157)

LO 19.5: Apply the modifiers most commonly used with codes in the Medicine section of CPT. Slide 19-27



Modifiers commonly used with codes from the Medicine section codes - 25 - 26 - 52 - 59

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317 -

Table 19.2

LO 19.6: Examine the common medical and procedural terms used in operative reports.

Slide 19-28



Common medical and procedural terms used with Medicine section coding - Table 19.3

Summary Slides Slides 19-29 through 19-38



Synopsis of the chapter

Teaching Tips LO 19.1:  Immunization Administration and Vaccines/Toxoids: The immunization codes (90460–90474) are reported along with the vaccine and toxoid codes (90476–90749).  Psychiatry: The Psychiatry guidelines now instruct that codes within the Psychiatry subsection include diagnostic services, psychotherapy, and other services which are provided to an individual, family, or group. The services can be provided by a physician or other qualified healthcare professional in all settings (e.g. outpatient, inpatient).  Dialysis and End-Stage Renal Disease: Hemodialysis: The codes within this range are assigned when hemodialysis is the dialysis procedure performed, and they include the evaluation and management services provided to the patient on the day of the hemodialysis procedure involving the renal disease.

End-Stage Renal Disease: To accurately code from this subheading, coders must find answers in the medical record to the following questions: • What is the age of the patient?

• What is the number of face-to-face visits per month?

• Were the services provided in the home?

• Were the services less than a full month of services?

Coding Tips and Guidelines o The guidelines before the 90460-90474 code range instruct the coder to not use modifier 51 when reporting both the immunization administration code and the vaccine/toxoid code. o Several codes under the Vaccines, Toxoids subheading have the lightning bolt symbol in front of the code. This symbol means that the code has been published prior to the drug being approved by the federal food and drug administration. The symbol will be removed once there is approval. The guidelines in many editions of the CPT manual indicate a website that can be referenced to get updates on these approvals. o The guidelines, code ranges, and code descriptions have undergone significant changes for the Psychiatry subheading of the Medicine section. It is important for the coder to read the extensive guidelines within this section. o CPT codes 90935 and 90937 include the evaluation and management services provided to the patient on the day of the hemodialysis procedure involving the renal disease. o It is very important to thoroughly read the guidelines at the beginning of the End-Stage Renal Disease Services subsection. It is also a good idea to refer to these guidelines

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318 before assigning a code from this code range as a reminder of the many guidelines and examples for accurate coding from this subsection.

LO 19.2:  Gastroenterology: Codes within this subsection are assigned to motility studies of the esophagus, stomach, duodenum, and colon.  Ophthalmology: Code selection within this subsection is determined by the status of the patient as new or established and by whether the examination was intermediate or comprehensive.  Special Otorhinolaryngologic Services: Included within this subsection are codes used to report vestibular function tests with or without recording.  Audiologic Function Tests: To assign a code from this subsection, coders must verify that the medical record documents the use of calibrated electronic equipment, the recording of results, and a report with interpretation.  Cardiovascular Services: Both diagnostic and therapeutic procedures are assigned codes within this subsection. For many of these procedures, the code descriptions include such services as access, monitoring, and injections, and thus these services are not reported separately.  Noninvasive Vascular Diagnostic Studies: Duplex scans (93880 and 93882) are included in this subsection. Duplex scans are performed to evaluate the direction of blood flow in the arteries or veins.

Coding Tips and Guidelines o The definitions of new and established patients for a general ophthalmologic examination are the same as the definitions included in the evaluation and management section of the CPT manual. The guidelines at the beginning of this subheading give very detailed definitions of an intermediate and comprehensive examination. o Be aware of the difference between a PTCA and a PTA. A PTA is a percutaneous transluminal angioplasty, which would be of a noncoronary vessel. o An instructional note directs the use of CPT codes 37211 to 37214 and/or thrombolysis of other than a coronary vessel. Cerebral thrombolysis is reported with code 37195.

Intravascular ultrasound (coronary vessel or graft) during diagnostic evaluation and/or therapeutic intervention is reported with 92978. o Many editions of the CPT manual include a grid that can be used to determine the catheter placement type code and any add-on procedures that can be coded separately when using codes for cardiac catheterization (3451-93533).

LO 19.3:  Pulmonary: Ventilator Management: CPT divides the services of ventilator management primarily by the location of the patient or site of the services: hospital, nursing facility, or patient’s home. The codes are further defined for each location by time.  Pulmonary Diagnostic Testing and Therapies: Codes within this subsection identify tests and studies that measure lung volume and capacity. Allergy and Clinical Immunology:  Allergy Testing: This testing may be done percutaneously, by scratching the skin; intracutaneously, by injecting a small amount of antigen just below the skin or by placing the agent directly on the skin or mucous membrane; or by inhalation.  Allergen Immunotherapy: CPT divides codes in this subsection into two groups. The first group involves administration of the allergen. This group is further divided based on who is providing the service: the prescribing physician (typically the allergist/immunologist) or another physician (such as the primary care provider). The second group involves the preparation and provision of the antigens given for immunotherapy.

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319    

Sleep Medicine Testing: CPT divides the services for sleep medicine and sleep studies by attended and not attended by a technologist or qualified healthcare professional. The codes are further divided by the parameters monitored and/or measured during the study.

Routine electroencephalography: Codes are divided by time of testing and patient’s state of consciousness at the time of the testing.

Electromyography: Codes are divided by nerve or nerve branch innervating a body area and the body area, number of extremities, and extent of the study. Add-on codes are used to report EMG testing performed with conduction studies.

Nerve Conduction Test: Codes are divide by the number of studies performed, not the number of nerves studied.

Coding Tips and Guidelines o At the beginning of the Pulmonary Diagnostic Testing and Therapies subsection, CPT provides definitions of many of the procedures described for pulmonary diagnostic testing. Read through the definitions, and map the terms to the codes within this subsection. o Codes 95782–95801 are out of numerical sequence in this subsection. o CPT provides definitions of many of the procedures described for sleep medicine testing at the beginning of the Neurology and Neuromuscular Procedures subsection. Read through the definitions, and map the terms to the codes within this subsection. o Parameters that may be studied during sleep medicine testing include:  Frontal, central, and occipital lobes by EEG, submental EMG, and bilateral EOG.  Electrocardiogram.  Airflow, nasal and/or oral.  Goniometry.  Bilateral anterior tibia by EMG.  Muscle activity.  Vital signs.  Snoring. o CPT provides direction for reporting routine EEGs (those of less than 41 minutes duration). Locate and highlight this directional note at the beginning of the subsection.

LO 19.4:  Hydration: There are very detailed guidelines at the beginning of this subsection. They should be reviewed very carefully before assigning codes from this subsection. When multiple infusions, injections, or combinations are administered, only one initial code is reported per day unless protocol requires two separate IV sites.  Therapeutic Injections/Infusions: The codes in this subsection are reported for injections and infusions for reasons other than hydration. When fluids are used to aid in the administration of the drugs, this is considered incidental and hydration codes are not reported separately.  Physical Medicine and Rehabilitation: Within this subsection, CPT divides evaluations and reevaluations for therapy into three groups: physical (97001–97002), occupational (97003– 97004), and athletic training (97005–97006).

Coding Tips and Guidelines o Payers establish how many additional minutes are needed over the 15 minutes indicated by each Physical Medicine and Rehabilitation code before an additional unit is billable.

For the purposes of the CPC exam, an additional 8 minutes or more must be provided to report an additional unit of modality.

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320

LO 19.5:  Some of the more common modifiers used within this section are 22, increased procedural services; 25, significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service; 26, professional services; and 52, reduced services.

LO 19.6:  Biofeedback: Training in which the patient is taught how certain responses to thought processes, stimuli, and actions can affect physical responses  Duplex scan: Ultrasound test used to evaluate the flow of blood within arteries and veins  Photodynamic therapy (PDT): Therapy in which a photosensitizing agent is applied to a lesion, such as an actinic keratosis, and the patient returns for light treatment, which activates the chemical agent in order to destroy the lesion

Chapter 19 Answer Key Exercise 19.1 1. In the Vaccine, Toxoid subsection, what does the lightning bolt symbol before a code indicate to the coder?

Ans: The lightning bolt before a code means that the code for that particular vaccine was published prior to FDA approval.

Feedback: The lightning bolt symbol means that the code has been published prior to the drug being approved by the Federal Food and Drug Administration. The symbol will be removed once there is approval.

2. How are codes in the Psychiatry subsection grouped and further classified?

Ans: Codes within the Psychiatry subsection include diagnostic services, psychotherapy, and other services which are provided to an individual, family, or group. The services can be provided by a physician or other qualified healthcare professional in all settings (e.g., outpatient, inpatient).

Feedback: Codes within the Psychiatry subsection include diagnostic services, psychotherapy, and other services which are provided to an individual, family, or group. The services can be provided by a physician or other qualified healthcare professional in all settings (e.g., outpatient, inpatient). Note: This subsection of the Medicine section had numerous code revisions, deletions, and additions in the CPT 2013 manual.

3. To accurately code for end-stage renal disease services, what questions must coders find answers to in the medical record?

Ans: What is the age of the patient?

What was the number of face-to-face visits per month?

Were the services provided in the home?

Were the services less than a full month of services?

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321 Feedback: To accurately code from this subheading, coders must find answers in the medical record to the following questions: 1) What is the age of the patient? 2) What is the number of face-to-face visits per month? 3) Were the services provided in the home? 4) Were the services less than a full month of services?

Exercise 19.2 1. During comprehensive or intermediate ophthalmologic exams, additional services may be provided that are not a normal part of these exams. Identify some of these services.

Ans: These services include examination under anesthesia, gonioscopy (glaucoma), fitting of contact lens for treatment of disease (keratoconus, ocular surface diseases), retinal and optic nerve scans, retinal imaging and mapping, and angioscopy.

Feedback: Additional services may be provided during comprehensive or intermediate ophthalmologic exams that are not a normal part of these exams. These services include examination under anesthesia, gonioscopy (glaucoma), fitting of contact lens for treatment of disease (keratoconus, ocular surface diseases), retinal and optic nerve scans, retinal imaging and mapping, and angioscopy.

2. To assign a code from the subheading Audiologic Function Tests, what does the coder need to find documented in the patient’s medical record?

Ans: The medical record would need to document the use of calibrated electronic equipment, recording of results, and a report with interpretation.

Feedback: According to the CPT manual, to assign a code from this subsection, Audiologic Function Tests (92550–92597), coders must verify that the medical record documents the use of calibrated electronic equipment, the recording of results, and a report with interpretation.

3. What is included in the cardiac catheterization codes that should not be reported separately?

Ans: The coding guidelines at the beginning of the Cardiac Catheterization subsection inform the coder that the introduction, positioning, and repositioning of catheters within the vascular system; recording of intracardiac and intravascular pressure; and evaluation and report are included in the code descriptions for cardiac catheterization.

Feedback: According to the coding guidelines at the beginning of the Cardiac Catheterization subsection, the introduction, positioning, and repositioning of catheters within the vascular system; the recording of intracardiac and intravascular pressure; and the evaluation and report are included in the code descriptions for cardiac catheterization. These guidelines also specify what is included in a right heart catheterization and a left heart catheterization.

Exercise 19.3 1. Explain what nerve conduction studies measure.

Ans: Nerve conduction studies measure the time required for a signal to traverse the nerve pathway to and from the muscle.

Feedback: Nerve conduction studies measure the time required for a signal to traverse the nerve pathway to and from the muscle.

2. List the parameters that may be studied during sleep medicine testing.

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322 Ans: Frontal, central, and occipital lobes by EEG, submental EMG, and bilateral EOG; electrocardiogram; airflow, nasal and/or oral; goniometry; bilateral anterior tibia by EMG; muscle activity; vital signs; snoring Feedback: Parameters that may be studied during sleep medicine testing include frontal, central, and occipital lobes by EEG, submental EMG, and bilateral EOG; electrocardiogram; airflow, nasal and/or oral; goniometry; bilateral anterior tibia by EMG; muscle activity; vital signs; and snoring.

3. Define allergen immunotherapy.

Ans: Allergen immunotherapy involves injecting small doses of what the patient is allergic to and increasing the amount of the dose over time to desensitize the patient to the substance over time.

Feedback: Allergen immunotherapy involves injecting small doses of what the patient is allergic to and increasing the amount of the dose over time to gradually desensitize the patient to the substance.

Exercise 19.4 1. Define modality as used in physical medicine and rehabilitation.

Ans: Modalities are the application of an agent or device used to change tissues. Modalities include heat, sound, light, and mechanical or electrical energy.

Feedback: Modalities are the application of an agent or device used to change tissues and include heat, sound, light, and mechanical or electrical energy.

2. What are the three distinct methods of active wound care?

Ans: Selective debridement (97597-97598), non-selective debridement (97602), and negative pressure wound therapy (97605-97606).

Feedback: Three distinct methods of wound care are included under this subheading: selective debridement (97597–97598), nonselective debridement (97602), and negative pressure wound therapy (97605–97606).

3. What services are included with infusion and injection procedures?

Ans: (1) Use of local anesthesia (2) IV start (3) Access to indwelling IV/subcutaneous catheter or port (4) Flush at conclusion of infusion (5) Standard tubing, syringes, and supplies

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323 Feedback: The following services are included with infusion and injection procedures: (1) use of local anesthesia, (2) IV start, (3) access to indwelling IV/subcutaneous catheter or port, (4) flush at conclusion of infusion, and (5) standard tubing, syringes, and supplies.

Exercise 19.5 1. A limited bilateral noninvasive physiologic study of both the upper- and lower-extremity arteries during the same encounter was performed. Since both the upper and lower extremities were studied, which modifier would need to be appended?

Ans: Modifier 59 would be appended.

Feedback: Modifier 59 would be appended to the second procedure. The instructional notes under CPT code 93922 inform the coder that when both the upper and lower extremities are evaluated in the same setting, 93922 may be reported twice by adding modifier 59 to the second procedure.

2. Which modifiers are used instead of modifier 59 to show that separate coronary arteries were involved?

Ans: LC – Left circumflex coronary artery; RC – Right coronary artery; LD – Left anterior descending artery Feedback: These modifiers are used instead of modifier 59 when procedures are performed in separate arteries: LC – Left coronary circumflex artery; RC – Right coronary artery; and LD – Left anterior descending artery. These abbreviations are found on the front inside cover of the CPT manual.

3. The patient was seen in the office for a vaccination and a separate evaluation and management service. Which modifier should be appended to the evaluation and management code?

Ans: Modifier 25 Feedback: Modifier 25 would be appended to the evaluation and management code when the patient was seen in the office for a vaccination and a separate evaluation and management service.

Exercise 19.6 1. What type of ultrasound study is often performed to check for blockage of blood flow in an extremity?

Ans: Duplex scan Feedback: A duplex scan is a type of ultrasound study used to evaluate the flow of blood within arteries and veins.

2. What type of study could be abbreviated REM or NREM in the medical documentation?

Ans: Polysomnography or sleep study Feedback: Polysomnography or sleep study is the type of study that could be abbreviated REM or NREM in the medical documentation.

3. Explain photodynamic therapy.

Ans: A photosensitizing agent is applied to a lesion such as an actinic keratosis, and the patient returns for light treatment which activates the chemical agent in order to destroy the lesion.

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324 Feedback: Photodynamic therapy is therapy in which a photosensitizing agent is applied to a lesion, such as an actinic keratosis, and the patient returns for light treatment, which activates the chemical agent in order to destroy the lesion.

Chapter 19 Review Using Terminology 1.

E

Allergen immunotherapy

8.

G

Isopter

2.

H

Apakia

9.

D

Minimally invasive

3.

J

Hemodialysis

10.

I

MMRV

4.

N

Hemofiltration

11.

C

Modalities

5.

K

Sensory Nerve Studies

12.

A

Noninvasive

6.

M

Interactive complexity

13.

L

Peritoneal dialysis

7.

F

Intracutaneous

14.

B

Spirometry

Checking your Understanding 1. The patient undergoes an initial 2-D echocardiogram, including spectral Doppler and color flow, to confirm a diagnosis of mitral valve stenosis with aortic insufficiency. Select the appropriate ICD10-CM and CPT codes: Ans: A. 93306, I08.0 Feedback: I08.0 identifies the combined disorder of mitral valve stenosis with aortic valve insufficiency.

The initial ECHO is coded as 93306 since it includes the spectral Doppler and color flow.

2. Misty, an 18-year-old female, was seen today and received hepatitis A and hepatitis B vaccines, adult dose, with counseling by her physician about the risks and advantages. Select the appropriate and CPT codes for this encounter: Ans: C. 90636, 90460, 90461 Feedback: The combined vaccine 90636 is reported first, and since the patient fell within the age guidelines (through 18) and was counseled by the physician, the administration codes are 90460 and 90461.

3. A 35-year-old female patient presented for a psychiatric diagnostic evaluation which included a history, mental stats exam, and recommendations. The evaluation and treatment plan were communicated to the family as the patient has requested their involvement in her case. Select the appropriate CPT code:

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325 Ans: B. 90791, 90785 Feedback: Be sure to read the guidelines with these codes (90791, 90785). 90785 is an add-on code, and the guidelines state this code may be used with 90791.

4. A patient undergoes a left heart catheterization, with coronary angiography and catheter placement in the bypass graft, and a bypass graft angiography. Select the appropriate code(s) for the procedure: Ans: A. 93459 Feedback: This code includes the placement in the bypass graft and the bypass graft angiography.

5. Barry has been diagnosed with intracranial stenosis within the arteries, and the physician has ordered a complete bilateral transcranial Doppler study to determine the flow of blood of the right and left circulation territories of the brain. Select the appropriate CPT code: Ans: D. 93886 Feedback: Since arterial flow is managed on both sides of the skull, the correct code would be 93886 as this is a complete study. 93880 is a duplex scan of extra cranial arteries, 93888 is a limited study, and 93890 is a vasoreactivity study.

6. Keegan presented to the office today for allergy testing as a result of chronic sinusitis. He received intracutaneous testing with allergenic extracts for airborne allergens. Interpretation of the tests revealed an allergy to dust and dust mites. Select the appropriate CPT code(s): Ans: B. 95027 Feedback: 95027 is based on the type of testing done (intracutaneous) and the testing was for airborne allergens. Since no other separately identifiable E/M services were performed, no other service is reported.

7. A 60-year-old patient was in a car accident and arrived at the ED in a coma. Based on the injuries, it was determined that his condition was terminal. An EEG was ordered for cerebral death evaluation. Select the appropriate CPT code for this procedure: Ans: C. 95824 Feedback: 95824 EEG for cerebral death evaluation only. 95822 is an EEG for recording in coma or sleep only; 95829 is an electrocorticogram at surgery.

8. Phil has been having problems with a previous bucket-handle injury to the medial meniscus of his left knee. He presents today for initial physical therapy evaluation of low complexity followed by these modalities: isotonic massage to his knee and active and passive range-of-motion exercises to develop strength and endurance. Select the appropriate CPT codes: Ans: A. 97161, 97010, 97110 Feedback: The patient underwent the initial physical therapy evaluation of low complexity as well as application of a modality and then 15 minutes of a therapeutic exercise routine.

9. Beth, a 46-year-old female with breast cancer, presents today for her chemotherapy treatment.

An IV line was started, and an antiemetic was administered over 35 minutes; then the patient

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326 received Cytoxan via IV infusion over 60 minutes, followed by a 1-hour infusion of Adriamycin.

Select the appropriate CPT codes for this encounter: Ans: A. 96360, 96413, 96417 Feedback: 96360, 96413, 96417 includes the antiemetic, and according to the CPT manual, when two sequential infusions up to one hour each are given, the correct sequencing is 96413 and 96417.

Applying your Knowledge Case One PREOPERATIVE DIAGNOSIS: Coronary artery disease POSTOPERATIVE DIAGNOSIS: Two-vessel coronary disease with ejection fraction of 60 to 65 percent PROCEDURES PREFORMED: Left heart catheterization, left ventriculogram, and coronary angiography via the left femoral artery INDICATIONS: This is an elderly male with palpitations with no significant chest discomfort and no previous cardiac history. Echocardiogram showed cardiomyopathy, ejection fraction of 60 percent, with slow heart movement globally. A cardiac catheterization was recommended to determine the cause of his cardiomyopathy. Risks and benefits were explained, and informed consent was obtained.

PROCEDURE: Patient was prepped and draped in a sterile manner, and the left groin was anesthetized with 1 percent plain lidocaine. Entry into the right femoral artery was accomplished by means of a single-wall puncture. A guidewire was inserted into the left femoral artery, and a hemostatic sheath with its dilator was advanced over the guidewire into the left femoral artery.

The guidewire and dilator were removed, and the hemostatic sheath was flushed with normal saline. A pigtail catheter was inserted with its guidewire and passed into the left ventricular chamber. The pigtail catheter was connected to the injection system, and left ventricular pressures were obtained.

Left ventriculogram was obtained. The catheter was removed, leaving the guidewire in place. The left coronary catheter was advanced over the guidewire to the aortic root and left main coronary artery; the guidewire was removed and the catheter connected to the injection system, and multiple injections of the left coronary system were completed.

At this time the injection system was disengaged from the catheter, and the left coronary catheter was removed, leaving the guidewire in place; a right coronary catheter was then advanced over the guidewire up to the aortic root and attached to the injection system. The catheter was then placed into the right coronary artery, and views were obtained.

The injection system was then disconnected from the catheter, and the catheters were removed.

FINDINGS: The left heart systemic blood pressure was 128/72 and left ventricular end-diastolic pressure 20 mmHg. Left ventriculogram demonstrated mild global hypokinesis with ejection fraction 60 to 65 percent.

There was no significant mitral regurgitation, and the aortic valve appeared normal.

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327 The left anterior descending had 20 to 25 percent distal narrowing. The remainder of the left anterior descending was free of focal stenosis. The left circumflex was found to have 30 percent smooth, discrete narrowing in the proximal portion. The right coronary artery was found to be free of narrowing or focal stenosis.

Process 1: CPT 1. What is the procedure?

Ans: Catheterization (left heart catheterization with left ventriculogram and coronary angiography) Feedback: The procedure is catheterization (left heart catheterization with left ventriculogram and coronary angiography).

2. Locate the main term in the index.

Ans: Catheterization Feedback: The main term is catheterization.

3. What additional questions or set of questions can be determined?

Ans: What is the anatomical site? Is the cardiac catheterization combined or of one side of the heart?

What side of the heart is being catheterized? Is the procedure diagnostic or therapeutic?

Feedback: Additional questions that can be determined include the following: What is the anatomical site? Is the cardiac catheterization combined or of one side of the heart? What side of the heart is being catheterized? Is the procedure diagnostic or therapeutic?

4. Upon review of all the code choices identified in the index, what additional questions can be determined?

Ans: Is there a combination code for the total procedure or are some components of the procedure (injections, imaging, catheter placement) coded in addition to the main procedure?

Feedback: Upon review of all the code choices identified in the index, the coder should consider the following: Is there a combination code for the total procedure or are some components of the procedure (injections, imaging, and catheter placement) coded in addition to the main procedure?

5. Based on the documentation, what is (are) the correct code(s) for this case?

Ans: C 93458 Feedback: 93452 and 93454 report left heart catheterization and ventriculography and at a separate procedure coronary artery angiography. As CPT provides a combination code for these procedures when performed during the same operative session, it would be incorrect to unbundle these procedures. 93458 reports a left heart catheterization with coronary angiography and is the correct code. 93563 reports injection of contrast during a cardiac catheterization for congenital heart conditions and a congenital condition is not documented in this case. (CAD) 93458 reports a left heart catheterization with coronary angiography and is the correct code. 93462 reports access to the left heart through a transseptal puncture; however, the patient’s heart was accessed via the femoral artery.

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328 Process 2: ICD ICD-10-CM 1. Based on the operative report header, what is the preoperative diagnosis?

Ans: Coronary artery disease (CAD) Feedback: Per the operative report header, the preoperative diagnosis is coronary artery disease (CAD).

2. Is the postoperative diagnosis the same as or different from the preoperative diagnosis?

Ans: Same Feedback: The postoperative diagnosis is the same as the preoperative diagnosis.

3. Is the postoperative diagnosis supported?

Ans: Yes Feedback: The postoperative diagnosis is supported.

4. What is the main term for this condition?

Ans: Atherosclerosis Feedback: The main term for this condition is atherosclerosis.

5. Based on the subterm choices, what question(s) can be developed for this condition?

Ans: What is the anatomical site? Is the condition in a graft, native, or autologous vessel?

Feedback: Based upon the subterm choices, the following questions can be developed for this condition: What is the anatomical site? Is the condition in a graft, native, or autologous vessel?

6. Based on the information in the Tabular List, is additional information needed to determine the appropriate diagnosis code?

Ans: Is angina also present? What form of angina is present?

Feedback: Based upon the information in the Tabular List, the following additional information is needed to determine the appropriate diagnosis code: Is angina also present? What form of angina is present?

7. Is any sign, symptom, or additional condition documented?

Ans: Yes, hypokinesis Feedback: Hypokinesis was documented as a sign, symptom, or additional condition.

8. Is the additional condition, sign, or symptom an integral part of the primary (or other) condition coded?

Ans: No, slow movement of the muscle of the heart is due to and a sign of the ischemia due to the CAD.

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329 Feedback: Slow movement of the muscle of the heart is due to and a sign of the ischemia due to the CAD. 9. Does the additional condition require or affect patient care, treatment, or management?

Ans: No Feedback: The additional condition does not require or affect patient care, treatment, or management.

10. Based on the documentation, what is (are) the correct ICD-10-CM code(s) for this case?

Ans: A I25.10

Feedback: Based upon the documentation, the correct ICD-10-CM code for this case is I25.10, which reports atherosclerotic heart disease of a native coronary artery without angina pectoris. We know this is of a native coronary vessel by the statement ―no previous cardiac history‖ found in the indication. I25.720 reports atherosclerotic heart disease of an autologous artery, a native artery which has been altered but not removed from its original site to act as a bypass graft. I25.111 reports atherosclerotic of a native vessel in heart disease with angina, which is not supported in the documentation of the condition. I25.10 is the correct code to report the documented condition; however, I25.5 reports ischemic cardiomyopathy, which is not documented.

Process 3: Modifiers 1. Was the procedure performed different from that described by the nomenclature of the code?

Ans: No Feedback: The procedure performed was not different from that described by the nomenclature of the code.

2. Was the procedure performed at an anatomical site that has laterality?

Ans: No Feedback: The procedure was not performed on an anatomical site that has laterality.

3. Was the procedure performed in the global period of another procedure?

Ans: No Feedback: The procedure was not performed in the global period of another procedure.

4. Were additional procedures performed during the operative session, and does the documentation support them?

Ans: No Feedback: Additional procedures were not performed during the operative session.

5. Did the surgeon have help from another surgeon or another appropriate person?

Ans: No Feedback: The surgeon did not have help from another surgeon or other appropriate person.

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330 6. Did a physician different from the surgeon provide the preoperative or postoperative portion of the procedure?

Ans: No Feedback: No physician different from the surgeon provided the pre- or postoperative portion of the procedure.

7. What modifier(s) should be appended to the CPT code for this case?

Ans: D none Feedback: No modifier should be appended to the CPT code for this case. Modifiers 59 and 51 would only be appropriate in cases where more than one CPT code is reported. LD, LC, and RC do identify the correct vessels imaged; however, the vessel does not need to be identified by a modifier as no procedures were performed on any of these vessels. Also, as the CPT code description includes any and all coronary arteries, the vessel(s) imaged do not need to be identified.

Case Two The patient returns for follow-up ocular examination 1 year after cataract surgery of the left eye.

The exam shows best acuity of 20/400 secondary to macular degenerative changes. Her pupils are normal; her pressures are 10. There is a small hemorrhage just inferior to the fovea in the left macula. The remainder of the ocular exam is unremarkable.

Diagnosis: No new ocular changes or disease of note apart from a right lower-lid marginal chalazion.

The patient was instructed to use a warm compress on the right lower lid chalazion. There are no other ocular concerns at present. Unfortunately, no treatment is available that would restore her acuity given her current retinal findings. She should continue to be examined periodically to make sure no other ocular disease develops.

Process 1: CPT 1. What is the procedure?

Ans: Ocular examination, follow-up Feedback: The procedure is ocular examination, follow-up.

2. Locate the main term in the index.

Ans: Ophthalmology, eye exam Feedback: The main term is ophthalmology, eye exam.

3. What additional questions or set of questions can be determined?

Ans: What is the reason for or type of examination? Were screenings provided? Is the patient new or established? Was the exam done under anesthesia?

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331 Feedback: The following additional questions can be determined: What is the reason for or type of examination? Were screenings provided? Is the patient new or established? Was the exam done under anesthesia?

4. Upon review of all the code choices identified in the index, what additional questions can be determined?

Ans: Was the examination performed intermediate or comprehensive?

Feedback: Upon review of all the code choices identified in the index, the following additional question can be determined: Was the examination performed intermediate or comprehensive?

5. Based on the documentation, what is the correct code for this case?

Ans: C 92012 Feedback: Based upon the documentation, the correct code for this case is 92012; it reports an intermediate ophthalmological exam of an established patient. An intermediate exam is typically a more limited exam focusing on a particular condition or problem such as an acute condition which does not require a complete examination of the visual system.

92002 and 92004 report ophthalmic examinations for new patients, and the documentation identifies this patient as a returning (established) patient. 92014 reports a comprehensive ophthalmic exam, which requires a general exam of the complete visual system, which was not provided during this exam.

Process 2: ICD ICD-10-CM 1. Based on the documentation, what is the diagnosis or reason(s) for the encounter?

Ans: Macular degeneration Feedback: Per the documentation, the diagnosis or reason for the encounter is macular degeneration (as the focus of treatment becomes the macular degeneration, this becomes the main term).

2. What is the main term for this condition?

Ans: Degeneration Feedback: The main term for this condition is degeneration.

3. Based on the subterm choices, what question(s) can be developed for this condition?

Ans: What is the anatomical site? What is the nature, cause, or type of degeneration?

Feedback: Based upon the subterm choices, the following questions can be developed for this condition: What is the anatomic site? What is the nature, cause, or type of degeneration?

4. Based on the information in the Tabular List, is additional information needed to determine the appropriate diagnosis code?

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332 Ans: For unspecified macular degeneration, none. Other forms of the condition require laterality.

Feedback: For unspecified macular degeneration, no additional information is needed to determine the appropriate diagnosis code. Other forms of the condition require laterality.

5. Is any sign, symptom, or additional condition documented?

Ans: Yes, chalazion and pseudophakos (prosthetic lens) Feedback: Chalazion and pseudophakos (prosthetic lens) were also documented.

6. Is the additional condition, sign, or symptom an integral part of the primary (or other) condition coded?

Ans: No Feedback: The additional condition, sign, or symptom is not an integral part of the primary (or other) condition coded.

7. Does the additional condition require or affect patient care, treatment, or management?

Ans: Yes, warm compresses for chalazion

Feedback: The additional condition does require or affect patient care, treatment, or management: warm compresses are required for chalazion.

8. Based on the documentation, what is (are) the correct ICD-10-CM code(s) for this case?

Ans: D H35.30, H00.12, Z96.1 Feedback: Based upon the documentation, the correct ICD-10-CM codes for this case are H35.30, H00.12, and Z96.1. Although the patient was scheduled for a follow-up exam for a previous cataract surgery, the focus of the encounter became the macular degeneration (H35.3) and chalazion of the right lower lid (H00.12), and these should be coded first before the reason for follow up, pseudophakos (Z96.1). ICD Section IV guidelines (H) clearly state to list first the code for the condition shown in the documentation to be chiefly responsible for the services provided. Z01.00 reports a routine examination of the eyes; however, the examination in this encounter was documented as a follow up with another condition found during the examination and, therefore, not a routine or preventive exam of the eyes.

Process 3: Modifiers 1. Was the service performed different from that described by the nomenclature of the code?

Ans: No Feedback: The service performed was not different from that described by the nomenclature of the code.

2. Was the service performed at an anatomical site that has laterality?

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333 Ans: Yes Feedback: The service was performed on an anatomical site that has laterality.

3. Was the service performed in the global period of another procedure?

Ans: No Feedback: The service was not performed in the global period of another procedure.

4. Were additional procedures or services performed during the encounter, and does the documentation support them?

Ans: No Feedback: Additional procedures or services were not performed during the encounter.

5. Did the surgeon have help from another surgeon or another appropriate person?

Ans: N/A Feedback: N/A 6. Did a physician different from the surgeon provided the preoperative or postoperative portion of the procedure?

Ans: N/A Feedback: N/A 7. What modifier should be appended to the CPT code for this case?

Ans: D none Feedback: No modifier should be appended to the CPT code for this case. Modifier 52 would be reported for an eye exam when only one eye is examined (CPT codes 92002-92014 are inherently bilateral). The documentation in this case clearly shows that both eyes were examined. Modifier E4 identifies the right lower eyelid, and modifier LT in this case would identify the left eye. Use of these modifiers would be incorrect as no procedure was performed on either eye which would require identification of the eye or eyelid.

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334

Chapter 20 – HCPCS Level II: Category II and Category III Codes LESSON PLANS Class Preparation: Teaching Focus and Resources Chapter 20 reviews the guidelines, modifiers, abbreviations and acronyms for HCPCS Level II codes. Category II and III code guidelines are also identified in this chapter. Knowledge of the appropriate use HCPCS Level II and category II and III codes aid in accurate code selection.

Learning Outcomes After completing Chapter 20, students will be able to: LO 20.1 Identify the general HCPCS II guidelines and format.

LO 20.2 Recognize the chapter-specific HCPCS Level II guidelines and format.

LO 20.3 Review the most commonly used HCPCS modifier codes.

LO 20.4 Examine the common abbreviations and acronyms used in HCPCS Level II. LO 20.5 Understand the chapter-specific CPT guidelines and format of the category II and category III codes.

Class Presentation LO 20.1: Identify the general HCPCS II guidelines and format.

Slides 20-1 through 20-4



Chapter introduction and key terms

Slide 20-5



General guidelines and format of HCPCS Level II

Slide 20-6



General guidelines and format of HCPCS Level II – continued - steps to locate appropriate H C P C S level II code

Slide 20-7



General guidelines and format of HCPCS Level II – continued - Format and General Headings

LO 20.2: Recognize the chapter-specific HCPCS Level II guidelines and format Slide 20-8



Chapter-Specific Guidelines and Format - A codes - Guidelines - A codes – Modifiers

Slide 20-9



Chapter-Specific Guidelines and Format – continued - B Codes

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335 -

C Codes E Codes

Slide 20-10



Chapter-Specific Guidelines and Format – continued - G Codes

Slide 20-11



Chapter-Specific Guidelines and Format – continued - H Codes

Slide 20-12



Chapter-Specific Guidelines and Format – continued - J Codes

Slide 20-13



Chapter-Specific Guidelines and Format – continued - L Codes

Slide 20-14



Chapter-Specific Guidelines and Format – continued - Q codes - S codes - V codes

LO 20.3: Review the most commonly used HCPCS modifier codes.

Slide 20-15



Commonly used HCPCS Level II modifiers - Introduction

LO 20.4: Examine the common abbreviations and acronyms used in HCPCS Level II. Slide 20-16



Common medical and procedural terms used with HCPCS Level II codes - Table 20.5

LO 20.5: Understand the chapter-specific CPT guidelines and format of the category II and category III codes.

Slide 20-17



Format and Guidelines of Category II and III codes - Category II codes F codes Modifiers

Slide 20-18



Format and Guidelines of Category II and III codes – continued - Category III codes T codes

Summary Slides Slides 20-19 through 20-24



Synopsis of Chapter

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336

Teaching Tips LO 20.1:  HCPCS Level II codes are made of up five characters beginning with an alphabetic letter that is followed by four numeric digits.  Steps used to locate the appropriate HCPCS Level II code are: 1. Identify the main term.

2. Locate the main term in the index, including the table of drugs.

3. Locate the code(s) identified in the index in the appropriate subsection.

4. Look for any instructional notes, indicators, and so on, and review the appendix coverage guides.

5. Determine whether a modifier is needed.

6. Assign the code(s).

Coding Tips and Guidelines o The table of drugs lists brand and generic names and also includes the amount (dose) and route of administration (i.e., IV, IM, IA). o It is very important to know the different abbreviations and acronyms used in the HCPCS Level II manual. This helps in selecting both the appropriate code and the most correct answer on the CPC exam. Many of the manuals include an abbreviation list.

LO 20.2:  There are often guidelines before each subheading that give specific instructions for the codes within the specific range. Before selecting the appropriate code, be sure to read these guidelines and look for any coverage guidelines that may be included in the HCPCS Level II manual.  Outpatient Prospective Payment System (OPPS): This is Medicare’s system for payment to outpatient departments of hospitals and other outpatient facilities. The OPPS code range includes drug, biological, and device codes that must be used by OPPS hospitals. These codes can be reported only for facility or technical services.  Dental Procedures: The codes within this subsection are maintained by the American Dental Association.

Coding Tips and Guidelines o Some routes of administration and their abbreviations for drugs are shown in Table 20.3.

Students may want to add this information to the HCPCS manual. o If a procedure other than that described in the G codes listed here is provided to a Medicare beneficiary, a CPT level I code must be used to report the service.

LO 20.3:  Modifiers are used to continue or modify the story of the patient’s encounter. Some of the HCPCS Level II modifiers are listed inside the front cover of many editions of the HCPCS Level I CPT manual. The HCPCS  Level II modifiers are listed in an appendix of many editions of the Level II manual. If the modifiers are not listed in an appendix, they are located somewhere else within the manual.

LO 20.4:  There are medical terms and procedural terms that are specific to HCPCS Level II. Table 20.5 lists some of the abbreviations, acronyms, and symbols most commonly used in the HCPCS Level II manual. Many editions of this manual include an appendix that lists many of the

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337 abbreviations and acronyms. It is extremely important that coders have an understanding of these terms and their use in HCPCS Level II coding.

LO 20.5:  Category II: The codes within category II (F codes) are supplemental tracking codes used for performance measurement. Modifiers (1P, 2P, and 3P) attached to these codes indicate that a specified service was considered but not performed due to medical, patient, or system reasons.

These category II modifiers are to be reported only with Category II codes. These codes are optional.  Category III: The codes within this subsection are T codes, which are temporary codes used for emerging technology services and procedures when an appropriate code in CPT category I does not exist. The guidelines at the beginning of this subsection contain much information about this code set and should be reviewed carefully. These guidelines instruct the use of a category III code instead of a category I unlisted code if there is an appropriate category III code. The codes in this subsection are five characters: four numeric digits followed by an alphabetic letter Coding Tips and Guidelines o There are several guidelines at the beginning of this subheading, and before selecting a code from this code range, the coder should review these guidelines. Codes such as the critical care codes in category I are time-based.

Chapter 20 Answer Key Exercise 20.1 1. Define the acronym HCPCS and identify the specific code levels.

Ans: Healthcare Common Procedure Coding System; Level I is CPT codes and Level II is the national codes.

Feedback: The Healthcare Common Procedure Coding System, which is more commonly termed HCPCS, consists of two levels. Level I comprises the Current Procedural Terminology (CPT) codes, and Level II comprises the national codes.

2. Which entity maintains HCPCS Level II? Ans: Center for Medicare and Medicaid Services (CMS) Feedback: HCPCS Level II is maintained by the Center for Medicare and Medicaid Services (CMS).

3. Explain the criteria for determining whether to use a Level I or Level II code.

Ans: If a Level I (CPT) and a Level II code description are identical, the CPT code should be used unless otherwise indicated by Medicare or another payer. If the Level I and Level II codes are not identical and the Level II code is more specific, the Level II code is to be reported.

Feedback: To determine whether it is appropriate to use a HCPCS Level I or Level II code, coders need to determine certain factors or criteria and follow these rules: If a Level I (CPT) code description and a Level II code description are identical, the CPT code should be used unless otherwise indicated by Medicare or another payer. If the Level I and Level II codes are not identical and the Level II code is more specific, the Level II code is to be reported.

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338 Exercise 20.2 1. Assign the appropriate modifier to report a patient’s origin site as an SNF and destination site as the hospital.

Ans: NH Feedback: NH designates an origin site of a skilled nursing facility (SNF) and destination site of the hospital.

2. Using your HCPCS Level II manual, assign the appropriate code for a body-worn hearing aid, monaural, for bone conduction loss.

Ans: V5040

3. Using your HCPCS Level II manual, assign the appropriate code(s) for trimming of five dystrophic nails, and indicate where you would look in the index to locate the code(s).

Ans: G0127. The coder would look at ―trim, nail.‖ Feedback: This code is for any number of nails, so the code would only be used once.

4. What criteria does Medicare require for the use of codes under the subheading Diabetic Shoes?

Ans: Peripheral neuropathy with evidence of callus formation, history of preulcerative calluses, history of ulceration, foot deformity, previous amputation, or poor circulation Exercise 20.3 1. Identify the appropriate HCPCS Level II modifiers for the following: a. Right foot, great toe b. Left hand, fourth digit c. Upper-left eyelid Ans: a. T5; b. F3; c. E1 Feedback: These modifiers are located in Appendix 2 of the HCPCS manual and also the front cover of the CPT manual.

2. Identify the appropriate HCPCS Level II modifiers for the following: a. Ambulance service provided under arrangement by a provider or service. b. Ambulance service furnished directly by a provider of service.

Ans: a. QM; b. QN 3. Identify the appropriate HCPCS Level II modifier for the following: a. Performance and payment of a screening mammogram and diagnostic mammogram on the same patient, same day.

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339 Ans: GG Feedback: Don’t confuse this with the GH modifier, which is a diagnostic mammogram converted from a screening mammogram on same day.

Exercise 20.4 1. Give an example in which less than or equal to is a factor in a code in the A-code range.

Ans: Answers will vary but should be taken from the dialysis supply codes A4720-A4725.

2. The abbreviation TENS stands for transcutaneous electrical nerve stimulation and is located in the E codes. Give an example of a code that has this abbreviation in the code description.

Ans: Answers will vary but should be taken from range E0720-E0731.

3. The abbreviation TPN is used for total parenteral nutrition. Give an example of a code that has this abbreviation in the code description.

Ans: Answers will vary but should be taken from range S9364-S9368.

Feedback: Locating TPN in the index will direct the coder to this range.

Exercise 20.5 1. Which category I codes do category III codes supersede?

Ans: Unlisted procedure codes Feedback: Category III codes supersede unlisted procedure codes in category I. 2. Which set of codes includes codes that are optional and are used to track performance measurement of services and procedures?

Ans: Category II 3. How often are category III codes updated?

Ans: Updated semi-annually and published in the CPT manual annually

Chapter 20 Review Using Terminology 1.

K

Advanced Life Support (ALS)

7. J

Intrathecal (IT)

2.

G

Basic Life Support (BLS)

8. F

Intravenous (IV)

3.

D

Durable Medical Equipment (DME)

9. E

Orthotic

4.

C

Enteral

10. I

Outpatient Prospective Payment System (OPPS)

5.

A

Intra-arterial (IA)

11. B

Parenteral

6.

H

Intramuscular (IM)

12. L

Route of Administration

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340

Checking your Understanding 1. A 20-year-old female is seen in her OB/GYN clinic. She receives an injection of Depo-Provera, 150mg, for family planning. Select the appropriate HCPCS Level II code: Ans: C. J1050 Feedback: J1050 1 mg is billed with 150 units.

2. Which of the following best describes category III codes?

Ans: A. Emerging technology temporary codes Feedback: Category III codes contain emerging technology codes that are assigned for data collection purposes. The codes are five digits long with an alpha character T at the end of the code. Category II codes are optional performance measurement tracking codes.

3. HCPCS Level II modifiers may be added to: Ans: D. HCPCS Level I and II codes Feedback: HCPCS Level II modifiers may be used with both CPT HCPCS Level I and HCPCS Level II codes. They are not used with ICD-10-CM codes.

4. A patient’s family receives 30 minutes of family training and counseling. This training and counseling was done for child development purposes. Select the appropriate HCPCS Level II code: Ans: D. T1027 x 2 Feedback: T1027 x 2 is the correct code. T1027 is per 15 minutes, and the family received thirty minutes of training and counseling.

5. CMS is no longer including the D codes as part of the HCPCS Level II code set. These codes are published and maintained by: Ans: C. American Dental Association Feedback: The HCPCS Dental codes are copyrighted, published, and maintained by the American Dental Association (ADA) as the Current Dental Terminology (CDT). The D codes are no longer published in the HCPCS Level II manual.

6. The patient receives an IV injection of 5 percent dextrose with water. Select the appropriate HCPCS Level II code: Ans: B. J7060 Feedback: J7060 - IV injection of 5% dextrose with water.

7. Which of the following HCPCS modifiers is appropriate to report when a diagnostic mammogram is converted from a screening mammogram on the same day for the same patient?

Ans: D. GH modifier Feedback: GH is the modifier to report when a diagnostic mammogram is converted from a screening mammogram on the same day, same patient. GS modifier is used for ESRD patients. GW modifier is used

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341 for hospice patients. GA modifier is used to indicate waiver of liability statement on file (this is the modifier used with an ABN).

8. The HCPCS Level II modifier for new equipment is: Ans: A. NU Feedback: NU is the modifier for new equipment. NR is the modifier for new when rented.

9. A patient received Level 2 advanced life support (ALS). Select the appropriate HCPCS Level II code: Ans: C. A0433

10. A category III code can be used in place of a(n): Ans: B Feedback: The use of unlisted codes does not offer the opportunity for the collection of specific data. If a category III code is available, it must be reported instead of a category I unlisted code.

Applying your Knowledge 1. Explain C Codes (Outpatient PPS, C1713 – C9899).

Ans: Outpatient Prospective Payment System (OPPS) is Medicare's system for payment to outpatient departments of hospitals and other outpatient facilities. Codes within this code range are used to report drugs, biologicals, and device codes that must be used by OPPS hospitals. These codes can only be reported for facility or technical services. Some of the items/services reported using codes in this subheading include brachytherapy sources; cardioverter-defibrillator, single or dual chamber/pacemaker; catheters; leads for pacemakers and cardioverter-defibrillators; magnetic resonance imaging (MRI); and transesophageal echocardiography (TEE). For example, C1750 is assigned for catheter, hemodialysis/peritoneal, long term.

2. Explain the criteria needed to determine the appropriate use of a HCPCS Level I or Level II code.

Ans: In order to determine whether it is appropriate to use a HCPCS Level I or Level II code, certain factors or criteria need to be determined and followed: If a Level I (CPT) and a Level II code description are identical, the CPT code should be used unless otherwise indicated by Medicare or another payer.

If the Level I and Level II codes are not identical and the Level II code is more specific, the Level II code is to be reported.

Feedback: In order to determine whether it is appropriate to use a HCPCS Level I or Level II code, certain factors or criteria need to be determined and followed: If a Level I (CPT) and a Level II code description are identical, the CPT code should be used unless otherwise indicated by Medicare or another payer.

If the Level I and Level II codes are not identical and the Level II code is more specific, the Level II code is to be reported.

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342 3. Discuss routes of administration, and give examples of some of the abbreviations and their definitions.

Ans: Enteral and parenteral therapies are forms of routes of administration. Routes of administration are the methods or paths used for the entrance of a drug or other substance into the body. Enteral therapy is within the intestine; this is often accomplished through the gastrointestinal tract via a gastric feeding tube or gastrostomy. In parenteral therapy, the patient receives the nutritional material other ways than through the intestine such as subcutaneous, intravenously, or intramuscularly. Some abbreviations include intraarterial (IA), intravenous (IV), intramuscular (IM), intrathecal (IT), subcutaneous (SC), and inhalation (INH).

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343

Chapter 21 – Practice Management LESSON PLANS Class Preparation: Teaching Focus and Resources Chapter 21 examines the definitions of providers and payers, including Medicare, Medicaid, and Tricare. Regulations and the parties responsible for enforcing these regulations are also reviewed.

AAPC's code of ethics is identified in this chapter.

Learning Outcomes After completing Chapter 21, students will be able to: LO 21.1 Recognize the AAPC professional code of ethics.

LO 21.2 Understand the definitions of providers and payers, including Medicare, Medicaid, TRICARE, and managed care entities.

LO 21.3 Identify regulations and the parties responsible for maintaining and enforcing the regulations.

Class Presentation LO 21.1: Recognize the AAPC professional code of ethics.

Slides 21-1 through 21-4 Slides 21-5 through 21-8

Chapter introduction and key terms AAPC Professional Code of Ethics

LO 21.2: Understand the definitions of providers and payers, including Medicare, Medicaid, TRICARE, and managed care entities.

Slide 21-9 Slide 21-10 Slide 21-11 Slide 21-12 Slide 21-13 -

Providers and Payers Defined Common types of providers Providers and Payers Defined – continued Centers for Medicare and Medicaid Services Providers and Payers Defined – continued Medicare Providers and Payers Defined – continued Claim forms Providers and Payers Defined – continued Other forms of insurance

LO 21.3: Identify regulations and the parties responsible for maintaining and enforcing the regulations.

Slide 21-14 -

Regulatory parties and regulations Office of Inspector General

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344 Slide 21-15 Slide 21-16 Slide 21-17 Slide 21-18 Slide 21-19

Slide 21-20 Slide 21-21

Slide 21-22 Slide 21-23 Slide 21-24

Regulatory parties and regulations – continued Office of Inspector General – continued Regulatory parties and regulations – continued Compliance plan Regulatory parties and regulations – continued Components of a compliance program Regulatory parties and regulations – continued Components of a compliane program- continued

Regulatory parties and regulations – continued - National Coverage Determinations - Centers for medicare and Medicaid Regulatory parties and regulations – continued - N C D s and L C D Regulatory parties and regulations – continued - Advance Beneficiary Notice N National Correct Coding Initiative Regulatory parties and regulations – continued - HIPAA Regulatory parties and regulations – continued - H I P A A - continued Regulatory parties and regulations – continued American Recovery and Reinvestment Act

Summary Slide Slides 21-25 through 21-29

Synopsis of chapter

Teaching Tips LO 21.1:  ―Commitment to ethical professional conduct is expected of every AAPC member. The specification of a Code of Ethics enables AAPC to clarify to current and future members, and to those served by members, the nature of the ethical responsibilities held in common by its members.‖ LO 21.2:  The most common providers include physicians, doctors of osteopathy, nurse practitioners, and physician assistants.  Medicare provides coverage for persons 65 years and older, disabled persons (after 2 years of disability), and persons with end-stage renal disease (ESRD). The Medicare program is made up of four parts: A. Hospital insurance B. Medical insurance, which pays for provider services, outpatient hospital and lab services, and Durable Medical Equipment C. Medicare Advantage, which provides managed care and private fee-for-service plan options D. Prescription drug plan

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345   

Medicaid, created in 1965 and funded by both state and federal funds, provides medical care for persons falling below the national poverty level. The Medicaid program is administered by each state and monitored by CMS. TRICARE and CHAMPVA provide healthcare coverage and benefits to active or retired uniformed service members and their families.

In addition to the government healthcare coverage listed above, several other forms of insurance are available that are generally offered by third-party payers.

Practice Management Tips o Claim forms: There are typically two types of claim forms used to report healthcare services: the CMS-1500 (see Figure 21.1) and the UB-04. Provider and outpatient facility services are reported on the CMS-1500 (Medicare Part B and C services).

Inpatient facility services are reported on the UB-04 (Medicare Part A services). o Payer contracts typically require that a good-faith attempt be made to collect the patient’s coinsurance, copayment, and deductible.

Coinsurance The patient-responsible portion, which is based on a percentage of the allowed charge.

Copayment The patient-responsible portion of a set amount per service or encounter.

Deductible A predetermined amount that is deemed the patient’s responsibility before the payer benefits begin. o Medicaid is considered the payer of last resort as the claim must first be submitted to and adjudicated by any other health or medical entity whose coverage is available to the patient before reimbursement is sought from the Medicaid program. o Third-party payers are so named as they are the third party in the patient (first party), provider (second party), and payer relationship.

LO 21.3:  Office of Inspector General (OIG) investigates allegations of fraud, waste, abuse, or misconduct and assists the executive branch in identifying and correcting operational deficiencies.  National Coverage Determinations (NCDs) are developed by the CMS. NCDs identify payment coverage for a specific service, procedure, test, or technology based on medical necessity or frequency.  An Advanced Beneficiary Notice (ABN) of Noncoverage is needed for any service that does not meet the coverage criteria established in an NCD or LCD.  National Correct Coding Initiative (NCCI) was created to encourage correct coding methodologies and control inappropriate payments due to improper coding of Part B claims.  Office of Civil Rights (OCR) was established to prevent discrimination due to color, race, national origin, disability, age, gender, or religion. The OCR is responsible for enforcing the rules of the Health Insurance Portability and Accountability Act (HIPAA) of 1996.

Practice Management Tips o Modifier 59 may be used to identify circumstances in which it is appropriate to report NCCI-identified code pairs together, such as a skin lesion biopsy of the arm and an excision of a skin lesion of the trunk performed during the same encounter. o Modifier 59 distinct procedural service: A distinct or separate procedure or service may be a different procedure, surgery, site, organ system, incision, excision, lesion,

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346

o

or injury. As this modifier is under scrutiny by the OIG due to misuse, careful consideration is required prior to appending modifier 59. If a more specific modifier is available to describe the situation in which the services were rendered, modifier 59 should not be used.

A covered entity is any provider or organization that transmits health information electronically. Examples are healthcare providers (only if they transmit information in an HHS-adopted transaction standard), healthcare clearinghouses, and health plans (payers). Worker’s compensation and automobile and home owners insurance are not considered covered entities and thus are exempt from HIPAA rules.

Chapter 21 Answer Key Exercise 21.1 1. What does adhering to the AAPC code of ethics mean to coders and the coding profession?

Ans: Adherence to these standards assures public confidence in the integrity and service of medical coding, auditing, compliance, and practice management professionals who are AAPC members.

Feedback: Commitment to ethical professional conduct is expected of every AAPC member. The specification of a Code of Ethics enables AAPC to clarify to current and future members, and to those served by members, the nature of the ethical responsibilities held in common by its members. This document establishes principles that define the ethical behavior of AAPC members. All AAPC members are required to adhere to the Code of Ethics, and the Code of Ethics will serve as the basis for processing ethical complaints initiated against AAPC members.

2. List three of the items in the code of ethics.

Ans: Answers may vary. Students may choose any three of the following: AAPC members shall: Maintain and enhance the dignity, status, integrity, competence, and standards of our profession.

Respect the privacy of others and honor confidentiality.

Strive to achieve the highest quality, effectiveness, and dignity in both the process and products of professional work.

Advance the profession through continued professional development and education by acquiring and maintaining professional competence.

Know and respect existing federal, state and local laws, regulations, certifications and licensing requirements applicable to professional work.

Use only legal and ethical principles that reflect the profession’s core values and report activity that is perceived to violate this Code of Ethics to the AAPC Ethics Committee.

Accurately represent the credential(s) earned and the status of AAPC membership.

Avoid actions and circumstances that may appear to compromise good business judgment or create a conflict between personal and professional interests.

Exercise 21.2 1. Define coinsurance, copayment, and deductible.

Ans: Coinsurance: The patient responsible portion based upon a percentage of the allowed charge.

Copayment: The patient responsible portion of a set amount based per service or encounter.

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347 Deductible: A predetermined amount which is deemed patient responsibility before the payer benefits begin.

Feedback: Coinsurance is the patient responsible portion based upon a percentage of the allowed charge.

Copayment is the patient responsible portion of a set amount based per service or encounter. Deductible is a predetermined amount which is deemed patient responsibility before the payer benefits begin.

2. Identify the four parts of Medicare.

Ans: The Medicare program is made up of the following four parts: A. Hospital insurance: pays for inpatient facility care (includes hospital, skilled nursing facility, hospice, and some home healthcare services).

B. Medical insurance: pays for provider services, outpatient hospital and lab services, and durable medical equipment (DME).

C. Medicare Advantage: as an alternative to the original Medicare plan, provides managed care and private fee-for-service plan options.

D. Prescription drug plan: provides prescription drug coverage through various Medicare plans.

Feedback: The Medicare program is made up of four parts: A. Hospital insurance: pays for inpatient facility care (includes hospital, skilled nursing facility, hospice, and some home health care services) B. Medical insurance: pays for provider services, outpatient hospital and lab services, and durable medical equipment (DME).

C. Medicare Advantage: as an alternative to the original Medicare plan, provides managed care and private fee-for-service plan options. Reimbursement for Part C claims are impacted by the provider’s management of the patient’s health. Payments are adjusted based on CMS hierarchical condition categories (HCCs), which are a means of assessing the risk of medically managing each patient based on current conditions and comorbid conditions that are impacting care.

D. Prescription drug plan: provides prescription drug coverage through various Medicare plans.

3. Which type of provider agrees to accept assignment of the claim and Medicare’s allowed amount as identified by the Medicare provider fee schedule for approved and medically necessary services?

Ans: Participating providers (PAR) Feedback: Medicare contracted providers, also known as participating (PAR) providers, agree to accept assignment of the claim and Medicare’s allowed amount as identified by the Medicare provider fee schedule (MPFS) for approved and medically necessary services. PAR providers are allowed 100 percent of the MPFS, with 80 percent paid by Medicare and 20 percent paid by the beneficiary. Another incentive for participation is faster processing of claims, resulting in more timely and direct reimbursement of services.

Exercise 21.3 1. Explain the American Recovery and Reinvestment Act (ARRA).

Ans: The ARRA was enacted to promote economic recovery and growth and provided the opportunity to enhance the nation’s health care system through investment in health information technology (HIT) and Electronic Health Records (EHR).

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348 Feedback: The American Recovery and Reinvestment Act (ARRA) of 2009 was enacted to promote economic recovery and growth and provide the opportunity to enhance the nation’s health care system through investment in health information technology (HIT) and Electronic Health Records (EHRs).

2. Define PHI. Ans: Protected health information (PHI) is any medical or financial information held or managed by a covered entity. PHI may be disclosed without the patient’s permission only for the purposes of facilitating treatment, payment, or healthcare operations.

Feedback: Protected health information (PHI) is any medical or financial information held or managed by a covered entity. PHI may be disclosed without the patient’s permission only for the purposes of facilitating treatment, payment, or healthcare operations.

3. Describe an ABN. Ans: An Advance Beneficiary Notice (ABN) of Noncoverage is needed for any service that does not meet the coverage criteria established in an NCD or LCD. An ABN, also known as form CMS-R-131, is not intended to be used when the service provided is never covered by Medicare but when a service usually covered by Medicare may not be covered under a particular circumstance, such as diagnosis restrictions, frequency of the service or procedure, or another payment limitation.

Feedback: An Advance Beneficiary Notice (ABN) of Noncoverage is needed for any service that does not meet the coverage criteria established in an NCD or LCD. An ABN, also known as form CMS-R-131, is not intended to be used when the service provided is never covered by Medicare but when a service usually covered by Medicare may not be covered under a particular circumstance, such as diagnosis restrictions, frequency of the service or procedure, or another payment limitation.

Chapter 21 Review Using Terminology 1.

A

Advance Beneficiary Notice (ABN)

2.

J

American Recovery and Reinvestment Act (ARRA)

3.

I

Covered Entity

4.

K

Health Insurance Portability and Accountability Act (HIPAA)

5.

C

Hierarchal Condition Category (HCC)

6.

G

Medically Unlikely Edits (MUE)

7.

B

Medicare Administrative Contractor (MAC)

8.

F

National Correct Coding Initiative (NCCI)

9.

E

National Coverage Determinations (NCD)

10.

D

Office of Inspector General (OIG)

11.

H

Protected Health Information (PHI)

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349

Checking your Understanding 1. Which of the following statements are not true for a non-PAR provider? Choose all that apply.

Ans: C. Payment is sent directly to the provider.

Feedback: Claims are filed by the provider and reimbursement is collected from the beneficiary.

2. Medicare provides coverage for: Ans: D. All of these Feedback: Medicare provides coverage for individuals over the age of 65, patients with ESRD, and disabled persons. Note: disabled persons are eligible after two years of disability.

3. The patient-responsible portion of a set amount per service or encounter is the definition of: Ans: C. Copayment Feedback: Coinsurance is the patient responsible portion based upon a percentage of the allowed charge.

Deductible is the predetermined amount which is deemed patient responsibility before the payer benefits begin.

4. Which type of claim form is used to report inpatient facility services?

Ans: A. UB-04 Feedback: Inpatient facility services are reported on the UB-04. Provider and outpatient facility services are reported on the CMS-1500 (Medicare Part B and C services).

5. Which service is not considered a Medicare Part A benefit?

Ans: A. DME Feedback: DME is not considered a Medicare Part A benefit. Hospice, inpatient stays, and some home healthcare services are considered Medicare Part A benefits.

6. Methods of reimbursement include: Ans: D. All of these Feedback: Methods of reimbursement include capitation, point of service, and fee for service.

7. Which of the following statements is not a benefit of an effective compliance plan?

Ans: A. Eliminates the risk of an audit Feedback: An effective compliance plan does not eliminate the risk of an audit; it reduces the risk of an audit.

8. Which modifier is under scrutiny by the OIG, making it important for coders to be knowledgeable about the correct use of this modifier?

Ans: B. Modifier 59

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350 Feedback: Modifier 59 is often overused in order to bypass a CCI edit.

9. Which of the following is responsible for enforcing the rules of HIPAA? Ans: C. OCR Feedback: The OCR is responsible for enforcing the rules of the Health Insurance Portability and Accountability Act of 1996 (HIPAA). OIG (Office of Inspector General) investigates allegations of fraud, waste, abuse, or misconduct and assists the executive branch in identifying and correcting operational deficiencies. NCD (National Coverage Determinations) identify payment coverage for a specific service, procedure, test, or technology based upon medical necessity or frequency. NCCI (National Correct Coding Initiative) was created to encourage correct coding methodologies and control inappropriate payments due to improper coding of Part B claims.

10. Which of the following is not considered a covered entity?

Ans: D. Worker’s compensation Feedback: Worker’s compensation, automobile insurance, and homeowner’s insurance are not considered covered entities and thus exempt from HIPAA rules.

Applying your Knowledge 1. Discuss the HITECH Act and its implications to a practice.

Ans : The American Recovery and Reinvestment Act of 2009 (ARRA) was enacted to promote economic recovery and growth and provided the opportunity to enhance the nation’s health care system through investment in health information technology (HIT) and Electronic Health Records (EHR). As part of this act and to promote the implementation of meaningful use of health information technology, the ARRA enacted the Health Information Technology for Economic and Clinical Health Act (HITECH Act). The HITECH Act addresses security and privacy issues related to the electronic transmission of health information. In addition to the security and privacy rules set out by HIPAA, the HITECH Act outlines rules and regulations as well as penalties for violation of these rules: (a) Provide authorized disclosures of PHI in an electronic format at a cost equal to the cost incurred to process the request, and (b) Mandatory notification of a breach in PHI affecting 500 or more patients to both HHS and the media in addition to the patient.

Feedback: American Recovery and Reinvestment Act (ARRA): Legislation enacted to promote economic recovery and growth and provide the opportunity to enhance the nation’s health care system through investment in health information technology.

Health Information Technology for Economic and Clinical Health (HITECH) Act: Legislation that addresses security and privacy issues related to the electronic transmission of health information and outlines rules and regulations as well as penalties for violations of the rules.

2. Discuss the completion of the required fields of an ABN and the appropriate modifiers needed.

Ans: Per CMS, a properly completed and executed ABN meets the following requirements: Completion of the following fields: A. Notifiers (physician, providers, practitioner, or suppliers) 1) Include name, address, and telephone number.

2) Notifier information may be added to the ABN in the form of a label, hand-written, or preprinted.

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351 3) For practices using a billing agency, the Notifier information may include both the provider of the ABN and the billing agency.

B. Patient Name C. Patient Identification Number (optional) 1) DO NOT include the patient’s Medicare or Social Security number.

D. Service, procedure, test, or supply provided or given which the provider believes may not be covered 1) Specification of frequency should be included in certain circumstances such as repeat procedures or test.

E. Reason for denial 1) Explained in language the patient can easily understand.

2) One valid reason for each item or service listed.

F. Estimated Cost 1) Should be within $100 or 25% of the actual cost.

2) Statements for cost estimates of ―No more than‖ or ―between $ and $‖ are also acceptable as long as this statement still meets the $100 or 25% requirement.

3) Multiple items can be added together to provide a single cost estimate.

4) If the cost cannot reasonably be estimated during the completion and delivery of the ABN, the notifier may indicate that no cost estimate is available.

G. Selection of one of the three options 1) Pre-selection or selection of an option by the Notifier will cause the ABN to be invalid.

H. Additional information (if needed) The ABN must be reviewed verbally with the patient or patient’s representative far enough in advance of delivery of the services or procedure so that the patient and/or representative has time to consider options, receive answers to questions, and make an informed decision.

Signature of an authorized representative obtained on the completed ABN prior to service/procedure is provided. Authorized representatives include legal representative, spouse, adult child, adult sibling, parent, or a close friend.

Date signature is obtained.

A completed and signed copy of the ABN must be retained, and the claim should be filed with the appropriate modifier.

GA: Waiver of liability statement on file – This modifier notifies the payer that the patient was informed prior to receipt of services that the services may not be covered and has accepted financial responsibility for these services. Proper use of this modifier results in reduction of payer-based request for patient refunds and timely adjudication of claims as needed for submission of additional insurance claims.

GY: Item or service statutorily excluded – This modifier informs the payer that although payment is not expected, a denial is requested. Use of this modifier allows timely filing to secondary insurance payers.

3. Discuss the AAPC code of ethics.

Ans: AAPC members shall: a) Maintain and enhance the dignity, status, integrity, competence, and standards of our profession. b) Respect the privacy of others and honor confidentiality. c) Strive to achieve the highest quality, effectiveness and dignity in both the process and products of professional work. d) Advance the profession through continued professional development and education by acquiring and maintaining professional competence. e) Know and respect existing federal, state and local laws, regulations, certifications and licensing requirements applicable to professional work. f) Use only legal and ethical principles that reflect the profession’s core values and report activity that is perceived to violate this Code of Ethics to the AAPC Ethics Committee. g) Accurately represent the credential(s) earned and the status of AAPC membership.

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352 h) Avoid actions and circumstances that may appear to compromise good business judgment or create a conflict between personal and professional interests.

Unit 5 Exam Answer Key 1. What is the portion of payment that patients are responsible for each time they visit a physician’s office?

Ans: A. Co-pay Feedback: The co-pay is considered the patient’s responsibility when they are seen at a physician’s office.

2. A PAR provider is a: Ans: D. Participating provider Feedback: A PAR provider is a physician that has a contract with a specific insurance company and has agreed to participate in that plan.

3. A 20-year-old female is seen in her OB/GYN clinic. She receives an injection of Depo-Provera, 150 mg, for family planning. Select the correct HCPCS Level II code: Ans: C. J1050 Feedback: The correct code is J1050, 1 mg reported with 150 units.

4. Which of the following is considered an inhalation drug?

Ans: A. Albuterol 5. Category II codes are: Ans: B. Optional performance measurement codes Feedback: The category II codes are optional performance measurement tracking codes. These codes are used in addition to the E&M service code.

6. Which route of drug administration is through the arterial system?

Ans: B IA Feedback: IA is intra-arterial administration; IV is intravenous; IM is intra-muscular; and SC is subcutaneous. All of these abbreviations are located in Appendix 3 of the HCPCS manual.

7. A patient who has terminal lung cancer is admitted to the hospice unit for general inpatient care.

Select the appropriate HCPCS Level II code: Ans: D. T2045 Feedback: T2045 is identified as hospice general inpatient care, per diem. T2044 is identified as hospice general inpatient care, respite care. T2042 and T2043 are used for hospice care but in-home care services.

8. COP is an abbreviation for:

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353 Ans: B. Conditions of participation Feedback: The Conditions of Participation are rules and regulations that healthcare organizations must meet in order to participate in Medicare and Medicaid.

9. A 78-year-old male presents to his primary care provider’s office with a complaint of urinary retention. Upon examination, the PC documents a smooth enlarged prostate. The physician orders a PSA, direct measurement to rule out prostate cancer and documents the DX as hypertrophy of the prostate. Select the appropriate CPT and ICD-10-CM codes: Ans: A. 84152, N40.1, R33.8 Feedback: 84152, N40.1, R33.8 are the correct codes. ICD-10-CM N40.1 is benign hypertrophy of the prostate with lower urinary tract symptoms (LUTS). There is an instructional note with this code to use additional code for associated symptoms such as urinary retention, R33.8.

10. A patient is exhibiting symptoms of dysphasia and chest pain. Evaluation to this point has ruled out cardiac origins and GERD. The physician orders a manometric study of the esophagus and gastroesophageal junction with stimulation of gastric acid to rule out achalasia. Select the appropriate CPT code(s): Ans: B. 91010, 91013 Feedback: 91010, 91013 are both required in this case; 91010 is billed first as 91013 is an add-on code.

11. A patient experiencing nystagmus and dizziness is being seen for vestibular function testing and receives the following test with recording: spontaneous test for nystagmus including gaze and function, testing for nystagmus in three positions, and optokinetic testing. Select the appropriate CPT code(s): Ans: C. 92541, 92542, 92544 Feedback: These tests are reported as the set and not billed with other tests.

12. Kiera, an 8-year-old, has received a cochlear implant. She is here today for postoperative analysis, and the fitting of this implant, as well as the connection and programming of the stimulator. Select the appropriate CPT code: Ans: D. 92603 Feedback: Since this is the first visit after surgery, and Kiera is 8 years old, the correct code is 92603.

13. Fred, age 60, has been experiencing abdominal pain and is undergoing testing for Crohn’s disease. His physician orders a capsule endoscopy in order to gain visualization of the gastrointestinal tract and esophagus through the ileum with interpretation and report. Select the appropriate CPT code(s): Ans: C. 91110 Feedback: 91110 cannot be reported with the other codes and visualizes the stomach and small intestine through to the ileum. In the case where the ileum is not visualized, the coder would append -52 to this code.

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354 14. For coding anatomic pathology when the specimen is not viewed using a microscope, which of the following codes would be appropriate?

Ans: B. 88300 Feedback: All of the other codes state surgical pathology, gross and microscopic.

15. A psychiatrist provided psychotherapy for crisis for a patient experiencing a high degree of anxiety. A history of the crisis state, a mental status exam, and a disposition were performed. The provider documented the time spent as 35 minutes. Select the appropriate CPT code(s): Ans: A. 90839 Feedback: The correct code is 90839 – Psychotherapy for crisis, first 60 minutes. The guidelines inform the coder that code 90791 (psychiatric diagnostic evaluation) is not to be reported with 90839.

16. Frank is a 42-year-old ESRD patient. To properly manage his disease this month, as he has had several issues, he has been to his physician three times. Select the appropriate codes: Ans: B. 90961, N18.6, Z99.2 Feedback: The proper answer for the management of ESRD in this situation is 90961 – ESRD related services monthly, for patients 20 years of age and older in the case where 2 to 3 physician visits per month are needed. ICD-10-CM code N18.6 reports the ESRD and Z99.2 reports dependence on renal dialysis.

17. A patient has been suffering from sleep apnea, and his physician orders a sleep study to measure his heart rate, O2 saturation, respiration analysis, and sleep time. Select the appropriate code(s) for this test: Ans: C. 95800 Feedback: 95800 contains all test components ordered.

18. A patient undergoes a left heart catheterization with catheter placement in the bypass graft, and the physician performs a bypass graft angiography. Code this procedure: Ans: A. 93459 Feedback: All components of the test are included in this single code.

19. Mrs. Tent was sent to the lab following her yearly examination with Dr. Jones. Dr. Jones ordered a general health panel, WBC count, bilirubin analysis, and a qualitative urinalysis for her urinary tract infection (UTI). Select the appropriate CPT and ICD-10-CM codes: Ans: A. 80050, 81005, Z00.00, N39.0 Feedback: The general health panel includes the WBC and the bilirubin, so they would not be charged separately. It does not include the urinalysis so that would be coded separately, and since the physician ordered a Qualitative UA the appropriate code choice would be 81005. For the ICD-10-CM code, the reason for the general health panel is the yearly examination, Z00.00, but there is also a urinalysis for a urinary tract infection, which is N39.0.

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355 20. A patient presents at his primary care provider’s office with pain in the left wrist. The physician orders a complete, three view x-ray of the wrist to be done in the outpatient department of the local hospital. The hospital will bill the technical component of the wrist x-ray. How will the radiologist bill for his services?

Ans: B. 73110-26 Feedback: 73110 with a 26 modifier for the professional component 21. What is the coder instructed to do with category III codes in the CPT? Ans: C. If there is a category III code available, it must be used instead of an unlisted category I code.

Feedback: Category III guidelines instruct the coder that if there is a category III code available, it must be used instead of an unlisted category I code.

22. A patient comes in with a 2-day history of sore throat, fever, and chills. The physician performs a rapid-strep test and prescribes a 10-day course of penicillin. Code the lab test: Ans: B. 87880 Feedback: 87880 is the correct code for Rapid-strep/Strep, group A. 23. Which of the following is the best description of an Advance Beneficiary Notice?

Ans: C. A written notice from Medicare given to a patient before certain services are performed that explains that Medicare may deny payment and, if so, the patient is responsible.

Feedback: An Advance Beneficiary Notice is a written notice from Medicare given to a patient before certain services are performed explaining that Medicare may deny payment and, if so, the patient is responsible.

24. The procedure that records the electrical impulses of the brain is called a(n): Ans: C. Electroencephalogram Feedback: The question references electrical impulses. Remembering medical terminology, the prefix electro- refers to electrical, cephalo to brain, and gram to recording.

25. The patient is at his physician’s office for a routine physical when he suffers cardiac arrest. The physician performs lifesaving measures and stabilizes the patient until the ambulance arrives. The ambulance team continues to administer lifesaving treatment to the patient and transports the patient to the hospital, which is 7 miles away from the physician’s office. Select the appropriate HCPCS Level II codes: Ans: D. A0427-PH, A0425 x7 Feedback: The ambulance code of the HCPCS is A0427 for ambulance services with advanced life support, emergency transport. A modifier of P (from the physician’s office) and H (to the hospital) must be used to show the point of origin and destination of the trip. The code of A0425 is used to code the mileage of 7 miles.

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356

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357

Appendix A: Final Exam: ICD-10-CM Answer Key ANESTHESIA 1. Ans: A Feedback: ICD-10-CM: C18.7, E03.9, E53.8, G25.82. This is straightforward for the sigmoid colon cancer; for hypothyroidism you would choose acquired since we have no other information; the B12 deficiency is unspecified; and last the one is the stiff person syndrome, or stiff man syndrome.

CPT: 00790. Even though the majority of the colon (large intestine) lies in the lower abdomen, the sigmoid portion of the colon is at the bottom. Digestive organs like the stomach and intestines are located inside the intraperitoneal cavity, along with the liver and spleen.

2. Ans: A Feedback: ICD-10-CM: D07.5, Z85.72. The adenocarcinoma of the prostate, D07.5, is what the patient walked in the door for. Since this is non-Hodgkin’s lymphoma, Z85.72 is the correct code.

Since the patient history was 40 cigarettes a day for 30 years, you may also want to report personal history of nicotine dependence Z87.891. Good student discussion CPT: 00914-53, 99100. The procedure is for a transurethral resection of the prostate, so CPT 00914 is the correct choice. However, the procedure was stopped, so the modifier 53 needs to be added. This documentation does not provide the physical status of the patient, so choosing an appropriate modifier for that is not available. However, the age of the patient does require a qualifying circumstance code (the 99100 code).

3. Ans: A Feedback: ICD-10-CM: M54.16. This is straightforward radiculitis unspecified lumbar.

CPT: 62322 for lumbar. Anesthesiologists, when not in surgery, are doing pain management, which involves injections. 62320 would be for the cervical or thoracic area of the vertebral column; this was in the lumbar area, so the correct choice is 62322.

4. Ans: C Feedback: ICD-10-CM: M25.552, R07.9, M54.5. Pain in hip will send you to M25.55, and left hip takes you to M25.552. The chest pain is NOS, so it would be R07.9, and backache unspecified is M54.5.

CPT: 20610, 0216T-50. 20610 reports the left hip greater trochanter bursa injection. The guidelines under Paravertebral Spinal Nerves and Branches direct you to the temporary codes for ultrasound guidance. The only level that was injected was L2, but it was bilateral; as the note in parentheses states, use modifier 50 for bilateral.

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358

5. Ans: D Feedback: ICD-10-CM: K64.1 second degree hemorrhoids (hemorrhoids that prolapsed with straining, but retract spontaneously) CPT: 46947 does have a note showing that it has been resequenced. Code 99152 would be appropriate for the use of moderate (conscious) sedation (moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient’s level of consciousness and physiological status, initial 15 minutes, patient age 5 year or older); 99153 would be used to report the additional 15 minutes.

6. Ans: D Feedback: ICD-10-CM: Q32.1, Congenital tracheal stenosis CPT: 00326. This is for a child younger than 1 year old so you would think a qualifying circumstances code would be necessary. However, since the code specifies the age of 1 year or younger, 99100 would be a duplication; therefore, it is not necessary.

7. Ans: D Feedback: ICD-10-CM: M17.11, Osteoarthritis, unilateral right knee CPT: 01402-P1, 99100. This was for a total knee arthroplasty, so the code of choice would be 01402.

Since the anesthesiologist documented the health of the patient, a physical status modifier is appropriate, and the patient’s age must come into play, so the 99100 unusual circumstance code is needed.

8. Ans: D Feedback: CPT: 01969 is an add-on code and cannot be used first or alone, therefore eliminating answers B and C. Instructional notes with these codes instruct the use of 01967 and 01969 in conjunction with each other. Also note this was for a cesarean hysterectomy, not delivery.

INTEGUMENTARY 1. Ans: C Feedback: ICD-10-CM: The correct code here is found by looking under contusion, finger with damage to the nail bed. The appropriate code would be S60.122A. The S60 category code requires a 7th character to report the status of the encounter which in this case would be initial ―A‖.

CPT: Since an examination was needed to determine the extent of the injury, the E/M service can be

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359 billed and requires a -25 modifier. CPT code 11740 would be used to report the evacuation of subdural hematoma.

2. Ans: C Feedback: ICD-10-CM: The diagnosis is found under tag, skin, which takes you to other hypertrophic disorder of the skin, unspecified, L91.8.

CPT: The first 15 tags are coded with 11200, and the additional five are coded with inclusion of the addon code 11201.

3. Ans: D Feedback: ICD-10-CM: The diagnosis is found under disease, mastopathy, cystic, diffuse, which includes cystic breast and fibrocystic disease of the breast. In this case, since there are cysts in both breasts, two codes are needed to specify right and left (N60.11, N60.12) since there is not a bilateral code for this category.

CPT: The puncture aspiration of multiple cysts is counted using two codes. The first aspiration code is 19000-50 (to report one cyst of each breast), and the other two cysts of the left breast as 19001 LT x 2.

4. Ans: C Feedback: ICD-10-CM: To code these lacerations, after reading the note, there is no additional information to indicate that there are or are not foreign bodies to be removed. Therefore, the category of unspecified open wound of the appropriate area is required: S41.102A for left upper arm, S51.801A for right forearm, and S61.402A for left hand. The 7th character A indicates the status encounter as initial.

CPT: When coding multiple wounds within the same category that require the same type of repair (in this case, simple), add together and report once. CPT code 12006 reports simple repair of the extremities 20.1 cm to 30.0 cm.

5. Ans: C Feedback: ICD-10-CM: E65 is the correct code for the pannus of the lower abdomen, which is the reason for the panniculectomy. The code for morbid obesity is found under obesity, morbid and is listed as E66.01 – morbid (severe) obesity due to excess calories. There is an instructional note with E66.01 leading the coder to use an additional code, if known, to identify the BMI (Body Mass Index).

CPT: Panniculectomy is found under lipectomy, excision, abdomen. No additional codes are to be billed with this code.

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360 6. Ans: D Feedback: ICD-10-CM: The correct diagnosis here is found by checking benign neoplasm of connective and other soft tissue of lower limb, including hip – in this case, the right leg – D21.21.

CPT: 14301 is the correct code. Only the code for the adjacent tissue transfer procedure (rotation flap) is coded. The guidelines instruct not to code separately for the excision of a benign or malignant lesion. The square cm size of the lesion would be 12cm x 5cm = 60 square cm so 14301 would be correct since the code description is for any area, defect 30.1 sq cm to 60.0 sq cm.

7. Ans: D Feedback: ICD-10-CM: The diagnosis came back as a sebaceous cyst and is coded as L72.3. L05.01 is a pilonidal cyst with abscess, which is not the diagnosis made here.

CPT: Incision and drainage of the sebaceous cyst is 10060, and since the office visit was needed to determine the cause of the pain, and a medically appropriate history and exam was performed with low medical decision making. This is an established patient, delete two of the three criteria were met, so the correct code is 99213 and the -25 modifier is required.

8. Ans: B Feedback: ICD-10-CM: The correct diagnosis was found as L70.0, acne vulgaris.

CPT: 17340 best describes cryotherapy procedures for treatment of acne. 17360 represents chemical exfoliation for acne.

9. Ans: A Feedback: ICD-10-CM: The correct diagnosis would relate to personal history of breast cancer (Z85.3) since the tumor has been removed and treatment has been completed.

CPT: Insertion of the breast prosthesis was delayed due to need to complete radiation therapy (19342).

CPT Guidelines state that the additional code of 19396 is used to report a customized breast implant.

10. Ans. C Feedback: The physician acts as both the surgeon and pathologist for a Mohs technique procedure. This is identified in the CPT manual guidelines before code range 17311–17315.

MUSCULOSKELETAL 1. Ans: B Feedback: ICD-10-CM: In this case, the correct answer is non-traumatic rotator cuff syndrome, right shoulder.

CPT: There is a need for both procedures, 23412 and 29827, since the repair of the rotator cuff tear

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361 required an open incision. The modifier -59 is needed to acknowledge the required separate procedure in the same session by the same physician.

2. Ans: D Feedback: In ICD-10-CM, the fracture is not only coded by site, but type; therefore, greenstick fracture of the left ulna is coded as S52.212A. The seventh character A represents an initial encounter.

CPT: 25535, closed treatment of the ulnar fracture with manipulation. Cast application is not billed separately from the initial closed manipulation of the fracture.

3. Ans: B Feedback: In ICD-10-CM, the correct diagnosis code is osteogenesis imperfecta, Q78.0. Osteogenesis imperfecta is imperfect bone formation (genesis = formation, osteo = bone) CPT: 20664 is for Halo placement with six or more pins for thin skull osteology (for example, in osteogenesis imperfecta).

4. Ans: B Feedback: In ICD-10-CM, this case deals with cutaneous abscess, furuncle and carbuncle of the trunk, specifically cutaneous abscess of left lower limb.

CPT: 20005 is appropriate based on the depth of the abscess. 10060 and 10061 are more superficial in nature.

5. Ans: D Feedback: In ICD-10-CM, the fractures are coded not only by location, but by type. In this case, two codes are required, one for each vertebrae. Therefore, since the information provided does not describe the type of fracture (i.e., stable or unstable), the proper codes are S32.049, unspecified fracture of the fourth lumbar vertebrae, and S32.059, unspecified fracture of the fifth lumbar vertebrae.

CPT: 22325 is for the first reduction (L4). 22328 is used for each additional fractured vertebrae (L5).

6. Ans: C Feedback: In ICD-10-CM, the correct diagnosis code is M20.12 for the hallus valgus of the left foot and M21.612 for the bunion of the left foot.

CPT: The proper procedure code is 28292, correction, hallux valgus (bunionectomy), with sesamoidectomy, when performed.

7. Ans: A

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362 Feedback: In ICD-10-CM, the proper sequence here is determined by the term crushing injury and then the lower leg: S87.81xA, crushing injury of right lower leg. The 7th character A represents initial encounter. There could be a discussion here with the student about adding an external cause code to identify how the injury occurred.

CPT: 27598 – Disarticulation at the knee. 27592 is amputation at the thigh, through the femur, open, circular, which is not the procedure done here.

8. Ans: A Feedback: In ICD-10-CM, the correct answer is fracture of lumbar vertebrae, fracture of coccyx, which identifies the initial encounter for closed fracture as the 7th digit: S32.2xxA. CPT: Open treatment of coccygeal fracture, 27202. There could be a discussion here with the student about adding an external cause code to identify how the injury occurred.

9. Ans: C Feedback: In ICD-10-CM, the correct diagnosis here is M84.88, other disorders of continuity of bone, unspecified, as vertebrae are not an option when coding more specific.

CPT: Bill only the services of Surgeon B who removed the lesions at L1 and L2. The modifier -62 was needed to demonstrate two distinct procedures done by different surgeons.

10. Ans: B Feedback: ICD-10-CM allows for the arthritis to be localized to the specific site: M17.12 is unilateral primary osteoarthritis, left knee.

CPT: Arthrocentesis in a large joint, 20610 would be correct. 99212 is not appropriate as an E/M was not performed. The J code bills the drug.

RESPIRATORY/CARDIOVASCULAR 1. Ans: A Feedback: ICD-10-CM: J95.02. This is an infection of a tracheostomy, J95.02, and the note below states to use additional code for the type of infection, cellulitis L03.8. Verifying the code as you check up 5 and down 5, you will find cellulitis of the neck, L03.818. The cancer is not related to this procedure, so there is no need to code it.

CPT: 31613. This is straightforward tracheostoma revision.

2. Ans: A Feedback: ICD-10-CM: J85.2. The only item that would be coded is the left upper lobe abscess; the pneumothorax has already been treated, so it doesn’t exist for this procedure.

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363 CPT: 32480-LT. This was a single lobe removal, so the proper code would be 32480 with the LT modifier to denote the left side.

3. Ans: C Feedback: ICD-10-CM: J18.9. The only confirmed diagnosis after the procedure was pneumonia, so that is the only code.

CPT: 31625, 31623-51. Both CPT codes are needed to report the fiber-optic bronchoscopy with biopsy and brushings.

4. Ans: B Feedback: ICD-10-CM: R06.89. Respiratory insufficiency falls under other abnormalities of breathing.

CPT: 31600. This was a planned tracheostomy so 31600 is appropriate. The division of the thyroid is just to do the tracheotomy and would not be coded separately.

5. Ans: B Feedback: ICD-10-CM: R91.8. This is Lung Mass NOS found of diagnostic imaging. Even though that is not stated, it is a given since you would not be able to find it any other way.

CPT: 31628, 31623-51. These codes properly cover the bronchoscopy; transbronchial lung biopsy, and the brushings.

6. Ans: D Feedback: In ICD-10-CM, the diagnosis is sick sinus syndrome, which is I49.5.

CPT: 33208. This code is appropriate for the new placement or replacement of a permanent pacemaker in both the atrial and ventricular area, which the coder will find upon reading through the documentation.

7. Ans: C Feedback: ICD-10-CM: C79.89, C34.10 The primary diagnosis code is the C79.89 for the neck metastasis since that is what is being treated this encounter. C34.10 would be reported for the lung carcinoma, we do not know which side in the lung; we are only given right relating to the neck CPT: 31536, 43200-59, 31600-59. The esophagoscopy was a look around and then the scope was removed, so 43200 is truly a separate procedure performed and should be coded. The microlaryngoscopy was the next procedure performed, and the correct code is laryngoscopy with operating microscope, 31536. Note also that towards the end of the documentation, it is noted that all of this was preceded by a tracheostomy which is the 31600; the modifier 59 (distinct procedural services) is also needed on the 31600 and the 43200 since both are listed as separate procedures.

8. Ans: D

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364 Feedback: ICD-10-CM: The procedure is for left renal artery stenosis, which is I70.1.

CPT: If you reference appendix L, you will find that the renal artery is a first order branch, so the appropriate code choice is 36251. Then, after reading the documentation, the coder will find that both the right and left were done so the bilateral code, 36252, is correct.

9. Ans: A Feedback: ICD-10-CM: T82.7xxS, I49.5, Z95.0, I25.810, I10. There are numerous diagnoses available for this patient, and whether or not all of them fit on a claim form, all are still coded. First is infected pacemaker wires, which is infection due to an internal prosthetic device, implant, and graft, cardiac. This is a secondary consequence or result, so the 7th character would be S for sequela: T82.7xxS. The next diagnosis is sick sinus syndrome, I49.5. This is status post pacemaker insertion, Z95.0. The next diagnosis is CAD, so under disease, artery, coronary, you are told to see atherosclerosis; you would not choose I25.7 since the history is of a bypass, not that the CAD is currently in the graft, nor has angina pectoris been noted; instead you would pick I25.810. The next diagnosis is history of CABG; since it is not a status post-surgery, it is not necessary to code this. The final diagnosis is essential hypertension, I10.

CPT: 33233, 33222, 93318. This is a straight removal, 33233, and pocket revision, 33222. There isn’t any documentation regarding a reimplantation, so none is coded. Also, an intraoperative transesophageal echocardiography with interpretation was done, so code 93318 is included.

DIGESTIVE 1. Ans: A Feedback: In ICD-10-CM, to diagnose the adhesions in this system, the code would be K66.0, peritoneal adhesions (postprocedural) including adhesions of the abdominal wall. The carcinoma of the colon is diagnosed as C18.7, malignant neoplasm of the sigmoid colon. The adhesions are coded first as this is the purpose of the procedure.

CPT: Laparoscopy, surgical; enterolysis (freeing of intestinal adhesion) (separate procedure). This is coded as this was the only procedure performed.

2. Ans: C Feedback: In ICD-10-CM, the correct diagnosis here is T18.128A, food in the esophagus causing other injury, and further identified as the initial encounter.

CPT: Esophagoscopy, rigid or flexible, with removal of foreign body. The other codes are more invasive and include exploration of other organs not performed here.

3. Ans: D Feedback: In ICD-10-CM, the location of the hemorrhoids is combined with possible complications. The correct answer here, based on the diagnosis of prolapsed internal hemorrhoids, third degree is K64.2, third degree hemorrhoids. Additionally, the chronic anal fissure is diagnosed with K60.1.

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365 CPT: 46261, hemorrhoidectomy, internal and external, 2 or more columns/groups; with fissurectomy.

4. Ans: C Feedback: In ICD-10-CM, the diagnosis is K80.00, calculus of gallbladder with acute cholecystitis without obstruction.

CPT: 47563 Laparoscopy, surgical cholecystectomy with cholangiography.

5. Ans: B Feedback: In ICD-10-CM, the correct code is Q38.1, ankyloglossia or tongue tie.

CPT: This description outlined a Z technique in the repair, making the only possible choice here frenoplasty, CPT code 41520, (surgical revision of frenum, e.g., with Z-plasty).

6. Ans: D Feedback: In ICD-10-CM, the diagnosis code C25.9 denotes malignant neoplasm of pancreas, unspecified.

CPT: The ultrasound guidance here allows for sampling and aspiration, and the paracentesis code, 49083, allows for that guidance.

7. Ans: A Feedback: In ICD-10-CM, the diagnosis code Q37.0 indicates cleft hard palate with bilateral cleft lip.

CPT: Palatopharyngoplasty (e.g., uvulopalatopharyngoplasty, uvulopharyngoplasty).

8. Ans: C Feedback: In ICD-10-CM, the correct codes here begin with K40.90, unilateral inguinal hernia, without obstruction or gangrene, not specified as recurrent. Additionally, the hydrocele is coded as N43.3, hydrocele, unspecified.

CPT: The critical piece in this situation was the gestational age and postconception age of the child.

9. Ans: B Feedback: In ICD-10-CM, the code for morbid obesity is found under obesity, morbid and is listed as E66.01, morbid (severe) obesity due to excess calories.

CPT: The revision code is 43771.

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366 10. Ans: D Feedback: In ICD-10-CM, the correct diagnosis code is K75.4, specifically identifying autoimmune hepatitis.

CPT: Allowing for both the liver biopsy and ultrasound guidance with the diagnosis of autoimmune hepatitis: 47000, 76942.

URINARY, MALE/FEMALE REPRODUCTIVE SYSTEMS, MATERNITY/DELIVERY 1. Ans: A Feedback: In ICD-10-CM, the correct code is N43.3, hydrocele, unspecified.

CPT: The code for excision of hydrocele, unilateral, is 55040-LT.

2. Ans: D Feedback: In ICD-10-CM, the correct answer is N28.1, cyst of kidney, acquired, cyst multiple or solitary of kidney, acquired.

CPT: Code 50390-LT for aspiration and/or injection of renal cyst or pelvis by needle, percutaneous. The translumbar study is coded using 74470, radiologic examination, renal cyst study, translumbar, contrast visualization, radiological and interpretation.

3. Ans: B Feedback: In ICD-10-CM, Z94.0 remains primary as the status of kidney transplant, and also included is N18.6, end stage renal disease – chronic kidney disease requiring chronic dialysis.

CPT: 50300, donor nephrectomy (including cold preservation); from cadaver donor, unilateral or bilateral.

50323, backbench standard preparation of cadaver donor renal allograft prior to transplantation, including dissection and removal of perinephric fat, diaphragmatic and retroperitoneal attachments, excision of adrenal gland and preparation of ureters, renal vein(s) and renal artery(s) ligating branches, as necessary.

4. Ans: A Feedback: ICD-10-CM: Z41.2, circumcision (in absence of medical indication), (ritual or routine).

CPT: 54161, circumcision, surgical excision other than clamp, device or dorsal slit; older than 28 days of age. The child was more than 28 days old. No modifier needed.

5. Ans: C

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367 Feedback: ICD-10-CM: N41.2, abscess of prostate.

CPT: 55725 for prostatomy, external drainage of prostatic abscess, any approach; complicated.

6. Ans: B Feedback: In ICD-10-CM, the code is based on the index for mass, testicle; you are directed to disease of specified site, which leads to N50.9.

CPT: This is not a fine needle aspiration; use code 54500-RT.

7. Ans: B Feedback: ICD-10-CM: N83.201 and N83.202 report unspecified ovarian cysts of right and left side.

CPT: 58925, ovarian cystectomy, unilateral/bilateral. Since the description allows for unilateral or bilateral, no modifier is necessary.

8. Ans: A Feedback: In ICD-10-CM, Z34.80, Z38.31, and Z39.2 allow for management of entire pregnancy, delivery and postpartum follow-up.

CPT: The global package would be billed here since the physician provided all components of the pregnancy/delivery/postpartum period. Use code 59510.

9. Ans: A Feedback: In ICD-10-CM, the correct answer here would be D39.2, neoplasm of uncertain behavior of placenta – malignant hydatidiform mole.

CPT: Total abdominal hysterectomy with or without removal of tubes, with or without removal of ovary, 58150.

10. Ans: C Feedback: ICD-10-CM: Z39.2, Examination for routine postpartum follow-up.

CPT: This physician only saw the patient for postpartum services; no other part of the global package is billable, so use code 59430.

11. Ans: A

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368 Feedback: In ICD-10-CM, the codes here include periodic examination – normal, adult, Z00.00, and removal of contraceptive device, Z30.432.

CPT: This is a preventive medicine visit and a return patient, so use codes 99395-25 and 58301.

12. Ans: D Feedback: ICD-10-CM: N85.6, Intrauterine synechiae.

CPT: 58559, Hysteroscopy, surgical; with lysis of intrauterine adhesions.

NERVOUS SYSTEM, EYES, EARS, ENDOCRINE 1. Ans: B Feedback: ICD-10-CM: E05.00, Thyrotoxicosis (hyperthyroidism) with diffuse goiter without thyrotoxic crisis or storm.

CPT: 60240, Thyroidectomy; total or complete.

2.Ans: C Feedback: ICD-10-CM: G70.01, Myasthenia gravis with (acute) exacerbation. Documentation states myasthenia gravis in crisis, G70.01 lists myasthenia gravis in crisis.

CPT: 60521, Thymectomy, partial or total; sternal split or transthoracic approach without radical mediastinal dissection.

3. Ans: B Feedback: ICD-10-CM: E04.1, Non-toxic single thyroid nodule.

CPT: 10021, Fine needle aspiration; without imaging guidance. The description does not qualify for the more intense procedure of needle biopsy.

4. Ans: B Feedback: ICD-10-CM: In the description, it stated that the patient fell and experienced loss of consciousness for about 20 minutes. Based on this description, the appropriate diagnosis code is S06.5x1A. The 7th character A reports the status of the encounter as initial.

CPT: 61314, Craniectomy or craniotomy procedures, surgery.

5. Ans: A

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369 Feedback: ICD-10-CM: Here you are directed only to code pain by site; since the specific area of the leg is not mentioned, the selected code is M79.605.

CPT: The physician utilized a specific procedure to eliminate the intractable pain. 63620 and 63621 are not correct as they describe stereotactic surgery. 63600 is the correct answer and includes stimulation and recording.

6. Ans: B Feedback: CPT: The proper code here is a diagnostic lumbar puncture, 62270.

ICD-10-CM: G44.009, Cluster headache syndrome, unspecified.

7. Ans: D Feedback: ICD-10-CM: In this case, the foreign body of the cornea is specifically identified as in the left eye, and this is the initial encounter; therefore, the code is T15.02XA. The X acts as a placeholder for this code since it requires a 7th character to indicate the status of the encounter.

CPT: 65275, which incorporates the removal of the foreign body and the repair of the cornea.

8. Ans: B Feedback: The code in ICD-10-CM identifies the specific eye; therefore, H33.21 represents serous retinal detachment (detachment, NOS) in the right eye.

CPT: 67107. The procedure here represents repair of retinal detachment; scleral buckling, with or without implant, with or without cryotherapy, photocoagulation and drainage of subretinal fluid.

9. Ans: B Feedback: In ICD-10-CM, the blepharoptosis requires identification of which eye. H02.432 is paralytic blepharoptosis of the left eye.

CPT: 67961, Excision and repair of eyelid, involving lid margin, tarsus, conjunctiva, canthus or full thickness, may include preparation for skin graft or pedicle flap with adjacent tissue transfer or rearrangement up to one-fourth of lid margin.

10. Ans: C Feedback: ICD-10-CM: Since the ear was not identified, the diagnosis is H66.3x9, other chronic suppurative otitis media, unspecified ear.

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370 CPT: 69421, Myringotomy including aspiration and/or Eustachian tube inflation requiring general anesthesia.

11. Ans: D Feedback: ICD-10-CM: The correct answer here describes cholesteatoma of the right ear, H71.91.

CPT: 69642, Tympanoplasty with mastoidectomy (including canalplasty, middle ear surgery, tympanic membrane repair); with ossicular chain reconstruction.

RADIOLOGY 1. Ans: A Feedback: ICD-10-CM: Z03.89. The reason for the chest x-ray is to establish whether this patient has contracted tuberculosis, so observation for suspected tuberculosis would be the appropriate code.

CPT: 71046, two views, is a chest x-ray; it doesn’t matter if it is portable or not.

2. Ans: C Feedback: ICD-10-CM: J98.4, Other diseases of the lung not elsewhere classified (since nothing was found).

CPT: 71270. This would be without for the oral and with contrast due to the intravenous contrast.

3. Ans: A ICD-10-CM: Z85.47, Personal history malignant neoplasm of the testis.

Feedback: CPT: 74178, a CT of both the abdomen and the pelvis without contrast (oral) followed by contrast.

4. Ans: D Feedback: ICD-10-CM: K31.84. This is straightforward coding for gastroparesis; there is a note to code first the underlying disease, if known. Abdominal cramping and pain are symptoms of the gastroparesis.

CPT: 78264; this is a gastric emptying study.

5. Ans: B

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371 Feedback: ICD-10-CM: I65.22 is for the occlusion and stenosis of left carotid artery; I71.2 is for thoracic aneurysm without mention of rupture.

PATHOLOGY 1. Ans: D Feedback: ICD-10-CM: C64.2, N03.9. The first listed diagnosis is kidney, left, so your choice is C64.2. If you continue reading the report, you will find additional pathologic findings, chronic glomerulonephritis, which takes you to N03. Then, searching through the codes, you find the only code that fits is N03.9.

CPT: 88307. After searching each category, you will find that this is the category that contains kidney, total.

2. Ans: B Feedback: ICD-10-CM: C16.5. The primary diagnosis is adenocarcinoma, stomach (C16.5). Also listed are history with dyspepsia (K30) and loss of weight (R63.4), but they are symptoms of the adenocarcinoma so they would not be included.

CPT: 88309, 88307. The first specimen is a segment of the stomach, which falls in the 88309 category.

The six lymph node candidates are listed in the gross description and need to be listed with the 88307, since that is the appropriate category for them.

3. Ans: C Feedback: In ICD-10-CM, severe dysplasia would be coded D06.9, carcinoma in situ - cervix.

CPT: 88305 is the category for a cervical biopsy. Even though it states submitted request for stains, you are not given any information regarding the results for the stain or even if it was performed, so you cannot code it.

4. Ans: B Feedback: ICD-10-CM: D04.39, L87.2. By reading the diagnosis carefully, you will find that it states that the malignancy on the cheek is in-situ, which will lead you to the correct diagnosis of D04.39, carcionoma in situ of skin of other parts of the face (right cheek). The hand is diagnosed with dermal elastosis, which is difficult to find exactly within the L87 category, but further reading in the documentation shows hyperkeratosis, which, along with the elastosis, makes L87.2 an appropriate choice.

CPT: 88305 x 2. Both of the specimens are for skin, so 88305 would be the appropriate category. In the guidelines at the beginning of the Surgical Pathology section, you are told that each specimen is counted as one and the code is for gross and micro of one specimen.

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372 5. Ans. C Feedback: ICD-10-CM: K29.50, B96.81. Using the Alphabetic Index, you are sent to K29.5, where there are two options with a 5th digit. Per the documentation, you would choose 0, without bleeding. The stain was positive for H. pylori, which has a correct code of B96.81.

CPT: 88305, 88312. Even though there are two fragments, the guidelines are clear that each unit is listed as a specimen. Here only one specimen (with two fragments) is listed. The final diagnosis lists that a Warthin-Starry stain was positive; therefore, it was performed and needs to be coded.

6. Ans: B Feedback: ICD-10-CM: C18.2. The gross description specifically says the right colon; we know that that is the ascending, so this choice is appropriate.

CPT: 88309. This is straightforward as far as code choice: the colon falls in the 88309 category.

7. Ans: C Feedback: In ICD-10-CM, this is straightforward adenocarcinoma, stomach: C16.5.

CPT: The guidelines state that the unit of service for codes 88300 through 88309 is the specimen. Since two specimens were examined, 88309 would be charged twice.

8. Ans: B Feedback: The organ or disease-oriented panel code 80047 is a basic metabolic panel (calcium ionized) and includes all of the labs ordered by Dr. Steele except for the urinalysis so the panel code (80047) would be reported, not all of the individual tests, along with the automated urinalysis with microscopy (81001) MEDICINE 1. Ans: B Feedback: ICD-10-CM: H27.02 is correct for aphakia, left eye. An accident code would not be used unless this is the first occurrence, but since he is coming for a fitting, someone has already seen him for the original injury.

CPT: 92352. This is for aphakia, and this code is specifically for that; mentioned in the report is the fact that it is monofocal, which rules out the 92353.

2. Ans: B Feedback: ICD-10-CM: N18.6. We are given that it is end stage renal disease, so N18.6 is the correct code choice.

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373 CPT: 90970-G6 x4. The code 90970 is for a patient over 20 years of age that did not receive services for the entire month coded per day. This patient was just in town for a week. The modifier is for a patient with ESRD who is seen less than six sessions in a month. This modifier can be found in the HCPCS manual.

3. Ans: D Feedback: ICD-10-CM: E86.0. All you are given in the description is dehydration, so E86.0 is the appropriate choice.

CPT: 96360, J7042. The infusion was for only 1 hour, which qualifies the 96360 code. The note following 96361 states, ―Report 96361 for hydration infusion intervals of greater than 30 minutes beyond 1 hour increments.‖ Since the hydration only lasted 20 minutes past the hour, you do not code 96361. You also need to code for the dextrose, which is J7042.

4. Ans: B Feedback: ICD-10-CM: I25.110. In the conclusion you are given I25.110, atherosclerotic heart disease of native coronary artery with angina.

CPT: 93458. This code provides the additional specificity to cover the left heart catheterization including intraprocedural injections for left ventriculography, when performed.

5. Ans: B Feedback: ICD-10-CM: I65.21, Z98.890. This is a status post-surgical ([endarterectomy] removal of plaque from an artery), but the impression has the right artery completely occluded so that would be listed first.

CPT: 93880. This is a duplex scan of the extracranial arteries with a bilateral study.

6. Ans: C Feedback: ICD-10-CM: R55, R42. The reason for the Holter Monitor was due to syncope, R55, and dizziness, which is R42.

CPT: 93227. This is a physician review and interpretation of the recording, so the physician’s services would be the only thing coded.

7. Ans: B Feedback: ICD-10-CM: N95.1. This is a straightforward symptomatic menopausal or female climacteric state.

CPT: 97810, 97811. The total face-to-face time with the patient was 30 minutes. The initial code of 97810 is for the initial 15 minutes, and the 97811 is for the additional 15 minutes.

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374 8. Ans: B Feedback: ICD-10-CM: H93.12. The only choice of 5th digit that we have is for which ear, and the documentation specifies left ear.

CPT: 92625. This is for the assessment of tinnitus, which includes the pitch, loudness, matching, and masking; therefore, you would not code separately for 92562. Even though the tinnitus is for the left ear, the documentation specifically states a bilateral tinnitus assessment study.

9. Ans: D Feedback: ICD-10-CM: S13.4xxA. This is a case in which you need to use placeholders to fill in the spots: Whiplash is S13.4, cervical spine; however, you need to state whether this is the initial visit, subsequent visit, or sequela.

CPT: 98940. The guidelines state that the manipulations include the pre-manipulation patient assessment.

10. Ans: B Feedback: ICD-10-CM: I69.920. Aphasia will send you to R47.01 in the Tabular, but the excludes note indicates that aphasia due to late effects of cerebrovascular disease is I69.-20. In the documentation it mentions that the patient already had a stroke assessment; therefore, this is a late effect of that stroke and is coded I69.920.

CPT: 96015 would be the appropriate code. The description of the code in the CPT manual gives the Boston Diagnostic Aphasia Examination as an example.

11. Ans: A Feedback: ICD-10-CM: Z23. The patient is being seen for 2 vaccinations; in the Tabular List, you are given a note that states, ―Procedure codes are required to identify the types of immunizations given.‖ CPT: 90716, 90471, 90713, 90472. The first code is for the subcutaneous injection of the Varicella virus; then you code for the injection (1) vaccine. The next vaccine given is for the subcutaneous Poliovirus; then you code for the administration of the 2nd vaccine.

MEDICAL TERMINOLOGY 1. Ans: A Feedback: Esophagogastroduodenoscopy, or EGD, is the examination of the esophagus, stomach, and duodenum.

2. Ans: D Feedback: The color of jaundiced skin is yellow.

3. Ans: B

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375 Feedback: The coiled tubules on top of the testicles that hold the testicles in place are called epididymis.

4. Ans: C Feedback: The jellylike substance found inside the eye is called the vitreous humor.

5. Ans: D Feedback: A disease caused by overproduction of the growth hormone after puberty is acromegaly.

6. Ans: C Feedback: The rapid discharge of menstrual blood between periods is called metrorrhagia.

7. Ans: A Feedback: Multigravida means many pregnancies. Nulligravida defines those who have never been pregnant, primigravida defines a first pregnancy, and multipara is defined as many births.

8. Ans: D Feedback: Presbycusis is hearing impairment of old age. Hardening of the stapes is called otosclerosis; inflammation of the outer ear is otitis externa; and sense of revolving of the body or the environment is vertigo.

9. Ans: C Feedback: Myringotomy is the incision in the tympanic membrane for draining of pus from the middle ear. A labyrinthectomy would be excision of the labyrinth, stapedectomy is removal of the stapes, and mastoidectomy is removal of the mastoid bone.

10. Ans: A Feedback: Kyphosis is an abnormal bump caused by increased convexity of the thoracic spine (also known as hunchback). Lordosis is an increased concavity of the lumbar spine, scoliosis is an ―S‖ shaped curvature of the thoracic spine, and osteopenia is an abnormal reduction of bone mass.

11. Ans: C Feedback: Myocardium is the specialized striated muscle tissue of the heart.

12. Ans: B

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376 Feedback: Septum is a thin partition or membrane that divides two cavities or soft masses of tissue.

13. Ans: B Feedback: Mediastinum is the region between the pleural sacs containing the heart and all of the thoracic viscera except the lungs.

14. Ans: A Feedback: Dyspnea is difficulty in breathing.

15. Ans: A Feedback: Venae cavae are either of two large veins that drain blood from the upper body and from the lower body and empty into the right atrium of the heart.

16. Ans: A Feedback: Pneumothorax is the accumulation of air or gas in the pleural cavity, occurring as a result of disease or injury, or sometimes induced to collapse the lung in the treatment of tuberculosis and other lung diseases.

17. Ans: C Feedback: In a bronchoscopy, a scope is inserted into the airways to allow for visual examination of the lower airways.

18. Ans: C Feedback: Ultrasonography is an imaging technique that uses high frequency sound waves to visualize internal body structure or a developing fetus.

19. Ans: A Feedback: Metastasis is the spread of a disease from one part of the body to another.

20. Ans: A Feedback: Lobectomy is the removal of a lobe of one of the organs, usually the brain, lung, or liver.

EVALUATION AND MANAGEMENT 1. Ans: D

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377 Feedback: ICD-10-CM: C79.51 is a secondary lesion in the sacrum, and the history of prostate cancer is Z85.46.

CPT: The criteria mentioned in this scenario satisfy the criteria for a level 5 new patient examination.

2. Ans: A Feedback: ICD-10-CM: The correct diagnosis here is allergic contact dermatitis due to the oil from the poison oak plant, so L23.7 would be correct. L24.7 applies to irritant contact dermatitis due to plants, except food. Since the physician determined this to be allergic in nature, the irritant form of dermatitis would not apply.

CPT: The rash is determined to be poison oak, and 99212 would be the appropriate level due to the problem-focused history and exam and straightforward medical decision making.

3. Ans: A Feedback: ICD-10-CM: Z38.00,P22.0, P07.16, P07.32; Newborn, single, born in hospital, vaginal delivery (Outcome of delivery codes are first listed on the newborn record), Hyaline membrane disease; other low birth weight newborn, 1500-1749 grams; preterm newborn, gestational age 29 completed weeks CPT: 99464, 99468. Attendance at delivery, then the neonatal critical care, initial.

4. Ans: B Feedback: 99223 would be the correct initial (admit) code. The codes for subsequent days 2-4 would be 99232 for days 2 and 3 and 99231 for day 4. The discharge code for day 5 would be 99238 to reflect 30 minutes.

5. Ans: C Feedback: ICD-10-CM. The correct diagnosis code for the chronic atrial fibrillation is I48.2. I48.1 is for persistent atrial fibrillation and the documentation stated chronic versus persistent.

CPT: 99244. The documentation met the requirements for a consultation, request, render an opinion, and a report; however Medicare does not recognize consultation codes so an appropriate code would need to be chosen from the new patient office visit range (99201-99205). A comprehensive history and exam were performed and the decision making was of moderate complexity so the appropriate CPT code would be 99204..

6. Ans: A Feedback: ICD-10-CM. B02.9 is the correct code for Zoster (herpes zoster),shingles without complications.

CPT: 99342 would be the correct code since this was a new patient, place of service home. Codes 99203 and 99204 would report a service performed in the outpatient setting. The history and exam are listed as

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378 detailed and the medical decision making as low complexity. Since this is a new patient, all three key components of 99343 must be met, which would be moderate medical decision making, so 99342 would be the correct code.

7. Ans: C Feedback: CPT codes 99291, 99292 x4 would be the appropriate code choices. The physician spent a total of 3 hrs or 180 minutes with the patient. This time does not have to be continuous. The grid in the CPT manual with codes 99291 and 99292 help the coder to report the appropriate code(s).

8. Ans. C Feedback: CPT code 99375 represents care plan oversight services for a patient under care of home health agency for 30 minutes or more and would be the appropriate code for this case. 99380 is for a nursing facility patient.

9. Ans: B The description of modifier 25 is significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional during a postoperative period. Also, the guidelines with the preventive medicine services discuss the use of modifier 25.

10. Ans: A Feedback: 99232, subsequent hospital care, expanded problem-focused history and exam would be correct. 99233 requires a detailed history and exam. 99213 represents an office visit and 99253 is a consultation code.

HCPCS 1. Ans: A Feedback: HCPCS codes are Level II codes. CPT codes are Level I, and Level III no longer exists.

2. Ans. B Feedback: F2 represents left hand, third digit. These modifiers can be found on the inside cover of the CPT manual and in Appendix 2 of the HCPCS manual.

3. Ans. B Feedback: E0297, E0277 are the appropriate codes representing hospital bed total electric without mattress and powered pressure-reducing air mattress. E0296 is total electric but with a mattress while E0295 is semi-electric.

4. Ans: D Feedback: T1027 reflects family training and counseling for child development, per 15 minutes. Since the scenario defines 30 minutes, code T1027 would be reported twice.

5. D

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379 Feedback: GH modifier reports a diagnostic mammogram converted from screening mammogram on same day. GA is the modifier to report waiver of liability statement, and GW is to identify the service is not related to the hospice patient’s terminal illness.

Coding Guidelines/Compliance/Practice Management 1. Ans: D Feedback: Medicare Part B pays for DME (durable medical equipment).

2. Ans: D Feedback: The purpose of the medical record includes source of statistics, compliance with coding and reimbursement, and continuity of care.

3. Ans: D Feedback: The remittance advice is provided directly to the health care provider while the explanation of benefits is provided to the insured patient.

4. Ans: A Feedback: Government programs include Medicaid, Medicare and Tricare.

5. Ans: A Feedback: GA modifier reports a waiver of liability statement and is used to show an ABN is on file. The definitions for modifiers GZ, GY, and GB can be found in Appendix 2 of the HCPCS manual.

6. Ans: A Feedback: The Chapter-Specific Guidelines in the ICD-10-CM Manual instruct the coder that if the encounter is for the administration of chemotherapy, code Z51.11 would be the first-listed code, followed by the code for the primary site of cancer.

7. Ans: C Feedback: Copayment is the patient responsible portion of a set amount per service or encounter.

Coinsurance is the patient responsible portion that is based on a percentage of the allowed amount.

Deductible is a predetermined amount that is deemed the patient’s responsibility before the payer benefits begin.

8. Ans: D Feedback: Medicare provides coverage for individuals over the age of 65, patients with ESRD (end stage renal disease), and persons with disabilities.

9. Ans: B Feedback: There is no time limit associated with coding sequelae (late effects). This can be found in Section 1.B.10 of the ICD-10-CM general coding guidelines.

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380 10. Ans: B Feedback: An ABN (Advanced Beneficiary Notice) is a waiver needed for any service that does not meet the coverage criteria established in an NCD or LCD. PHI is the abbreviation for protected health information. NCD is National Coverage Determination. MUE is medically unlikely edits which are edits that identify limits for units of service for a given service or procedure completed by a single provider per patient per day.

11. Ans: C Feedback: Payment is sent to the beneficiary, not the provider.

12. Ans: D Feedback: Worker’s compensation and automobile and home owner’s insurance are not considered covered entities and thus are exempt from HIPAA rules.

13. Ans: A Feedback: Albuterol is a bronchodilator used to open up airways in the lungs. Estradiol valerate is a medication used in hormone therapy and is taken by mouth or by injection. Phenobarbital is a barbiturate administered orally. Ampicillin is an antibiotic generally administered orally.

14. Ans: D Feedback: Ensuring the proper ICD-10-CM code is chosen, staying within compliance guidelines, and linking medical necessity to the service provided are all important aspects of a coder’s ability to translate provider documentation.

15. Ans: B Feedback: Confirmation does NOT require documentation of the type of test performed. This can be found in Section 1.C.1.f.1 of the ICD-10-CM Chapter-Specific Coding Guidelines.

16. Ans: D Feedback: Sequela (late effect) is used in ICD-10-CM to describe a residual condition that occurs after the initial illness or injury.

17. Ans: B Feedback: Placeholder is the character used to extend codes through the sixth character and is represented by an ―X‖ allowing the seventh character extender to remain in place.

18. Ans: C Feedback: It is NOT appropriate to determine the ICD-10-CM code directly from the Alphabetic Index.

There are often instructional notes in the Tabular List that give further instruction on the appropriate code to choose.

19. Ans: C

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381 Feedback: This shows the medical necessity (abdominal pain) and linkage for the service provided (a KUB).

20. Ans: B Feedback: Non-healing burns are coded as acute burns. Necrosis of burned skin should be coded as a non-healed burn. This can be found in Section 2.19.d.3 of the ICD-10-CM Chapter-Specific Coding Guidelines.

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