2011 CPT Appendix A Updates

Instructor's Guide
AC210610: Basic CPT/HCPCS Exercises
Page 1 of 100
Answer Key Chapter 1

Introduction to Clinical Coding
Exercise 1.1
1. The patient is seen as an outpatient for a bilateral mammogram. CPT Code: 77055-50 Note that the description for code 77055 is for a unilateral (one side) mammogram. 77056 is the correct code for a bilateral mammogram. Use of modifier -50 for bilateral is not appropriate when C ! code descriptions differentiate between unilateral and bilateral. 3. Surgeon performs a c stourethroscop !ith dilation of a urethral stricture. CPT Code: 5"3#1 !he documentation states that it was a urethral stricture" but the C ! code identifies treatment of ureteral stricture. Correct code# 5$$%& 5. The chiropractor documents that he performed osteopathic manipulation on the nec$ and bac$ %lumbar&thoracic'. CPT Code: ()("5 Note in the paragraph before code '%'$5" the bod( regions are identified. !he nec) would be the cer*ical region+ the thoracic and lumbar regions are identified separatel(. !herefore" three bod( regions are identified. Correct code# '%'$6 7. * #5- ear-old patient has a repair of a recurrent+ incarcerated inguinal hernia. CPT Code: #(507 !he documentation supports the selection of the code for ,recurrent- not ,initial.- Correct code# .'5$&
Instructor's Guide
Page 2 of 100
(.
The surgeon performs an e,cision of a 1.5 cm deep intramuscular soft tissue tumor of the scalp. CPT Code: "1011 C ! distinguishes between an ,intramuscular- soft tissue tumor e/cision from subcutaneous. Code $&0&& is for a subcutaneous tumor" which does not match the documentation. Correct code# $&0&0
Instructor's Guide
Page 3 of 100
Chapter 2
Application of the CPT Syste
!atching Exercise
1. --- Complete list of modifiers (1) ". --- Complete list of add-on codes (C) 3. --- )"5"5 Copper (2) #. --- Complete list of recent additions+ deletions and re1isions (3) 5. --- 111(2 /nitial e1aluation for condition (4) *. .. C. *ppendi, . Categor // code *ppendi, 0
0. 3.
*ppendi, * Patholog and 4aborator code
"eferencing CPT Assistant

1. 5efer to note belo! CPT code "(530. /n the Professional 3dition of CPT t!hat!hat does the follo!ing note indicate6 CPT Assistant 2eb (7:3+ *pril 0":13+ 8ar 03:179 CPT Changes, An Insiders View 2003 3nswer# !his note refers the coder to the 5ebruar( &''6 edition of CPT Assistant (page 0)" and 3pril $00$ edition of CPT Assistant (page &0)" 6arch $000 (page &7) and the C ! changes boo) for the (ear $000.for additional information about use of this code. 3ll of these references focus on some aspect of code $'500. 3. /f a ph sician performs an arthroscop !ith :oint debridement in the anterior compartment %CPT code "()#7'+ and through different portals performed an arthroscop complete s no1ectom in the posterior compartment %CPT code "()#5'+ can both procedures be separatel reported during the same operati1e session appending modifier 5(6 3nswer# No. 5rom a C ! coding perspecti*e it would not be appropriate to report both codes if performed within the same wrist during the same operati*e session" regardless of how man( times the arthroscope is inserted into the wrist. 3rthroscop( of all compartments" radioiulnar" radiocarpal and midcarpal" anterior or posterior" are considered inclusi*e components of codes $'%.0-$'%.7. !herefore" it would not be appropriate to report for different compartments (CPT Assistant, 1ecember $000).
Instructor's Guide
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Application of CPT Exercises

1. The ph sician performs a s no1ial biops of the metacarpophalangeal :oint. ;sing the *lphabetic /nde,+ !hat $e !ord%s' lead ou to the coding selection6 <hat is the correct code6 3nswer (se*eral entries in inde/)# 7(no*ium" 4iops(" 6etacarpophalangeal 8oint99.. 4iops(" 6etacarpophalangeal 8oint9999..999 6etacarpophalangeal 8oint" 4iops(" 7(no*ium9...99
$6&05 $6&05 $6&05
Instructor's Guide
Page 5 of 100
3.
*fter an in:ection of 4idocaine+ the surgeon performed a percutaneous tenotom %*chilles tendon'. 5efer to "7705-"7707. <hat is the correct code assignment6 3nswer# :idocaine is a local anesthesia+ therefore" code $7605 is assigned.
5.
5efer to codes 57550-57557. The surgeon performed an e,cision of a cer1ical stump+ 1aginall + !ith repair of an enterocele. <hat is the correct code assignment6 3nswer# 57556. !he description for this code would be# Excision of cervical stump, vaginal approach; with repair of enterocele.
7.
.iops of lacrimal sac ;nde/# 4iops(" lacrimal sac Code# 6%5$5
Instructor's Guide
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Chapter #
!odifiers
!atching Exercise
8atch the follo!ing modifiers !ith the appropriate description. 1. --- 3P (C) ". --- 2# (4) 3. --- 73 (1) #. --- P5 (3) *. .. C. 0. Ph sical status %anesthesia' modifier =CPCS >ational modifier Categor // modifier CPT 8odifier *ppro1ed for =ospital ?utpatient ;se onl CPT 8odifier not *ppro1ed for =ospital ?utpatient ;se
5. --- 53 (2)
3.
Select the !odifier Exercise

1. Patient is seen in the ph sician@s office for his earl ph sical %CPT code ((3(5- Preventive Medicine E/M). 0uring the e,am+ the patient reAuests that the ph sician remo1e a mole on his shoulder. <hat CPT modifier !ould be appended to the ((3(5 to e,plain that the 3&8 ser1ice !as unrelated to e,cision of the mole6 3nswer# 6odifier $5 3. * surgeon performed an esophageal dilation %#3#53' on a #-!ee$-old ne!born !ho !eighed 3.1 $g. <hat CPT modifier !ould be appended to CPT code to describe this special circumstance6 3nswer# 60 rocedure erformed on ;nfants less than . )g 5. * planned arthroscopic meniscectom of $nee !as planned for a patient. 0uring the procedure+ the scope !as inserted but the patient !ent into respirator distress and the procedure !as terminated. <hat CPT modifier !ould be appended to the CPT code %"())0' for the ph sician@s ser1ices6 3nswer# 50 1iscontinued rocedure. !his modifier would be appended to the planned procedure for physician services.
Instructor's Guide
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Coding$!odifier Exercise
Case Study % 1
The surgeon performed a carpal tunnel release %median ner1e' on the left and right !rist. ;nde/# Carpal !unnel s(ndrome Code(s)# 6.7$&-50 (modifier for bilateral)
Instructor's Guide
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Case Study % #
The surgeon performed a tonsillectom and adenoidectom on a "5- ear-old male. 2our hours after lea1ing the surger center+ the patient presents to the clinic !ith a 1-hour histor of bleeding in the throat. The bleeding site !as located9 ho!e1er+ it !as in a location that could not be treated outside the ?5. The patient !as ta$en bac$ to the ?5 for control of postoperati1e bleeding. Code both procedures. ;nde/# !onsillectom( and <emorrhage" !hroat Code(s)# .$%$&# !onsillectom( and adenoidectom(" age &$ (ears or older .$'6$-7% Control orophar(ngeal hemorrhage with secondar( surgical inter*ention (modifier for return to => for a related procedure during the postoperati*e period)
Instructor's Guide
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Chapter &
Surgery Part I
*ns!ers to the e,ercises in this section !ill not appl modifier 51 %multiple procedures' or seAuencing for claims submission. The focus of these e,ercises is to practice accurate assignment of CPT codes !ithout regard to pa er guidelines. The ans!ers !ill include use of lateral modifiers %such as 5T+ 2*' and 8odifier 50 for bilateral. 2or the purposes of instruction+ this boo$ uses a dash to separate each fi1e-character CPT code from its t!o-character modifier. =o!e1er+ dashes are not used in actual code assignments and reimbursement claims.
Integu entary Syste
Exercises
Source: >ational Cancer /nstitute. n.d. Bisuals?nline. 0on .liss+ artist. http:&&1isualsonline.cancer.go1&details.cfm6imageidC#37".
&.1' !edical Ter inology "e(iew

8atch the medical terms !ith the definitions.
1.--".---
biops
(C)
*.
(1)
freeDe tissue remo1al of damaged tissue from !ound
basal cell carcinoma
..
Instructor's Guide
Page 10 of 100
3.---
cr osurger (3)
C.
remo1al of a piece of tissue for e,amination
#.---
debridement
(4)
0. 3.
malignant neoplasm benign neoplasm
5. --- lipoma (2)
&.2' Clinical Concepts

2ill in the blan$s for the follo!ing scenarios. Choose from one of the t!o ans!ers pro1ided in parentheses.
1. 2. 3.
The ph sician uses a laser to remo1e a lesion of the bac$. 2or coding purposes+ this !ould be classified as ------------------- %e,cision or destruction'. The surgeon remo1es a ".0 cm seborrheic $eratosis of the nec$. The lesion !ould be defined as ------------- %benign or malignant'. The ph sician sutured a 3 cm , " cm superficial laceration of the $nee. The !ound reAuired routine remo1al of gra1el and dirt. 2or coding purposes+ this !ould be classified as: ---------------%simple or intermediate repair'.
4. 5.
The s$in graft reAuired har1esting health s$in from the patient@s right thigh to co1er the defect of the arm. This t pe of graft is called: ------------- %autograft+ allograft or ,enograft'. The 3.0 cm lipoma e,tended into the tendon of the shoulder. The code for this procedure !ould be selected from the ------------ chapter %integumentar or musculos)eletal'.
&.#' Integu entary Syste
Coding )rill
2or all coding e,ercises+ re1ie! the documentation and underline $e term%s'. /dentif the terms used to loo$ up the code selection in the *lphabetic /nde,. *ssign CPT codes to the follo!ing cases. /f applicable+ append CPT&=CPCS 4e1el // modifiers. /n some cases+ the student !ill be prompted to ans!er Auestions about the case stud . 1. <ith the use of a E*F laser+ the surgeon remo1ed a ".0 cm Fiant congenital melanoc tic ne1us of the leg. Patholog confirmed that the lesion !as premalignant. ;nde/# :esion" 7)in" 1estruction" remalignant (Note that laser is classified as destruction and the morpholog( of the lesion is premalignant.) Code(s)#
Instructor's Guide
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&7000 3.
1estruction" premalignant+ first lesion
* surgeon reports that the patient has a ".0 cm basal cell carcinoma of the chin. The e,cision reAuired remo1al of 0.5 cm margins around the lesion. ;nde/# :esion" s)in" e/cision" malignant Code(s)# &&6.0 (si?e calculated as $.0 cm @ .5 cm @ .5 cm A e/cised diameter)
5.
?perati1e Procedure: Sha1ing of a 0.5 cm p ogenic granuloma of the nec$ ;nde/# :esion" s)in" sha*ing (Note that p(ogenic granuloma is a benign lesion+ characteri?ed as a red papule.) Code(s)# &&005 7ha*ing of dermal lesion" single
7.
?perati1e >ote: Patient see$ing treatment for a c st of left breast. * "1-gauge needle !as inserted into the c st. The !hite+ c stic fluid !as aspirated and the needle !ithdra!n. Pressure !as applied to the !ound and the site co1ered !ith a bandage. ;nde/# 4reast" C(st" uncture 3spiration Code(s)# &'000-:! uncture aspiration of c(st of breast
(.
Patient has a diagnosis of a decubitus ulcer of the leg. The surgeon debrided the necrotic tissue %10 sA. cm' that e,tended do!n to and included part of the muscle. ;nde/# 1ebridement" 7)in" 7ubcutaneous tissue (No direct inde/ lin)" must search the range of codes.) Code(s)# &&0.0 1ebridement s)in" subcutaneous tissue" and muscle
Instructor's Guide
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&.&' Case Studies * Integu entary Syste and E ergency )epart ent "eports
1. +perati(e ,ote
+perati(e
This 5(- ear-old male de1eloped a sebaceous c st on his right upper bac$. *fter ensuring a comfortable position+ the s$in surrounding the c st !as infiltrated !ith G H I locaine !ith epinephrine to achie1e local anesthesia. *n elliptical incision surrounding the c st !as made9 total e,cised diameter of 5.0 cm. The c st !all !as dissected free from the surrounding tissues. =emostasis !as obtained and the !ound !as copiousl irrigated. The !ound !as closed !ith 3-0 Bicr l+ figure-of-eight stitches.
Abstract from Documentation:

<hat t pe of lesion !as remo1ed6 6ust determine whether the lesion is benign or malignant. 3 sebaceous c(st is considered to be a benign lesion (Upper bac) is listed as trun) in C !.) =o! !as it remo1ed6 2/cised <hat is the e,cised diameter of the lesion6 7i?e of lesionA 5.0 cm 0id the ph sician close the !ound routinel or !as there a la ered closure6 Note# >outine wound closure (included in C ! code)" no mention of la(ered closure.
Time to Code:
;nde/# :esion" 7)in" 2/cision" 4enign (&&.00-&&.7&) Code(s)# &&.06 (2/cision" benign lesion" trun)" e/cised diameter o*er ..0) 3. E ergency )epart ent "ecord
Instructor's Guide
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Chief Complaint:
Scalp laceration hitting her head and sustaining a laceration of her right scalp. >o loss of consciousness. >o s ncope. >o nec$ pain. >o 1omiting. She has been acting normall according to her daughter since the in:ur .
=istor of Present /llness: Patient is an ))- ear-old !hite female !ho lost her balance and fell in her room toda +
Post 8edical =istor : 8edications: *llergies: /mmuniDations: h(sical 2/amination#
= pertension9 dementia Colace+ iron+ h drochlorothiaDide+ Pa,il >one. >ot up to date.
Feneral: *lert female in no acute distress. =ead+ 3ars+ 3 es+ >ose and Throat: There is a 3.5 cm full s$in thic$ness scalp laceration. 8inimal s!elling. >o deformit . Pupils are eAual and reacti1e to light. 3,traocular muscles intact. T mpanic membranes normal. ?rophar n, negati1e. >ec$: Supple. >ontender =eart: 5egular. >o murmurs or gallops noted. 4ungs: .reath sounds eAual bilaterall and clear. 3,tremities: *traumatic. 2ull range of motion. >eurological: *!a$e+ alert and oriented to person. >ot to place or time. >o focal motor. 8o1es all e,tremities s mmetricall . 0eep tendon refle,es 1J. Procedure: *nesthesia local in:ection 3 cc lidocaine !ith epinephrine. Prepped. 3,plored. >o foreign bod noted. Closed in a single la er !ith interrupted staples. Pol sporin. ?intment !as placed. 0iagnosis: 3.5 cm simple scalp laceration. 0isposition and Plan: <ound care instructions9 head in:ur instructions9 staples out in 10-1" da s.

<hat !as the treatment for the laceration6 Closed with staples. <hat $e pieces of documentation are needed to code this case6 !(pe of wound repair (simple)" si?e (0.5 cm)" and location (scalp).
Instructor's Guide
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Time to Code:
;nde/# Bound" >epair" 7imple Code(s)# &$00$ 7imple repair of superficial wounds of scalp" 0.5 cm
!usculos-eletal Syste
Exercises
Source: >ational Cancer /nstitute. n.d. Bisuals?nline. ;n$no!n photographer&artist. http:&&1isualsonline.cancer.go1&details.cfm6imageidC1777.
Instructor's Guide
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&..' Crossword Pu//le

2ill in the blan$s to the follo!ing scenarios. Choose from one of the t!o ans!ers pro1ided in parentheses.
1. 2. 3. 4.
The 5adiolog 5eport re1ealed that the fracture !as not aligned correctl during the healing process. This fracture !ould be referred to as --------------- %nonunion or malunion'. *t bedside+ the 3mergenc 0epartment ph sician realigned the fracture. The manipulation is $no!n as ----------------- %closed+ open'. The patient has ad1anced arthritis of the elbo! :oint. The ph sician performs a fusion of the :oint to pro1ide stabilit . This procedure is referred to as ------------- %arthrodesis+ tenol sis'. 0uring the procedure+ the surgeon encountered numerous restricti1e bands of scar tissue. 2or this condition+ ou !ould e,pect to see --------------- documented in the health record %l(sis of adhesions+ s no1ectom '.
5.
8edial malleolus is located in the ------------ %$nee+ an)le'.
Instructor's Guide
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Instructor's Guide
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&.1' !usculos-eletal Syste
Coding )rill
5e1ie! the documentation and underline $e term%s'. /dentif the terms used to loo$ up the code selection in the *lphabetic /nde,. *ssign CPT codes to the follo!ing cases. /f applicable+ append CPT modifiers. 1. The surgeon performed a closed reduction of a scapular fracture. ;nde/# 5racture" scapula" closed treatment" with manipulation Code(s)# $0575 Closed treatment of scapular fracture with manipulation (Note that the reduction indicates that manipulation was performed.) 3. The patient had been diagnosed !ith an infected abscess e,tending belo! the fascia of the $nee. The surgeon performed an incision and drainage of the abscess. ;nde/# ;ncision and 1rainage" )nee Code(s)# $700& ;ncision and drainage" deep abscess" bursa or hematoma )nee region (1eep abscess supported b( documentation of below the fascia) 5. The surgeon performed a percutaneous tenotom of the left hand+ second digit and third digit. ;nde/# !enotom(" finger Code(s)# $6060-5& and $6060-5$ 7. * patient is diagnosed !ith osteochondroma of the scapula. The surgeon e,cises the tumor. ;nde/# !umor" 7capula" 2/cision (=steochondroma is benign) Code(s)# $0&.0 2/cision or curettage of bone c(st or benign tumor of cla*icle or scapula
Instructor's Guide
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(.
Patient treated for posttraumatic osteoarthritis of right $nee. The surgeon performed a total $nee arthroplast . *ll components !ere remo1ed and surfaces !ere irrigated. The components !ere cemented into place beginning !ith a femoral component and follo!ed b the tibial component and then the patellar component. ;nde/# >eplacement" Cnee Code(s)# $7..7->! 3rthroplast(" )nee
&.2' Case Studies * !usculos-eletal Syste and E ergency )epart ent "eports
1. E ergency )epart ent "eport Chief Complaint: 4eft !rist in:ur
+perati(e
=istor of Present /llness: The patient is a 5- ear-old female that presents in the 30 after accidentall falling off her bic cle. She tried to brace her fall !ith her left !rist and no! sa s there is pain that increases !ith mo1ement. She had no other in:uries. There !ere no head in:uries. Bital Signs: .lood pressure 117&7"+ temperature (7.)+ pulse 107+ respirations "0. Feneral: The patient is alert+ oriented , 3 in no acute distress seated in the hospital bed. 3,tremities: Ph sical e,am of the left upper e,tremit re1eals no deformit . To palpation the patient has tenderness of the distal radius and ulna. >o tenderness to palpation of the hand. 5ange of motion is limited in the !rist but intact in the hand and elbo! !ith no tenderness in the elbo!. 3mergenc 0epartment Course: I-ra of the left !rist re1ealed a .uc$le fracture of the distal radius and ulna. Bolar splint and sling !ere applied. The patient !as discharged. *ssessment: .uc$le fracture left distal radius and ulna Plan: /ce and ele1ate+ return if !orse+ follo!-up !ith orthopedics in "-3 da s+ T lenol !ith codeine eli,ir p.r.n. for pain !as prescribed.
Instructor's Guide
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<hat !as the treatment for the fracture6 3pplied *olar splint
Time to Code:
;nde/# 7plint" arm" short Code(s)# $'&$5-:! 3pplication of short arm splint (forearm to hand) static (Note# 7tatic is used for immobili?ing of the inDur(+ d(namic allows for mobili?ation.)
Instructor's Guide
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3. +perati(e "eport Preoperati1e 0iagnosis: Postoperati1e 0iagnosis: Procedure: 8echanical complication from internal 0.07" K !ire+ first metatarsal+ right foot Same 5emo1al of K !ire+ right foot
The patient !as brought to the operating room and placed on the table in supine position under the influence of /B sedation. 4ocal anesthesia !as administered. The right foot !as prepped and draped in the usual sterile fashion. The right foot !as e,sanguinated !ith an 3smarch bandage and his an$le tourniAuet !as inflated. * 1 cm dorsal medial s$in incision !as made directl o1er the palpable head of the pin. The incision !as deepened bluntl + ta$ing care to preser1e and retract neuro1ascular structures. The periosteum !as sharpl incised from the underl ing pin+ and the pin !as remo1ed !ith a large straight hemostat. The !ound !as flushed !ith copious amounts of sterile normal saline. The s$in !as reappro,imated !ith a 5-0 Bicr l in a subcuticular fashion. The site !as dressed !ith Ieroform gauDe and a dr sterile compression dressing. # cc of 0.5H 8arcaine !as in:ected for postoperati1e anesthesia.

<hat is a K !ire6 in fi/ation to hold bone fragments together <hat procedure !as performed for this patient6 >emo*al of pin
Time to Code:
;nde/# >emo*al" fi/ation de*ice Code(s)# $06%0->! >emo*al of implant+ deep (buried pin) 5. +perati(e "eport Preoperati1e 0iagnosis: Postoperati1e 0iagnosis: Procedure: 4eft middle trigger finger 4eft middle trigger finger Tenol sis
Instructor's Guide
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;nder satisfactor /B bloc$ anesthesia+ the patient !as prepped and draped in the usual fashion. * trans1erse incision !as made parallel to the distal palmar crease o1erl ing the middle finger and the !ound !as then deepened b sharp dissection and blunt dissection being 1er careful to preser1e all blood 1essels intact and not to disturb the neuro1ascular bundle. The fle,or tendon sheath !as identified and di1ided longitudinall for a distance of appro,imatel 1&5 cm. There !as no bo! stringing of the fle,or tendon follo!ing this+ and there !as good gliding motion of the fle,or tendon passi1el !ithout an obstruction. The patient then had closure of the subcutaneous tissue !ith one interrupted #-0 plain catgut suture+ and the s$in !as closed !ith 3 interrupted #-0 n lon 1ertical mattress sutures. .etadine ointment and dr sterile dressing !ere applied. .ul$ hand dressing !as applied. The patient+ ha1ing tolerated the procedure !ell+ had the tourniAuet released !ithout an unto!ard effects and !as returned to the ambulator unit in satisfactor condition.

<hat is a trigger finger6 3 trigger finger occurs when the motion of the tendon that opens and closes the finger is limited" causing the finger to loc) or catch as the finger is e/tended. <hat !as performed to correct the condition6 5le/or tendon sheath was di*ided (incision into tendon sheath)
Time to Code:
;nde/# !rigger finger repair Code(s)# $6055-5$ !endon sheath incision
Instructor's Guide
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"espiratory Syste
Exercises
&.3' !edical Ter inology "e(iew

8atch the follo!ing terms !ith the correct definition. 1.--".--3.--#.--5.--lar n, (2) *. .. C. 0. 3. ma:or air passages of lungs connects mouth to esophagus structure leads from throat to stomach a bone in the nose 1oicebo,
esophagus (C) bronchus (3) phar n, (4) ethmoid (1)

1.
* patient is suspected of a lesion on the 1ocal cord. The ph sician !ould most li$el perform a ------------- for further diagnosis and&or treatment %lar(ngoscop(+ bronchoscop '.
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2. 3. 4. 5.
The patient is e,periencing sinus bloc$ages in the area bet!een the e e soc$ets. These sinuses are called --------------- %frontal+ ethmoid'. The patient has pleural fluid that must be remo1ed. The ph sician !ould most li$el perform a ---------- to remo1e the fluid %pneumocentesis+ pneumonectom '. * piece of cand is lodged in the bac$ of the patient@s throat. The ph sician !ould ma$e the diagnosis of foreign bod in the --------------- %phar(n/+ trachea'. * patient is seen in the 3mergenc 0epartment for epista,is and the ph sician performs cauter . The purpose of this procedure is to ------------------------ %remo1e the nasal bloc$age+ control nasal hemorrhage'.
&.11'
"espiratory Syste
Coding )rill
5e1ie! the documentation and underline $e term%s'. /dentif the terms used to loo$ up the code selection in the *lphabetic /nde,. *ssign CPT codes to the follo!ing cases. /f applicable+ assign CPT&=CPCS 4e1el // modifiers. 1. The surgeon performed a thoracoscop for a !edge resection of the lung. ;nde/# !horacoscop(" 7urgical" with Bedge >esection of the lung Code(s)# 0$657 !horacoscop(" surgical+ with wedge resection of lung" single or multiple 3. * patient seen in the 3mergenc 0epartment for epista,is. Ph sician performs an anterior pac$ing of left nasal passage. ;nde/# 2pista/is Code(s)# 00'0&-:! Control nasal hemorrhage" anterior" simple 5. * patient is seen !ith difficult breathing due to de1iated nasal septum. The surgeon performs a submucous resection of the septum. ;nde/# Nasal 7eptum" 7ubmucous >esection (resection directs coder to see Nasal 7eptum'
Instructor's Guide
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Code(s)# 005$0 7eptoplast( or submucous resection 7. * patient !as diagnosed !ith sAuamous cell carcinoma of the lar n,. The surgeon performed a supraglottic lar ngectom !ith radical nec$ dissection to remo1e the metastasis to the l mph nodes. ;nde/# :ar(ngectom( (7upraglottic procedure preser*es part of the *oice bo/) Code(s)# 0&06% :ar(ngectom(+ subtotal supraglottic" with radical nec) dissection (. <ith the use of an operating microscope+ the surgeon performs a direct lar ngoscop for remo1al of a piece of a toothpic$. ;nde/# :ar(ngoscop(" direct (>ange of codes) Code(s)# 0&50& :ar(ngoscop(" direct with foreign bod( remo*al with operating microscope
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&.12' Case Studies * "espiratory Syste "eports

1. +perati(e "eport Preoperati1e 0iagnosis: Postoperati1e 0iagnosis: Procedure: Chronic lar ngitis !ith pol poid disease Same
+perati(e
0irect lar ngoscop and remo1al of pol ps from both cords
Procedure 0etail: *fter adeAuate premedication+ the patient !as ta$en to the operating room and placed in supine position. The La$o lar ngoscope !as inserted. There !ere noted to be large pol ps on both 1ocal cords+ essentiall obstructing the glottic air!a . ;sing the straight-cup forceps+ the pol ps !ere remo1ed from the left cord first. The !ere remo1ed up to the anterior third+ but the anterior tip !as not remo1ed on the left side. The pol ps !ere remo1ed from the right cord up to the anterior commissure. There !as minimal bleeding noted. The patient !as e,tubated and sent to reco1er in good condition.

<hat t pe of endoscop !as performed6 :ar(ngoscop(-direct <hat procedure !as performed during the endoscop 6 >emo*al of pol(ps
Time to Code:
;nde/# :ar(ngoscop(" direct Code(s)# 0&5.0 :ar(ngoscop(" direct" e/cision of tumor (Note that pol(ps are recogni?ed as tumors in this section.) 3. +perati(e "eport Preoperati1e 0iagnosis: .ilateral true 1ocal cord lesions
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Postoperati1e 0iagnosis: ?peration:
.ilateral true 1ocal cord intracordal c st 8icrolar ngoscop and biops
/ndications: This is a 5)- ear-old man !ith a histor of tobacco use !ho has had a hoarse 1oice for the past couple of ears. The patient also has an alcohol histor . Considering his ris$ factors and hoarseness+ the patient agreed to undergo the surgical procedure to not onl better define the lesion but also the nature of the lesion b getting biopsies for patholog . ?perati1e 2indings: .ilateral intracordal mucoid c sts !ithout an e1idence of ulcerations or other mass lesions of the 1ocal cords. 0etails of Procedure: Patient !as brought to the operating room and laid supine on the operating table. *fter adeAuate anesthesia+ a dedo lar ngoscope !as used to sur1e the supraglottic area. ?nce other abnormalities !ere ruled out+ attention !as then directed to the true 1ocal cords. The patient !as then suspended using the dedo lar ngoscope and the operating microscope !as then brought into the field. ;nder binocular microscop the nature of the lesions !as better assessed. /t appeared that the 1ocal cords themsel1es !ere smooth and 1er soft to palpation. * .oucher retractor !as then used to grasp the right true 1ocal cord and a sic$le $nife !as then used to ma$e an incision laterall . 4eft-going scissors !ere then used to create a submucosal flap. The mucoid mass !as then e,truded and grasped !ith the non-traumatic graspers and the scissors !ere then used to dissect the full e,tent of the mass. The suction !as then used to 1erif the operati1e site on the right true 1ocal cord+ and once adeAuate resection !as achie1ed+ the mucosal flap !as then placed bac$ onto normal position. *ttention !as then gi1en to!ards the left intracordal c st+ !hich !as not as prominent as the right. *gain using left nontraumatic graspers the left true 1ocal cord !as grasped and medialiDed !ith enough tension so that the sic$le $nife could be used to ma$e an incision laterall . * submucosal flap !as then de1eloped using the suction tip and the mucosal c st !as then identified and carefull e,cised from the tissues of the true 1ocal cord+ careful not to 1iolate the ligaments or get into the 1ocals muscle. *t this point+ once adeAuate e,cision !as obtained+ the mucosal flap !as then replaced. *t this time+ *frin-soa$ed pledgets !ere then used to create adeAuate hemostasis. The *frin-soa$ed pledgets !ere then remo1ed at the conclusion of the operation. The operating microscope !as then ta$en out the field. The patient !as then ta$en out of suspension and his care !as then handed o1er to the anesthesiologist.

<hat t pe of endoscop !as performed6 :ar(ngoscop( <hat !as performed during the endoscopic procedure6 2/cision of mucoid mass and e/cision of c(st (5or coding purpose" these are referred to as ,tumors-Egeneric term for growths.)
Time to Code:
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;nde/# :ar(ngoscop(" =perati*e Code(s)# 0&5.& :ar(ngoscop(" direct" operati*e with operating microscope (=nl( coded once e*en though more than one c(st was remo*ed. Note the ph(sician used an operating microscope.)
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Cardio(ascular Syste
Exercises
&.1#' !edical Ter inology "e(iew

8atch the follo!ing terms !ith the correct definition. 1. --". --3. --#. --5. --fistula graft (1) stenosis (2) thrombus (4) ligation (3) (C) *. .. C. 0. 3. surgicall closing off a 1essel blood clot surgicall made passage piece of tissue that is transplanted surgicall narro!ing of a passage
&.1& Clinical Concepts

1. 2. 3. 4.
* central 1enous access de1ice that is inserted in the subcla1ian 1ein !ould be classified as ------------ %centrall( inserted+ peripherall inserted'. 5emo1al of a blood clot from a 1ein is called a%n' -------------- %atherectom + thrombectom('. * direct arterio1enous %*B' anastomosis connects the radial arter to the ----------------%cephalic *ein+ inferior 1ena ca1a'. Through a small incision in the leg+ the surgeon inserts a catheter into the femoral arter . The balloon is inflated to open the arter for impro1ed blood flo!. This procedure is referred to as -----------%open transluminal balloon angioplast + percutaneous transluminal balloon angioplast('.
5.
Central 1enous access de1ices are often used on patients !ho reAuire ---------------- %angioplast + chemotherap('.
&.1.' Cardio(ascular Syste
Coding )rill
5e1ie! the documentation and underline $e term%s'. /dentif the terms used to loo$ up the code selection in the *lphabetic /nde,. *ssign CPT codes to the follo!ing cases. /f applicable+ append CPT&=CPCS 4e1el // modifiers.
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1.
* surgeon performed a Auadruple coronar arter b pass using a saphenous 1ein. ;nde/# Coronar( arter( b(pass (range of codes) Code(s)# 005&0 Coronar( arter( b(pass" *ein onl(+ four coronar( *enous grafts
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3.
?perati1e >ote: 0iagnosis: Thrombosis of right *B %Fore-Te,' graft
Procedure: * trans1erse incision !as made in order to complete a thrombectom of the graft. .ecause the balloon catheter could not be passed+ it !as elected to perform an arteriotom for remo1al of the thrombus. The area !as irrigated and the incision !as closed. ;nde/# !hrombectom(" 3rterio*enous 5istula" Fraft leads to a percutaneous thrombectom( code. !his is an open approach since the arteriotom( was performed. 7ee in inde/# !hrombectom(" 1ial(sis Fraft" without >e*ision. !; # 6an( e/perienced coders rel( mainl( on the ;nde/ to pro*ide the range of codes and do not focus on locating the e/act inde/ entr(. Code(s)# 06%0& !hrombectom(" open" arterio*enous fistula without re*ision 5. * surgeon performs a percutaneous transluminal angioplast on the femoral-popliteal arter for a patient !ith peripheral arter disease. ;nde/# 3ngioplast(" opliteal 3rter(" ;ntraoperati*e (Note that femoral arter( leads to same code) ercutaneous !ransluminal 3ngioplast(" 3rter(" 5emoral- opliteal Code(s)# 07$$.05.7. !ransluminal balloon angioplast(" percutaneousEfemoral-popliteal>e*asculari?ation" endo*ascular" open or percutaneous" femoralGpopliteal arter((s)" unilateral+ with transluminal angioplalst( 7. <ith an incision into the arm+ the surgeon repaired a ruptured false aneur sm of a,illar -brachial arter . ;nde/# 3neur(sm >epair" 4rachial 3rter( Code(s)# 050&0 1irect repair of aneur(sm for ruptured aneur(sm" a/illar(-brachial arter(" b( arm incision
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(.
Percutaneous transcatheter placement of stent in femoral arter ;nde/# !ranscatheter" lacement" ;ntra*ascular 7tents Code(s)# 07$05 !ranscatheter placement of an intra*ascular stent" percutaneous" initial *essel
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4.16: Case Studies - Cardiovascular System Operative Reports

1. +perati(e ,ote Procedure: Permanent pacema$er implantation. 0etails of Procedure: The patient !as prepped and draped in the usual sterile fashion. The left subcla1ian 1ein !as accessed and the guide!ire !as placed in position. * deep subcutaneous pacema$er poc$et !as created using the blunt dissection techniAue. * 2rench 7 introducer sheath !as ad1anced o1er the guide!ire and the guide!ire !as remo1ed. * bipolar endocardial lead model !as ad1anced under fluoroscopic guidance and tip of pacema$er lead !as positioned in the right 1entricular ape,. >e,t+ the 2rench-(.5 introducer sheath !as ad1anced o1er a separate guide!ire under fluoroscopic guidance and the guide!ire !as remo1ed. Through this sheath+ a bipolar atrial scre!-in lead !as positioned in the right atrial appendage and the lead !as scre!ed in.

<hat is the coding selection for a permanent pacema$er6 >e*iew of the inde/ re*eals the selection as 00$06-00$07. <hat documentation determines the correct code selection6 ;f insertion is in the atrium" *entricle" or both. ;n this case it is both.
Time to Code:
;nde/# ;nsertion" acema)er <eart Code(s)# 00$0% ;nsertion" atrial and *entricular 3. +perati(e "eport
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Preoperati1e 0iagnosis: Postoperati1e 0iagnosis: Procedure:
Status post Port-a-Cath Same 5emo1al of Port-a-Cath
/ndications: The patient has completed the chemotherap treatment and elects to remo1e the Port-a-Cath. Procedure: The patient !as placed in supine position. 5ight subcla1ian area !as prepped and adeAuatel draped. 4ocal anesthesia !as gi1en :ust o1er the port+ and trans1erse incision !as made. S$in incision !as deepened do!n to port area. 2ibrinous capsule !as e,posed and retracted and sharpl dissected to remo1e the soft tissue. 3ntire fibrinous capsule !as e,cised and then the tunnel !as clamped and tied off the fibrinous capsule+ after the entire s stem !as remo1ed. The area !as irrigated. =emostasis !as assured. Subcutaneous la er !as closed using #-0. S$in !as appro,imated using 5-0 Bicr l running stitches. Steri-strips applied. Patient tolerated the procedure !ell.

5e1ie! CPT >otes preceding the coding section for central 1enous access procedures. <hat is a Port-a-Cath6 Henous access de*ice <hat !as the operati1e actionI !he port was remo*ed.
Time to Code:
;nde/# >emo*al" Henous 3ccess 1e*ice Code(s)# 065'0 >emo*al of tunneled central *enous access de*ice with subcutaneous port
)igesti(e Syste
Exercises
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&.11' Crossword Pu//le

1.
The scope !as introduced through the mouth and ad1anced to the second portion of the duodenum. Cannulation of the common bile duct !as accomplished. The common bile duct and intrahepatics !ere normal. This operati1e note describes an ------------ %3F0+ 2>C '.
2. 3. 4.
The scope !as inserted through the anus and ad1anced to the cecum. This procedure is described as a ---------------- %colonoscop(+ sigmoidoscop '. The ph sician remo1ed part of the intestine+ !hich reAuired surgical connection of the t!o ends. This procedure is called a%n' ----------------- %anastomosis+ fistulotom '. The patient presents !ith a !ea$ened area that has de1eloped in the scarred muscle tissue around a prior abdominal surgical incision. This condition describes an ------------ hernia %incisional+ inguinal'.
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5.
The patient presents !ith adhesions in the intestines. The ph sician performs a%n' ------------ to correct the condition %enteroenterostom + enterol(sis'.
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&.13' )igesti(e Syste
Coding )rill
5e1ie! the documentation and underline $e term%s'. /dentif the terms used to loo$ up the code selection in the *lphabetic /nde,. *ssign CPT codes to the follo!ing cases. /f applicable+ append CPT&=CPCS 4e1el // modifiers. 1. ?perati1e >ote: The patient is morbidl obese !ith a .8/ of 37. Procedure performed: 4aparoscopic insertion of gastric band. ;nde/# :aparoscop(" Fastric >estricti*e rocedures Code(s)# .0770 :aparoscop(" placement of adDustable gastric restricti*e de*ice 3. The surgeon performed an esophagoscop for remo1al of a pol p 1ia snare. ;nde/# 2sophagus" 2ndoscop(" >emo*al" ol(p Code(s)# .0$&7 2sophagoscop( with remo*al of pol(p b( snare techniJue 5. The patient suffered a perforation of the phar n, !all from a bottle cap. The surgeon performed a suture repair of the !ound. ;nde/# !hroat" 7uture" Bound (No direct inde/ entr( under har(n/.) Code%s': .$'00 7uture phar(n/ for wound or inDur( 7. The surgeon performed a laparoscopic repair of paraesophageal hernia !ith implantation of mesh. ;nde/# :aparoscop(" <ernia >epair" araesophageal Code(s)# .0$%$ :aparoscop(" repair of paraesophageal hernia with implantation of mesh (. * patient is diagnosed !ith papillomas of the anus. ;sing cr osurger + the surgeon remo1es the three papillomas.
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;nde/# :esion" 3nal" 1estruction Code(s)# .6'&6 1estruction of lesions" anus" cr(osurger(
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&.24' Case Studies * )igesti(e Syste E ergency )epart ent "eports

1. +perati(e "eport
+perati(e and
Preoperati1e 0iagnosis: ?peration: *nesthesia: tube placement.
/nadeAuate p.o. inta$e. Percutaneous endoscopic gastrostom tube placement. /B sedation.
Postoperati1e 0iagnosis: Same
Clinical =istor : The patient is a 75- ear-old female patient !ith inadeAuate p.o. inta$e !ho presents no! for P3F
?perati1e Procedure: *fter establishment of an adeAuate le1el of /B sedation and 1iscous spra of the orophar n,+ 3F0 scope !as inserted !ithout difficult to the second portion of the duodenum from !hence it !as graduall !ithdra!n. There !ere no stri$ing duodenal findings. The p lorus appeared unremar$able and on 1isualiDation+ the antrum+ bod + and fundus of the stomach !ere also unremar$able. <ith !ithdra!al of the scope+ the esophagus and F3 :unction 1isualiDed normal. /nsufflation of the stomach !as underta$en and at point of ma,imal transillumination in the epigastrium+ local infiltration !as underta$en b 0r. Lune and a slit incision !as made. >eedle !ithin a cannula !as then threaded percutaneousl directl into the stomach under 1isualiDation. /nner cannula !as remo1ed and guide!ire !as passed. 4oop forceps !ere then passed endoscopicall and guide!ire !as grasped in the stomach and brought out orall + !hence it !as anchored to a P3F tube !hich !as pulled to emanate 1ia the anterior abdominal !all being anchored to appropriate position. The patient tolerated the procedure !ell. There !ere no complications.

<hat is a P3F tube6 =ften called a ,feeding tube"- it is a tube inserted in the stomach for recei*ing nutrition. =o! !as the P3F tube inserted6 2ndoscopicall( (2F1)
Time to Code:
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;nde/# Fastrostom( !ube" 1irected lacement" 2ndoscopies Code(s)# .0$.6 2F1 with directed placement of percutaneous gastrostom( tube
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3. E ergency )epart ent "ecord Chief Complaint: 2oreign bod in throat =istor of Present /llness: This is a 73- ear-old male !ho has a histor of esophageal stricture+ !ho has had multiple endoscopies to ha1e foreign bodies remo1ed. =e !as eating roast beef last night and it stuc$ in his throat. =e sa s an thing he tries to eat or drin$ comes right bac$ up. =e called 0r. 8arcus earl this morning and stated that he !ould meet him in the emergenc room. Patient denies an chest pain+ fe1er+ chills+ and shortness of breath or other s stemic complaints. 0r. 8arcus performed an esophagoscop and remo1ed se1eral pieces of meat as !ell as a pea. The patient did recei1e conscious sedation for the procedure. <e !atched him in the emergenc room on his reco1er . /mpressions: 8eat impaction in esophagus.

<hat t pe of endoscop !as performed6 2sophagoscop( <hat procedure !as performed during the endoscop 6 >emo*al of foreign bod(
Time to Code:
;nde/: 2ndoscop(" 2sophagus" >emo*al" 5oreign 4od( Code(s): .0$&5 2sophagoscop( with remo*al of foreign bod( 5. +perati(e "eport Preoperati1e 0iagnosis: Thrombosed hemorrhoids
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/ndications: This "5- ear-old female+ one !ee$ postpartum+ complains of e,tremel painful hemorrhoids. 3,amination re1ealed circumferential prolapsed hemorrhoids !ith partial thrombosis in multiple areas. Procedure: *fter induction of general anesthesia+ she !as prepped and draped in the usual sterile fashion. The patient !as placed in lithotom position and a retractor !as placed in the anus. Ber prominent+ large+ partiall thrombosed e,ternal hemorrhoid !as identified at 7-) oMcloc$ in the lithotom position. /t !as grasped !ith a hemorrhoidal clamp. * "-0 chromic stitch !as placed at the ape,. The .o1ie electrocauter !as then used to ellipticall e,cise the large hemorrhoid+ sta ing superficial to the sphincter muscle. .leeding !as controlled !ith .o1ie electrocauter . The mucosa !as closed !ith a running chromic stitch+ lea1ing the end-point epidermis open. T!o other 1er large e,ternal hemorrhoids !ith thrombosis !ere then identified+ at the 5 oMcloc$ position in lithotom and at the 10-11 oMcloc$ position. These t!o hemorrhoids !ere e,cised in the e,act same fashion as the first hemorrhoid. *t the conclusion+ there !as no e1idence of bleeding. The patient !as returned to the reco1er area in good condition.

<hat method !as used to remo1e the hemorrhoids6 2/cision <here the hemorrhoids internal or e,ternal6 2/ternal =o! man columns or groups !ere documented6 0
Time to Code:
/nde,: <emorrhoid" 2/cision Code%s': .6$50 <emorrhoidectom(" e/ternal" $ or more columnsGgroups 7. +perati(e "eport Preoperati1e 0iagnosis: Procedures Performed: 5ight colon cancer9 probable li1er metastasis 5ight colectom and biops of right lobe li1er nodule
Postoperati1e 0iagnosis: Cecal cancer+ e,tensi1e bilateral li1er metastasis
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/ndications: Patient is a 77- ear-old man !ho presented !ith anemia. Colonoscop demonstrated bleeding cecal carcinoma. CT scan suggested li1er metastasis. =e presents no! for a palliati1e right colectom and biops of li1er nodule. 0escription: The patient !as brought to the operating room and placed in a supine position. Satisfactor general endotracheal anesthesia !as achie1ed. =e !as prepped and draped e,posing the anterior abdomen and a lo!er midline incision !as created sharpl through subcutaneous tissues b electrocauter . 4inea *lba !as parted and e,ploration !as performed. The right colon !as mobiliDed b dissection in the a1ascular plane. The patient had a three to four centimeter cecal cancer. The right ureter !as identified and preser1ed. The terminal ileum and distal ascending colon !ere di1ided !ith F/*-70 stapling de1ices. The right colic arter and l mph node tissue !ere resected bac$ to the origin of the superior mesenteric arter !ith clamps and 3-0 sil$ ties. The specimen !as for!arded to patholog . * stapled functional end-to-end anastomosis !as then performed. The antimesenteric edges !ere reappro,imated !ith a single fire of F/*-70 stapler. The defect created b the stapler !as then closed !ith interrupted 3-0 sil$ 4embert sutures. The mesocolon !as reappro,imated !ith some interrupted 3-0 sil$ sutures. =emostasis !as confirmed. The right anterior li1er nodule !as biopsied !ith a Tru-Cut needle. =emostasis !as achie1ed. The midline fascia !as closed !ith running 1-0 Prolene suture. The s$in !as appro,imated !ith staples. The !ound !as dressed. The procedure !as concluded. The patient tolerated the procedure !ell and !as ta$en to reco1er in stable condition. 3stimated blood loss !as less than 100 cc. There !ere no complications. atholog( >eport# N1-5ight =emicolectom : *denocarcinoma of cecum N"-4i1er .iopsies: 8etastatic adenocarcinoma

4ocate the code selection for colectom . <hat additional information is needed from the operati1e report to assign a correct code6 artial or !otal and additional procedures /n the inde,+ !hat code selection is pro1ided for the li1er biops 6 .7000" .700&" .7&00 <hat differentiates bet!een these codes6 ercutaneous" performed at time of maDor procedure" and if wedge biops( was performed.
Time to Code:
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;nde/# K&-Colectom(" artial with 3nastomosis K$-4iops(" :i*er Code(s)# ..&.0 Colectom(" partial+ with anastomosis .700& 4iops( of li*er" needle+ when done for indicated purpose at time of other maDor procedure (:ist separatel( in addition to code for primar( procedure.)
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Chapter &
Surgery Part II 5rinary Syste Exercises
*ns!ers to the e,ercises in this section !ill not appl modifier 51 %multiple procedures' or seAuencing for claims submission. The focus of these e,ercises is practice accurate assignment of CPT codes !ithout regard to pa er guidelines. The ans!ers !ill include use of lateral modifiers+ such as 5T+ 2* and 8odifier 50 for bilateral. 2or the purposes of instruction+ this boo$ uses a dash to separate each fi1e-character CPT code from its t!o-character modifier. =o!e1er+ dashes are not used in actual code assignments and reimbursement claims
&.21 !edical Ter inology "e(iew

8atch the medical terms !ith the correct definitions. 1. --". --3. --#. --5. ---lith (1) ureter (C) bladder (3) $idne (2) urethra (4) *. .. C. 0. 3. sac that stores urine duct leads urine out of bod from bladder duct from $idne to bladder stone organ that purifies blood and e,cretes !aste in urine

2ill in the blan$s for the follo!ing scenarios. Choose from one of the t!o ans!ers pro1ided in parenthesis.
1.<hich of the follo!ing procedures !ould be associated !ith the diagnosis of ureteral calculus6
%lithotrips(+ c stope, '
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2.<hich of the follo!ing procedures !ould be performed to treat ureteral stenosis6 %insertion of ureteral
stent+ transurethral resection'
3.The surgeon inserts a telescope-li$e tube into the bladder from the nature orifice to 1isualiDe the lo!er
urinar tract. This procedure is referred to as a ------------------ %c(stourethroscop(+ 35CP'.
4.The surgeon remo1ed urinar
stones through an incision directl into the bod of the $idne . This
procedure is $no!n as a ---------------------------- %ureterectom + nephrolithotom('.
5.<hich of the follo!ing procedures !ould be performed for urinar

suspension+ c storrhaph '
stress incontinence6 %urethral
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&.2#' 5rinary Syste
Coding )rill
2or all coding e,ercises+ re1ie! the documentation and underline $e term%s'. /dentif the terms used to loo$ up the code selection in the *lphabetic /nde,. *ssign CPT codes to the follo!ing cases. /f applicable+ append CPT&=CPCS 4e1el // modifiers. /n some cases+ the student !ill be prompted to ans!er Auestions about the case stud . 1. ;sing calibrated electronic eAuipment+ an uroflo!metr test is performed to measure ho! !ell the bladder empties and the storage capacit of the bladder. ;nde/# Uroflowmetr( Code(s)# 5&7.& Comple/ uroflowmetr( 3. ?perati1e >ote: Patient has a ureteral stricture. Performed a c stoscop !ith ureteroscop and laser treatment of the stricture. ;nde/# C(stourethroscop(" 1ilation" Ureter Code(s)# 5$0.. C(stourethroscop( with ureteroscop(+ with treatment of ureteral stricture 5. The surgeon aspirates the c st of the $idne !ith the use of a percutaneous needle. ;nde/# Cidne(" C(st" 3spiration Code(s)# 500'0 3spiration andGor inDection of renal c(st b( needle" percutaneous 7. >ephrolithotom for remo1al of $idne stones ;nde/# Nephrolithotom( Code(s)# 50060 Nephrolithotom(+ remo*al of calculus
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(.
The surgeon performs a laparoscopic ablation of a renal c st. ;nde/# C(st" Cidne(" 3blation Code(s)# 505.& :aparoscop(" ablation of renal c(st
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&.2&' Case Studies * 5rinary Syste "eports

1. +perati(e "eport Preoperati1e 0iagnosis: Procedure: =istor of lo! grade transitional cell carcinoma 2le,ible c stoscop
+perati(e
/ndications: Patient is a #(- ear-old male diagnosed !ith lo!-grade transitional cell carcinoma of the bladder. =e is here toda for his regular bladder tumor follo!-up. 0etails: Patient@s genitalia !ere prepped and draped in the t pical fashion. "0 cc of "H lidocaine :ell !as instilled into the urethra. The anesthesia !as gi1en fi1e minutes to set in. The N1( 2rench fle,ible c stoscope !as passed through the urethra into the bladder. ?nce inside the bladder+ the entire bladder mucosa !as e1aluated. >o lesions !ere identified. .oth ureteral orifices !ere seen and !ere found to be normal. *t this point+ the scope !as remo1ed. Patient !ill be called in three months for his ne,t follo!-up.

<hat !as 1isualiDed during the endoscop procedure6 Urethra to bladder
Time to Code:
;nde/# C(stourethroscop( Code(s)# 5$000 C(stourethroscop( (separate procedure) 3. +perati(e "eport Preoperati1e 0iagnosis: * 7-mm stone in the left lo!er pole
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Postoperati1e 0iagnosis: ?peration Performed: *nesthesia:
* 7-mm stone in the left lo!er pole 4eft e,tracorporeal shoc$!a1e lithotrips /ntra1enous sedation
/ndications for Procedure: This is a 57- ear-old man !ho has been $no!n to ha1e a stone in the left upper pole for a number of ears. =e recentl presented !ith left renal colic. *n I-ra sho!ed the stone to ha1e migrated into the pro,imal ureter. 5ecentl + he under!ent c stoscop + the stone !as successfull flushed into the $idne + and a double-L stent !as placed. =e no! needs to be treated !ith 3S<4. 0escription of Procedure: The patient !as placed onto the treatment table+ and+ after the administration of intra1enous sedation+ he !as positioned o1er the shoc$!a1e electrode. The I-ra sho!ed the stone to no! be located in the lo!er pole of the left $idne . .ia,ial fluoroscop !as utiliDed to position the stone at the focal point of the shoc$ !a1e generator. The stone !as initiall treated at 17 $B+ increasing up to "# $B. The stone !as treated !ith 3000 shoc$s. Throughout the procedure+ fluoroscopic manipulations and ad:ustments !ere made in order to maintain the stone in the focal point of the shoc$!a1e generator. *t the conclusion of the procedure+ the stone appeared to ha1e fragmented nicel + and the patient !as placed on a stretcher and ta$en to the reco1er room in good condition.

=o! !ere the stones remo1ed6 Hia shoc)wa*e lithotrips( (7tone was treated with 0000 shoc)s.)
Time to Code:
;nde/# :ithotrips(" Cidne( Code(s)# 505'0 :ithotrips(" e/tracorporeal shoc) wa*e
!ale 6enital Syste
Exercises
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Source: >ational Cancer /nstitute. n.d. Bisuals?nline. ;n$no!n photographer&artist. http:&&1isualsonline.cancer.go1&details.cfm6imageidC17)".
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&.2. !edical Ter inology "e(iew

8atch the medical terms !ith the definitions. 1.--". --3. --epidid mis (2) 1as deferens (C) testicles (3) *. .. C. organ that produces sperm surgical remo1al of one or both testicles duct that con1e s sperm from testicles to urethra #. --5. --orchiectom (4) circumcision (1) 0. 3. surgical remo1al of fores$in duct along !hich sperm passes to 1as deferens

1. 2. 3.
The male patient is see$ing a steriliDation procedure to pre1ent the release of sperm. This procedure is referred to as --------------- %orchiectom + *asectom('. The surgeon uses a clamp de1ice to remo1e the prepuce. This procedure is $no!n as a ----------%circumcision+ 1asectom '. * patient has been diagnosed !ith undescended testis. <hich of the follo!ing procedures !ould correct this condition6 %urethroplast + orchiope/('
&.21' !ale 6enital Syste
Coding )rill
2or all coding e,ercises+ re1ie! the documentation and underline $e term%s'. /dentif the terms used to loo$ up the code selection in the *lphabetic /nde,. *ssign CPT codes to the follo!ing cases. /f applicable+ append CPT&=CPCS 4e1el // modifiers. /n some cases+ the student !ill be prompted to ans!er Auestions about the case stud . 1. Patient is a 55- ear-old male !ith a 8entor inflatable three-piece penile prosthesis that had been causing problems. =e !as e,periencing issues !ith prolonged erections !hile deflating the prosthesis. /t !as elected to remo1e the prosthesis and insert a 0uraphase // penile prosthesis. There !as some e1idence of infection in the area+ !hich !as irrigated.
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;nde/# >emo*al" rosthesis" enis Code(s)# 5..&& >emo*al and replacement of all components of a multi-component inflatable penile prosthesis through an infected field at the same operati*e session" including irrigation and debridement of infected tissue
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3.
The patient !ith erectile d sfunction elects to ha1e the surgeon implant a three-piece inflatable prosthesis. ;nde/# enile rosthesis" ;nsertion" ;nflatable Code(s)# 5..05 ;nsertion of multi-component" inflatable penile prosthesis
5.
The surgeon performs a 1-stage distal h pospadias !ith urethroplast using local s$in flaps. ;nde/# <(pospadias" Urethroplast(" :ocal 7)in 5laps Code(s)# 5.0$. &-stage distal h(pospadias repair with urethroplast( b( local s)in flaps
&.22' Case Studies 7 !ale 6enital Syste "eports

1. +perati(e "eport Preoperati1e 0iagnosis: Postoperati1e 0iagnosis ?peration Performed: : 4eft h drocele Same 4eft h drocelectom
+perati(e
/ndications: This 55- ear-old male !ith a histor of left h drocele s!elling causing discomfort reAuesting inter1ention after e1aluation and preoperati1e consultation. ?peration: Patient !as sterilel prepped and draped in the usual fashion. * trans1erse incision across the left hemiscrotum !as made appro,imatel # cm in length do!n to the le1el of the h drocele. = drocele !as remo1ed from the incision and stripped of its fibrous attachments. = drocele !as opened and drained. The e,cess sac !as remo1ed and discarded. The sac !as then e1erted !ith the testicle+ and a running N"-0 chromic stitch in a loc$ing fashion !as placed across the edges of the sac. 8eticulous hemostasis !as achie1ed. The testicle and spermatic cord !ere then replaced bac$ to the patient@s left scrotum. There !as no damage done to the 1as deferens. The dartos
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la er !as reappro,imated using N"-0 running loc$ing chromic stitch. The s$in !as closed in a running horiDontal mattress fashion using N3-0 chromic. The patient tolerated the procedure !ell.

4ocate h drocele in the *lphabetic /nde,. <hat documentation from the operati1e report is needed to accuratel assign codes6 Unilateral *s. bilateral" if performed as an aspiration" or e/cision tunica *aginalis (co*ering o*er testis-scrotum) or of spermatic cord. ;n this case" tunica *aginalis.
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Time to Code:
;nde/# <(drocele" 2/cision" Unilateral" !unica Haginalis Code(s)# 550.0 2/cision of <(drocele" unilateral 3. +perati(e "eport Preoperati1e 0iagnosis: Postoperati1e 0iagnosis: Procedure Performed: *nesthesia: Complications: Specimens 5emo1ed: 3le1ated prostate specific antigen Same ;ltrasound-guided prostate needle biops Feneral anesthesia >one T!el1e core needle biopsies of the prostate
/ndications: The patient is a 57- ear-old man. =e !as found on recent labs to ha1e an ele1ated PS* at the le1el of #.5. =e !as therefore consented for prostate needle biops . 0etails of Procedures: Patient !as brought bac$ to the C sto Suite and mo1ed into the lateral decubitus position. *fter smooth induction of general anesthesia+ a digital rectal e,am !as performed. There !ere no nodules palpated. The prostate !as smooth+ firm+ and benign feeling. The ultrasound probe !as then inserted into the rectum. There !ere no abnormalities seen on ultrasound. <e then proceeded to ta$e a total of 1" core needle specimens of the prostate+ t!o from the right base+ t!o from the right mid+ t!o from the right ape,+ follo!ed b t!o from the left base+ t!o from left mid+ and t!o from the left ape,. The patent tolerated the procedure !ell. There !as minimal blood loss. Patient !as transferred bac$ to the Post-anesthesia Care ;nit in stable condition. =e !ill be sent home !ith three da s of antibiotics+ and !e !ill follo! up on his patholog .

<hat techniAue !as used to obtain the biops 6 Needle
Time to Code:
;nde/# 4iops(" rostate
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Code(s)# 55700 4iops(" prostate+ needle or punch" single or multiple" an( approach
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8e ale 6enital Syste
Exercises
Source: >ational Cancer /nstitute. n.d. Bisuals?nline. ;n$no!n photographer&artist. http:&&1isualsonline.cancer.go1&details.cfm6imageidC17)3.
&.23 !edical Ter inology "e(iew

8atch the follo!ing medical terms !ith the correct definition. 1. --cer1i, (1) *. surgical procedure9 instrument inserted into abdominal !all to 1ie! internal organs ".--3.--#. --5. --1agina (C) o1ar (4) colposcop (2) laparoscop (3) .. C. 0. 3. produces eggs tube leading from genitalia to cer1i, passage forming lo!er end of uterus surgical procedure to e,amine 1agina and cer1i,
&.#4' Clinical Concepts

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1.
*s a result of a positi1e Pap smear+ the surgeon recommends a ------------- to determine the cause %h steroscop + colposcop('.
".
* surgeon remo1es both o1aries. This procedure is referred to as a ------------- %omenectom + oophorectom('.
3.
The surgeon e,cised e,tensi1e adhesions during the abdominal procedure. 2reeing of adhesions is $no!s as ------------ %ligation+ l(sis'.
#.
The surgeon reports that the patient has a lesion on the e,ternal genitalia. 0ocumentation in the health record !ould indicate that it !as a%n' ---------- lesion %*ul*ar+ endocer1ical'.
5.
<hich of the follo!ing procedures !ould be associated !ith remo1al of uterine fibroids6 %m(omectom(+ cerclage of uterine cer1i,'
&.#1' 8e ale 6enital Syste
Coding )rill
2or all coding e,ercises+ re1ie! the documentation and underline $e term%s'. /dentif the terms used to loo$ up the code selection in the *lphabetic /nde,. *ssign CPT codes to the follo!ing cases. /f applicable+ append CPT&=CPCS 4e1el // modifiers. /n some cases+ the student !ill be prompted to ans!er Auestions about the case stud . 1. O perati1e >ote: Patient treated for a ".5 cm lesion of 1agina. The lesion !as lasered and hemostasis obtained for bleeding. Specimens sent to patholog for e1aluation. ;nde/# :esion" *agina" destruction (results in code 5706&) (:aser is a form of destruction.) Code(s)# 5706& 1estruction of *aginal lesion(s) 3. ?perati1e >ote: Patient has chronic complaints of right pel1ic pain. Ta$en to ?5 for a laparoscop . /nspection into the pel1is re1ealed multiple adhesions attached to the left tube and o1ar . These adhesions !ere l sed bluntl !ith probe. >o other abnormalities noted. ;nde/# :aparoscop(" :(sis of 3dhesions Code(s)#
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5%660 :aparoscop(" surgical+ with l(sis of adhesions 5. The surgeon inserts a scope into the 1agina and passed to uterus !here a biops of endometrium !as performed. ;nde/# <(steroscop(" 7urgical with 4iops( Code(s)# 5%55% <(steroscop(" with sampling (biops() of endometrium
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&.#2' Case Studies 7 8e ale 6enital Syste "eports

1. +perati(e ,ote
+perati(e
This 7#- ear-old !oman under!ent a partial 1ul1ectom 7 months ago for carcinoma in situ. She no! !as found to ha1e recurrent disease of her 1ul1a and a partial 1ul1ectom !as performed. The s$in !as dissected to!ards the introitus and the posterior 1agina !as dissected for appro,imatel 1 inch into the pro,imal 1agina. The 1aginal mucosa !as undermined for at least " cm and appro,imated to the perineal s$in b interrupted "-0 Bicr l sutures. The anterior 1ul1a lesion !as then e,cised !ith a margin of appro,imatel 0.5 cm. The lesion itself !as appro,imatel " cm in diameter. .leeding points !ere cauteriDed. <ounds closed !ith interrupted 30 Bicr l. Patholog 5eport: Specimens: 1ul1a lesion !ith anal margin+ anterior 1ul1a+ periurethral

5e1ie! the *lphabetic /nde, for coding selections for 1ul1ectom procedures. <hat documentation is needed for the coding selection6 Complete" artial" >adical" 7imple >ote the definitions for simple+ radical+ partial+ and complete 1ul1ectom codes %listed before code 57#05'. <hat documentation from this operati1e note leads ou to the correct definition6 h(sician dictates that the *ul*ectom( was partial (remo*es less than %0L of *ul*ar area). <as this a radical %remo1al of s$in and deep subcutaneous tissue' or si !le %remo1al of s$in and superficial subcutaneous tissue' procedure6 !he term undermined (dig beneath) implies that it was be(ond the superficial subcutaneous tissues. ;t ma( be a good step to Juer( the ph(sician in this case.
Time to Code:
;nde/# Hul*ectom(" partial (566$0" 56600-5660$) Code(s)# 56600 Hul*ectom(" radical" partial
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3. +perati(e "eport
Preoperati1e 0iagnosis: Postoperati1e 0iagnosis: Procedures: Specimen to 4ab: 3stimated .loods 4oss:
Perimenopausal bleeding. Possible endometrial h poplasia. Perimenopausal bleeding = steroscop . 0ilatation and curettage. 3ndometrial curetting 4ess than 5 m4
0escription of Procedure: The patient !as ta$en to the operating room and under satisfactor general anesthesia !as e,amined+ noted to ha1e a normal-siDe uterus. >o adne,al masses noted. She !as prepped and draped in the routine fashion+ the speculum placed in the 1agina+ and the anterior lip of the cer1i, grasped !ith a single-tooth tenaculum. The uterus sounded to ) cm and easil admitted a N"1 K-Pratt+ so no further dilation !as necessar . * 1"-degree h steroscope !as placed+ using lactated 5inger as the distending medium+ and the cer1ical canal !as normal. The ca1it re1ealed :ust fronds of tissue. There !as tissue stic$ing out that did not ha1e a particularl pol poid appearance. >o other lesions could be appreciated that !ere pol poid. Curettage !ith a 8ilan curette and a serrated curette and then pol p forceps being introduced re1ealed minimal tissue+ and 1 piece of tissue of 5 mm that might be consistent !ith !hat !as seen on pre1ious sonogram. The h steroscope !as then replaced. >o other lesions could be appreciated+ and the !alls appeared smooth. *t this time the h steroscope !as remo1ed+ and the tenaculum remo1ed. The tenaculum site !as touched !ith sil1er nitrate. The bleeding !as minimal at the end of the procedure. She !as ta$en to the reco1er room in satisfactor condition.

<hat procedures !ere performed6 <(steroscop(" 1MC" remo*al of tissue (curette) 5efer to coding te,tboo$. <hat guidelines pertain to this case6 No additional code is assigned to identif( 1MC when performed with h(steroscop(.
Time to Code:
;nde/# <(steroscop(" 7urgical with 4iops( Code(s)# 5%55% <(steroscop(" surgical+ with sampling of endometrium andGor pol(pectom(" with or without 1MC
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5. +perati(e "eport Preoperati1e 0iagnosis: Postoperati1e 0iagnosis: Procedure: ;terine fibroids 8ultiple uterine fibroids+ uterus -"50 g+ " cm right o1arian c st 4aparoscopic-assisted 1aginal h sterectom !ith bilateral salpingooophorectom Procedure in 0etail: The patient !as ta$en to the operating room and placed in the supine position. *fter adeAuate general anesthesia had been obtained+ the patient !as prepped and draped in the usual fashion for laparoscopicassisted 1aginal h sterectom . The bladder !as drained. * small infraumbilical s$in incision !as made !ith the scalpel+ and 10 mm laparoscopic slee1e and trocar !ere introduced !ithout difficult . The trocar !as remo1ed. The laparoscope !as placed and " 4 of C0" gas !as insufflated in the patient@s abdomen. * second incision !as made suprapubicall and a 1"-mm laparoscopic slee1e and trocar !ere introduced under direct 1isualiDation. * 5-mm laparoscopic slee1e and trocar !ere placed in the left lo!er Auadrant under direct 1isualiDation. * manipulator !as used to e,amine the patient@s pel1ic organs. There !as a small c st on the right o1ar . .oth o1aries !ere free from adhesions. The ureters !ere free from the operati1e field. *fter measuring the o1arian distal pedicles+ the endo-F/* staple !as placed across each round ligament. *t this time+ attention !as turned to the 1aginal part of the procedure. * !eighted speculum !as placed in the 1agina. The anterior lip of the cer1i, !as grasped !ith a 4ahe tenaculum. Posterior colpotom incision !as made and the posterior peritoneum entered in this fashion. The uterosacral ligaments !ere bilaterall clamped+ cut+ and =eane sutured !ith N1 chromic. The cardinal ligaments !ere bilaterall clamped+ cut+ and ligated. The anterior 1aginal mucosa !as then incised !ith the scalpel+ and !ith sharp and blunt dissection+ the bladder !as freed from the underl ing cer1i,. The bladder pillars !ere bilaterall clamped+ cut+ and ligated. The uterine 1essels !ere then bilaterall clamped+ cut+ and ligated. BisualiDation !as difficult because the patient had a 1er narro! pel1ic outlet. /n addition+ se1eral small fibroids made placement of clamps some!hat difficult. ;sing the clamp+ cut+ and tie method after the anterior peritoneum had been entered !ith scissors+ the uterus !as then left !ithout 1ascular suppl . The fundus !as deli1ered b flipping the uterus posteriorl 9 and through an a1ascular small pedicle+ =eane clamps !ere placed across+ and the uterus !as then remo1ed en bloc !ith the tubes and o1aries attached. *t this point+ the remaining =eane pedicles !ere ligated !ith a free-hand suture of 0 chromic. Sponge and instrument counts !ere correct. *1ascular pedicles !ere inspected and found to be hemostatic. The posterior 1aginal cuff !as then closed using running interloc$ing suture of N1 chromic. The anterior peritoneum !as then grasped+
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and using pursestring suture of 0 chromic+ the peritoneum !as closed. The 1aginal cuff !as then closed reincorporating the pre1iousl tagged uterosacral ligaments into the 1aginal cuff through the anterior and posterior 1aginal cuff. *nother figure-of-eight suture totall closed the cuff. =emostasis !as e,cellent. 2ole !as then placed in the patient@s bladder and clear urine !as noted to be draining. *t this point+ the laparoscope !as placed bac$ through the 10-mm slee1e and the 1aginal cuff inspected. * small amount of old blood !as suctioned a!a + but all areas !ere hemostatic. The laparoscopic instruments !ere remo1ed after the e,cess gas had been allo!ed to escape. The incisions !ere closed first !ith suture of "-0 Bicr l through the fascia of each incision+ and then the s$in edges !ere reappro,imated !ith interrupted sutures of 3-0 plain. Sponge and instrument counts !ere correct. The patient !as a!a$ened from general anesthesia and ta$en to the reco1er room in stable condition.

5efer to the $e term = sterectom in the *lphabetic /nde,. <hat $e documentation is needed to lead to the correct coding range6 Haginal and then :aparoscopic dri*es the coding range. 3fter the range of codes is identified and *erified" other )e( documentation is needed (for e/ample" si?e of uterus" remo*al of tubes and o*aries).
Time to Code:
;nde/# <(sterectom(" Haginal" >emo*al !ubesG=*aries Code(s)# 5%55$ :aparoscopic" surgical" with *aginal h(sterectom(" for uterus $50 g or less with remo*al of tube(s) and o*ar((s)
,er(ous Syste
Exercises
&.##' !edical Ter inology "e(iew
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&.#&' Clinical Concepts

2ill in the blan$s to the follo!ing scenarios. Choose from one of the t!o ans!ers pro1ided in parentheses. 1. <hich of the follo!ing procedures !ould be performed to treat a patient diagnosed !ith Par$inson@s disease6 %spinal infusion+ insertion of neurostimulator' ". *s a result of a traumatic in:ur + the surgeon sutures the se1ered ner1e. This procedure is $no!n as a ---------- %neurorrhaph(+ neurol sis'. 3. Surgical treatment of carpal tunnel s ndrome !ould be documented as ----------- %release compression of median ner*e+ neuroplast of median ner1e'. #. The patient is gi1en #0 mg&m4 /8 of 0epo-medroO for relief of pain. 2or coding purposes+ this in:ection !ould be considered as ------------- %single inDection+ continuous infusion'.
&.#.'
,er(ous Syste
Coding )rill
5e1ie! the documentation and underline $e term%s'. /dentif the terms used to loo$ up the code selection in the *lphabetic /nde,. *ssign CPT codes to the follo!ing cases. /f applicable+ assign CPT&=CPCS 4e1el // modifiers. 1. ?perati1e >ote for Cer1ical 3pidural /n:ection: Patient has been e,periencing nec$ pain for se1eral ears. ;sing fluoroscopic guidance+ an epidural needle is inserted into the epidural space. * combination of an anesthetic and cortisone steroid solution is in:ected into the epidural space.

5efer to .asic CPT&=CPCS for guidance on coding for spinal in:ections. <hat documentation is needed for coding selection6 7ite of inDection and substance (site is cer*ical" substance is anesthetic and steroid). Useful website# http#GGwww.spine-health.com
Time to Code:
;nde/# ;nDection" 7pinal Cord" 3nesthetic 6$0&0-6$0&' Code(s)# 6$0&0 ;nDection" single" (including anesthetic" steroid)+ cer*ical
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3.
*s a result of an in:ur + the surgeon sutures a lacerated digital ner1e of the right hand. ;nde/# 7uture" Ner*e Code(s)# 6.%0&->! 7uture of digital ner*e" hand or foot" & ner*e
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5.
The patient undergoes a transforaminal epidural in:ection of an anesthetic agent at the 45 facet :oint. ;nde/# 2pidural" ;nDection Code(s)# 6..%0 ;nDection" anesthesia agent+ transforaminal epidural+ lumbar or sacral" single le*el
7.
The patient !as diagnosed !ith an encephalocele at the base of the s$ull. 2or surgical inter1ention+ a craniotom for repair !as performed. ;nde/# 2ncephalocele" >epair" Craniotom( Code(s)# 6$&$& Craniotom( for repair of encephalocele" s)ull base
(.
<ith the use of an operating microscope+ the surgeon performed a repair of lacerated digital ner1e of right inde, finger and right thumb. ;nde/# 7uture" Ner*e =perating 6icroscope Code(s)# 6.%0&-55 7uture of digital ner*e" hand or foot & ner*e 6.%0$-56 each additional ner*e 6'''0 =perating 6icroscope
&.#0' Case Studies 7 ,er(ous Syste "eports

1. +perati(e "eport Preoperati1e 0iagnosis: Postoperati1e 0iagnosis: ?peration Performed: Spinal cord stimulator batter replacement Spinal cord stimulator batter replacement
+perati(e
5emo1al of spinal cord stimulator batteries and replacement !ith ne! batteries
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>o complications >o specimens /ndications for Surger : Patient is a 77- ear-old man !ho had spinal cord stimulator implanted appro,imatel fi1e ears ago. =e comes bac$ because of lac$ of functioning in this s stem. 0ecision !as made to proceed !ith remo1al of the old batteries and replacement !ith ne! ones. The patient understands the ris$s and benefits of the procedure. 0escription of Surger : The patient !as placed in supine position and the area !here the batteries !ere located on the left side !as prepped and draped in the sterile fashion. The patient !as infiltrated !ith lidocaine 1H. /t !as reopened !ith a N15 blade+ and then the batteries !ere remo1ed from the poc$et and disconnected from the lead !ires. * ne! batter s stem !as reconnected. <ound !as closed !ith N3-0 Bicr l and staples for s$in.

<hat is a spinal cord stimulator6 3lso called neurostimulator" it is an implantable de*ice often used to treat chronic pain. !he pulse generator holds the batteries+ therefore" replacement of batteries codes as replacement of pulse generator.
Time to Code:
;nde/# >eplacement" Neurostimulator" ulse FeneratorG>ecei*er" 7pinal Code(s)# 606%5 ;nsertion or replacement of spinal neurostimulator pulse generator 3. +perati(e "eport Preoperati1e 0iagnosis: Postoperati1e 0iagnosis: Procedure: 4eft ulnar ner1e entrapment at the elbo! 4eft ulnar ner1e entrapment at the elbo! 4eft ulnar ner1e decompression at the elbo!
/ndications: The patient has a histor of numbness in the fourth and fifth digits of the left hand and also some !ea$ness in the grip. =e complains of pain in the ulnar side of the left arm. =e had an 38F+ !hich !as positi1e for entrapment of the left ulnar ner1e at the elbo!+ and he had conser1ation treatment !ith some impro1ement of the mode of function+ !ith se1ere significant numbness and pain. .ecause of the s mptoms+ the decision !as made to proceed !ith a decompression of the left ulnar ner1e at the elbo!.
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0escription of Surger : The patient !as placed in supine position !ith the left hand on the surgical stand. The arm !as then prepped+ draped and then an incision !as mar$ed at the le1el of the left elbo!. The incision !as infiltrated !ith lidocaine 1H and then the incision !as made !ith a N15 blade. <ith the use of bipolar coagulator+ the bleeding !as easil controlled and then the ulnar ner1e !as e,posed at the le1el of the elbo! pro,imall and distall . The ulnar ner1e !as completel compressed and !as released from a dense scar. *ntibiotic solution !as used to irrigate the area and then the area !as closed !ith N3-0 Bicr l and staples.

<hat procedure !as performed %$e operati1e term'6 1ecompression <hat is the location of the ner1e entrapment6 :eft ulnar ner*e
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Time to Code:
;nde/# Ner*es" 1ecompression Code(s)# 6.7&%-:! Neuroplast(+ ulnar ner*e at elbow 5. +perati(e "eport Preoperati1e 0iagnosis: Postoperati1e 0iagnosis: ?peration: 45-S1 herniated disc on the left side 45-S1 herniated disc on the left side 45-S1 discectom and 45 ner1e root decompression
/ndications for Surger : The patient is a 53- ear-old male !ho has a histor of lo! bac$ pain and left leg pain in the 45 distribution. *n 85/ sho!s the presence of a herniated disc at 45-S1 migrated up impinging the 45 ner1e root on the left side. The patient has been treated conser1ati1el !ithout an impro1ement. 0escription of Surger : The patient !as intubated and placed in prone position. Then an incision !as mar$ed on the lo!er bac$ and !as prepped and draped in sterile fashion. The incision !as made !ith a N10 scalpel+ .o1ie coagulator and do!n to the fascia. *t this point+ the fascia !as incised !ith a N15 blade. * flap of the fascia !as then retracted !ith N"-0 Bicr l and the muscle !as gentl dissected and retracted !ith a Ta lor retractor. ;nder the microscope+ a curette !as placed bet!een the 45-S1 and I-ra s !ere obtained. The I-ra s sho!ed that the curette !as bet!een 45 and S1 until under the microscope !ith microdissection+ and !ith the use of a 8idas 5e, the lamina of 45 !as partiall drilled off and ello! ligament !as opened+ remo1ed and then the 45 ner1e root !as identified. * large herniated disc !as then found+ remo1ed and the 45 ner1e root !as completel decompressed. *t this point+ the interspace at 45-S1 !as entered for the disc remo1ed laterall + and then a complete decompression of the 45 into the foramen !as accomplished. *t this point+ the area !as irrigated !ith antibiotic solution and a paste of 0epo-8edrol+ *micar and morphine !as left in place. The fascia !as closed !ith a N"-0 Bicr l+ subcutaneous tissue !ith a N3-0 Bicr l+ and the s$in !as closed !ith subcuticular N#-0 Bicr ls.

5efer to "asic CPT/#CPC$ for coding guidance. <hat is a discectom 6 3 discectom( is a surger( done to remo*e a herniated disc from the spinal. 3 laminectom( is often in*ol*ed to permit access to the inter*ertebral disc. *fter the location of the curette !as confirmed+ !hat !as the first surgical action6 :amina was partiall( drilled off (hemilaminectom(). >efer to this term in the 3lphabetic ;nde/.
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Time to Code:
;nde/# <emilaminectom(. 600$0-600.. Code(s)# 60000 :aminotom( (hemilaminectom() with decompression of ner*e root(s)" including foraminotom( andGor e/cision of herniated inter*ertebral disc+ one interspace" lumbar 3n interacti*e *ideo of this procedure can be found at http#GGwww.spine-health.com.
Eye and +cular Adnexa Exercises
&.#1' !edical Ter inology "e(iew
Instructor's Guide
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&.#2' Clinical Concepts

2ill in the blan$s to the follo!ing scenarios. Choose from one of the t!o ans!ers pro1ided in parentheses. 1. 2. 3. 4. 5. * patient is diagnosed !ith crossed e es. <hich of the follo!ing procedures !ould be performed to correct this condition6 %1itrectom + strabismus surger(' <hich of the follo!ing procedures is associated !ith treatment of glaucoma6 %lenscectom + trabeculectom(' <hich of the follo!ing procedures is associated !ith treatment of retinal detachment6 %scleral buc)ling+ $eratoplast ' The patient presents !ith a small bump in the e elid as a result of a clogged oil gland. The surgeon performs an e,cision for remo1al of the -------------- %chala?ion+ blepharoptosis'. The patient is see$ing treatment for e,treme dr e es. <hich of the follo!ing procedures !ould be used to treat this condition6 %insertion of punctal plugs+ phacoemulsification'
&.#3'
Eye and +cular Adnexa Coding )rill
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5e1ie! the documentation and underline $e term%s'. /dentif the terms used to loo$ up the code selection in the *lphabetic /nde,. *ssign CPT codes to the follo!ing cases. /f applicable+ assign CPT&=CPCS 4e1el // modifiers. 1. Patient diagnosed !ith e,otropia. Surgeon performs bilateral recession of lateral rectus muscles.

<hat is the definition of e,otropia6 !(pe of strabismus in which the e(es are turned outward. 5efer to "asic CPT/#CPC$ te,tboo$: =o! is the lateral rectus muscle classified %1ertical or horiDontal'6 <ori?ontal
Time to Code:
;nde/# 7trabismus" >epair" =ne <ori?ontal 6uscle Code(s)# 670&&-50 7trabismus surger(" recession or resection procedure+ one hori?ontal muscle 3. ;nder general anesthesia+ the surgeon probes the nasolacrimal duct !ith irrigation. ;nde/# Nasolacrimal 1uct" 2/ploration" with 3nesthesia Code(s)# 6%%&& robing of nasolacrimal duct reJuiring general anesthesia
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#.
/ncision and drainage of abscess of the upper left e elid ;nde/# ;ncision and 1rainage" 3bscess" 2(elid Code(s)# 67700-2& 4lepharotom(" drainage of abscess" e(elid
&.&4' Case Studies 7 Eye and +cular Adnexa +perati(e and E ergency )epart ent "eports
1. +perati(e "eport Preoperati1e 0iagnosis: Postoperati1e 0iagnosis: ?peration: 0ermatochalasis of bilateral upper e elids 0ermatochalasis of bilateral upper e elids .ilateral upper lid blepharoplast
/ndications: Patient is a #1- ear-old female !ith a histor of progressi1e upper e elid hooding related to her redundant s$in. The patient complains that this ma$es her e elids feel hea1 and interferes !ith her 1ision+ particularl !hen she is tired. Patient !as seen in the ?utpatient Clinic and offered bilateral upper lid blepharoplast . 0etails: Patient brought to the operating room and placed on the operating table in supine position. *fter adeAuate intra1enous sedation had been obtained+ the patient@s upper e elids !ere mar$ed for incision and infiltrated !ith 5 cc of 0.5H lidocaine mi,ed !ith 1:300+000 epinephrine in each lid. The patient@s face and head !ere prepped and draped in the standard operati1e fashion. The pre1iousl mar$ed bilateral upper lids !ere incised through the s$in and the orbicularis muscle using N15 surgical blade. The mar$ed segment !as e,cised sharpl !ith N15 surgical blade !ith adeAuate tension on the operati1e field. The e,cision !as carried do!n through the muscle+ and the fat la er !as easil 1isible. This procedure !as repeated identicall on the opposite lid. >e,t+ the middle fat pad+ !hich !as readil identifiable+ !as gentl teased out !ith a conca1e applicator and forceps and the pad !as remo1ed !ith the .o1ie cauter . >e,t+ the medial fat pad !as also dissected out using gentle blunt dissection. The fat pad !as retracted into the field and remo1ed using the electrocauter . The procedure !as repeated identicall on the opposite lid. The operati1e field !as then e,amined for hemostasis. The electrocauter !as used to dr up an small bleeders. The !ound !as closed in a single la er using interrupted N7-0 3thibond sutures. The !ounds !ere dressed !ith .acitracin and iced moist gauDe and the patient !as transferred to the reco1er room in stable condition.
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Page 77 of 100

5efer to the $e operati1e term in the *lphabetic /nde, and note the code range. <hat documentation is needed from the record to correctl assign a CPT code%s'6 Note whether the procedure was performed on the upper or lower e(elids (unilateral or bilateral). Ne/t" note that the diagnostic information contributes to the coding in this case (e/cessi*e s)in weighting down lid). ;mportant to note that that the blepharoplast( codes appear in the ;ntegumentar( 7(stem section. 6ore e/tensi*e e(elid repair codes appear in the 2(e and =cular 3dne/a section (e.g. 67'0&).
Time to Code:
;nde/# 4lepharoplast( &5%$0-&5%$0 Code(s)# &5%$0-50 4lepharoplast(+ upper e(elid+ with e/cessi*e s)in weighting down lid 3. +perati(e ,ote 0iagnosis: Procedure: >asolacrimal duct obstruction >asolacrimal duct probing and irrigation for right e e
Procedure 0etails: The patient !as brought into the operating room. The operati1e e e !as prepped and draped. * punctal dilator !as used to dilate the superior and inferior puncta of the operati1e e e. * double-0 .o!man probe !as passed through one of the puncta and passed into the common canaliculus. The probe !as passed into the nasolacrimal sac and do!n the bon canal of the nasolacrimal duct. The probe !as passed into the nasal ca1it beneath the inferior turbinate. The probe !as remo1ed. * lacrimal cannula attached to a 3-cc s ringe filled !ith fluorescein solution !as used to cannulate the nasolacrimal duct. *n aspirating catheter !as placed in the ipsilateral nasal ca1it . 2luorescein !as irrigated into the nasolacrimal duct. 2luorescein !as aspirated from the nasal ca1it follo!ing the irrigation. This demonstrated patenc of the nasolacrimal drainage s stem. The lacrimal cannula and aspiration catheter !ere remo1ed. The patient tolerated the procedure !ell and !as transferred to the reco1er room in stable condition.

<hat documentation is needed to assign the correct CPT code6
Instructor's Guide
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Bhether the procedure reJuired general anesthesia or probing included insertion of tube or stent or balloon catheter dilation
Time to Code:
;nde/# Nasolacrimal 1uct" 2/ploration Code(s)# 6%%&0->! robing of nasolacrimal duct" with or without irrigation
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Auditory Syste
Exercises
&.&1' !edical Ter inology "e(iew

8atch the follo!ing terms !ith the correct definition. 1. --- m ringotom (C) *. .. C. 0. connects middle ear !ith nasophar n, eardrum surgical incision into eardrum surgical remo1al of innermost chain of 3 ossicles in middle ear 5. --- t mpanum (4) 3. surgical repair of middle ear
". --- t mpanoplast (2) 3. --- stapedectom (1) #. --- 3ustachian tube (3)
&.&2' Clinical Concepts

2ill in the blan$s to the follo!ing scenarios. Choose from one of the t!o ans!ers pro1ided in parentheses. 1. The patient is seen for chronic middle ear infection. Conser1ati1e treatment !ith antibiotics !ould not clear the infection+ so it !as elected to perform a --------------- to remo1e the infection %mastoidectom(+ otoplast '. ". The patient !as diagnosed !ith otosclerosis and as a result+ cannot hear sound. The surgeon performs a ----------------+ !hich remo1es a small bone and subseAuentl inserts a prosthesis to transmit sound %lab rinthectom + stapedectom('. 3. <hich of the follo!ing procedures is associated !ith reconstructi1e surger of the eardrum6 %t(mpanoplast(+ otoplast '
&.&#'
Auditory Syste
Coding )rill
5e1ie! the documentation and underline $e term%s'. /dentif the terms used to loo$ up the code selection in the *lphabetic /nde,. *ssign CPT codes to the follo!ing cases. /f applicable+ assign CPT&=CPCS 4e1el // modifiers. 1. Ph sician ?ffice >ote
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Page 80 of 100
3,amination of the ear canal on both sides re1ealed impacted cerumen+ tightl on the right side and a little bit on the left. <ith the use of ear curette+ the impacted cerumen !as remo1ed. .oth ears !ere irrigated !ith saline solution and suctioned dr to clean out all the debris. ;nde/# Cerumen" >emo*al Code(s)# 6'$&0 >emo*al of impacted cerumen" one or both ears (No need for modifier because the description states ,one or both.-) 3. The surgeon performs the PolitDer maneu1er for 3ustachian tube inflation /nde,: 2ustachian !ube" ;nflation without Catheteri?ation Code(s)# 6'.0& 2ustachian tube inflation" transnasal" without catheteri?ation
&.&&' Case Studies 7 Auditory +perati(e "eports

1. +perati(e "eport Preoperati1e 0iagnosis: Procedure: 5ecurrent otitis media !ith persistent bilateral middle ear effusion .ilateral m ringotom !ith 1entilating tube insertion
Procedure in 0etail: The patient !as prepped and draped in the usual fashion under general anesthesia. 8 ringotom !as performed in the anterior-inferior Auadrant and thic$ fluid suctioned from the middle ear space. * T pe / Paparella tube !as then inserted. Then a m ringotom !as performed on the left ear9 again thic$ fluid !as suctioned from the middle ear space. * T pe / Paparella tube !as then inserted. Cortisporin ?tic Suspension drops !ere then placed in both ear canals and cotton in the ears. The patient !as a!a$ened and returned to the reco1er room in satisfactor condition.
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5efer to "asic CPT/#CPC$ for guidelines pertaining to m ringotom for insertion of tubes. <hat coding guidance is pro1ided in the te,tboo$ for this procedure6 7elect code from t(mpanostom( range.
Time to Code:
;nde/# !(mpanostom( 6'.00-6'.06 Code(s)# 6'.06-50 !(mpanostom( (reJuiring insertion of *entilating tube)" general anesthesia
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3. +perati(e "eport Preoperati1e 0iagnosis: Postoperati1e 0iagnosis: ?peration: Conducti1e hearing loss+ right ear Conducti1e hearing loss+ right ear Stapedectom
Procedure: The patient !as prepped and draped in the usual manner. The e,ternal auditor canal !all !as in:ected !ith 1H lidocaine and 1:100+000 epinephrine. The t mpanomeatal flap !as ele1ated using a 1ertical rolling $nife. The middle ear !as entered and chorda t mpani ner1e identified and annulus lifted out of the t mpanic sulcus. *fter ele1ating the t mpanomeatal flap anteriorl + the ossicles !ere palpated+ and the malleus and incus mo1ed freel and the stapes !as fi,ed. The posterior superior canal !all !as curetted do!n after mobiliDing the chorda t mpani ner1e+ !hich !as left intact. The stapes footplate !as easil 1isualiDed and found to be mar$edl thic$ened. The p ramidal process !as identified and the stapes tendon cut+ and an /S :oint $nife !as used to dislocate the :oint bet!een the incus and stapes. >e,t+ a small and a large .uc$ingham mirror !ere used along !ith a drill to drill out the stapes footplate. *fter this !as done+ a .5 , #-mm Schu$necht piston prosthesis !as placed in position. Crimping !as achie1ed+ and there !as an e,cellent fit+ and the stapes footplate area !as then pac$ed !ith small pieces of Felfoam. The t mpanomeatal flap !as then put bac$ in proper position+ and the middle ear !as then pac$ed !ith ra on strips of Cortisporin and a cotton ball in the middle to form a rosette. The patient !as a!a$ened in the operating room and transferred to reco1er in no apparent distress.

<hat is a stapedectom 6 7urgeon remo*es a portion of bone and places prosthesis to transmit the sound.
Time to Code:
;nde/# 7tapes" 2/cision" with 5ootplate 1rill =ut Code(s)# 6'66&->! 7tapedectom( or stapedotom( with reestablishment of ossicular continuit(" with or without use of foreign material+ with footplate drill out.
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Chapter .
"adiology
!edical Ter inology "e(iew
1. --- CT Scan (4) ". --- >uclear 8edicine (2) *. .. uses electromagnetic radiation to ma$e images creates multiple images !ith computer technolog to pro1ide cross-sectional 1ie!s uses po!erful magnet and radio !a1es to ta$e images uses high-freAuenc sound !a1es to 1ie! organs and structures in bod images de1eloped based on energ emitted from radioacti1e substances
3. --- 85/ (C) #. --- ;ltrasound (1)
C. 0.
5. --- I-ra (3)
3.
Case Studies
Case Study % 1
>adiolog( >eport 4eft *n$le %t!o 1ie!s': The left an$le sho!s no e1idence of fracture or dislocation. The 1isualiDed bones and their respecti1e articular surfaces are intact. Conclusion: >ormal left an$le ;nde/# N-ra(" an)le 70600-706&0 Code(s)# 70600-:! >adiologic e/amination" an)le+ two *iews
Case Study % #
4ilateral 7creening 6ammogram Comparison !as made to multiple prior studies 2indings: 3,amination demonstrates moderatel dense fibroglandular tissue. * nodular densit is seen in the left central areolar region+ !hich !as seen on the prior studies and is essentiall unchanged. There is no
Instructor's Guide
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e1idence of an suspicious calcifications on the multiple 1ie!s. S$in and nipples ha1e no abnormalit . *s compared !ith prior stud + there is no significant inter1al change. /mpression: >o radiographic e1idence of malignanc . >o significant inter1al change since prior stud . ;nde/# 6ammograph(" screening Code(s)# 77057 7creening mammograph(" bilateral
Instructor's Guide
Page 85 of 100
Case Study % .
CU4" Upper F; 7eries The K;. stud re1eals a large amount of fecal matter present in the colon. Staples are seen in the right upper Auadrant. The stomach is high and trans1erse in t pe. There is a small sliding hiatal hernia and there is small gastroesophageal reflu,. The duodenal bulb fills !ithout ulceration. The stomach empties !ell. ?pinion: Small sliding hiatal hernia !ith intermittent gastrointestinal reflu,. ;nde/# N-ra(" Fastrointestinal !ract Code(s)# 7.$.& >adiological e/amination" gastrointestinal tract" upper+ with or without dela(ed films" with CU4
Case Study % 1
=ral Cholec(stogram The gallbladder concentrates the contrast medium !ell and numerous radiolucent calculi are demonstrated. 0iagnosis: Cholelithiasis ;nde/# Cholec(stograph( Code(s)# 7.$'0 Cholec(stograph(" oral contrast
Case Study % 3
CU4 and ;ntra*enous (elogram The K;. is normal. >o urinar calcifications can be identified. 2ollo!ing the intra1enous in:ection+ there is a good delineation of the urinar tract. The $idne s are small measuring (.5 cm in their greatest length. The renal collecting s stem+ ureters+ and bladder appear normal. ?pinion: The $idne s measure slightl small. The urinar tract is other!ise normal. ;nde/# (elograph(
Code(s)# 7..00 Urograph( (p(elograph()" intra*enous" with or without CU4" with or without tomograph(
Instructor's Guide
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Chapter 0
Pathology and 9a:oratory
Case Studies
Case Study % 1
G ! R"# C$ %&S'R(
Sodium )otassium C*loride 'otal CO2 34 Glucose +,! Creati-i-e &o-i.ed Calcium 6.1
13/
3.3
06
114
21
1./
;nde/# =rgan or 1isease-=riented anel" 6etabolic" 4asic Code(s)# %00.7 4asic 6etabolic anel
Case Study % #
* stool sample is submitted to the lab for =elicobacter p lori ;nde/# <elicobacter (lori" 7tool Code(s)# %700% <elicobacter p(lori" stool
Case Study % .
* ph sician suspects that a patient might ha1e an adrenocortical insufficienc and orders an insulin tolerance panel %Cortisol and Flucose' test. ;nde/# ;nsulin (7can range of codes %0.$$" %0.0$-%0.05) Code(s)# %0.0. ;nsulin tolerance panel+ for 3C!< insufficienc(
Case Study % 1
:ipid anel
Instructor's Guide
Page 87 of 100
Test C*olesterol2 serum $3# 'ri4lycerides
"esult 216 51 110
"eference "anges 75-211 31-71 21-251
;nde/# =rgan or 1isease-=riented anel" :ipid anel Code(s)# %006& :ipid anel
Instructor's Guide
Page 88 of 100
Case Study % 3
'est !ame Re6ere-ce Ra-4e Result Glyco*emo4lo5i3.6 7 6./ 5.0 ;nde/# Fl(cohemoglobin Code(s)# %0006 <emoglobin" gl(cos(lated (3&C)
Instructor's Guide
Page 89 of 100
Chapter 1
E$!
Case Studies
Case Study % 1
The patient !as seen in the ph sician@s office after falling and in:uring her an$le. The ph sician performed a brief =P/+ a problem-focused e,am+ and the decision-ma$ing !as straightfor!ard. <hat component%s' of the histor is missing from this scenario6 3nswer# >=7 and 57<
Case Study % #
* #(- ear-old established patient 1isits his famil ph sician for a ph sical that is reAuired b his place of emplo ment. The ph sician documents a comprehensi1e histor + e,am and orders a series of routine tests+ such as a chest I-ra and 3KF. /n addition+ the ph sician counsels the patient about his smo$ing habit. <hat CPT code !ould be selected to represent this ser1ice6 3nswer# ''0'6
Case Study % .
* patient is seen on Lanuar "3+ "00) b a primar care ph sician !ho is a member of ;ni1ersit *ssociates. * cardiologist %also a member of ;ni1ersit *ssociates' sees the patient on >o1ember "#+ "00(. <ould the 1isit on >o1ember "#th be classified as a ne! or established patient6 3nswer# New. 2*en though the patient was seen one (ear prior" the patient is now seen b( a ph(sician of a different specialt(" which would be classified as a new patient.
Case Study % 1
The ph sician sees a patient in Sunn *cres >ursing 2acilit as a follo!-up 1isit. The patient has a urinar tract infection that is not responding to medication. The ph sician documents a problem-focused inter1al histor + e,panded problem-focused e,am and the medical decision-ma$ing !as of moderate comple,it . <hat is the correct CPT code assignment for this ser1ice6 3nswer# ''00%. Note that two of the three )e( components must be met or e/ceeded.
Instructor's Guide
Page 90 of 100
Case Study % 3
Ph sician documents that critical care ser1ices !ere pro1ided to a 1"- ear-old patient for (0 minutes. <hat is the correct 3&8 code assignment for this ser1ice6 3nswer# ''$'&" ''$'$
Instructor's Guide
Page 91 of 100
Chapter 2
!edicine
Case Studies
Case Study % 1
* 35- ear-old patient recei1es an /8 in:ection of the 4 me disease 1accine. ;nde/# ;mmuni?ation 3dministration" =ne HaccineG!o/oid Haccines" :(me 1isease Code(s)# '0.7& ;mmuni?ation administration" ;6" one *accine '0665 :(me disease *accine" adult dosage" for intramuscular use
Case Study % #
* 55- ear-old patient !ith T pe // diabetes mellitus e-mails her registered dietitian to as$ ad1ice about adding a food product to her diet. The dietitian promptl responds to the Auestion and $eeps a record of this correspondence. The date of the last 1isit !as t!o !ee$s ago. ;nde/# =nline ;nternet 3ssessment and 6anagement" Nonph(sician Code(s)# '%'6' =nline assessment and management ser*ice pro*ided b( Jualified nonph(sician health care professional to an established patient" guardian" or health care pro*ider not originating from a related assessment and management ser*ice pro*ided within the pre*ious 7 da(s" using the ;nternet or similar electronic communications networ).
Case Study % .
* 5(- ear-old female is undergoing chemotherap treatment. She is seen in the clinic for a refill for her portable infusion pump. ;nde/# ;nfusion ump" 6aintenance Code(s)# '65$& >efilling and maintenance of portable pump
Case Study % 1
Instructor's Guide
Page 92 of 100
Patient !as diagnosed !ith actinic $eratosis !ith lesions on se1eral locations of the face. The patient recei1es irradiation of the areas !ith photod namic therap illuminator for 15 minutes. ;nde/# hotod(namic !herap(" 2/ternal hotod(namic therap(
Code(s)# '6567
Instructor's Guide
Page 93 of 100
Case Study % 3
* 3"- ear-old female is referred to the .eha1ioral =ealth Clinic due to significant personalit changes. * series of tests is administered to e1aluate the patient@s emotionalit + intellectual abilities+ personalit and ps chopatholog . The computeriDed test is completed in order to assist !ith establishing a diagnosis. ;nde/# s(chiatric 1iagnosis" s(chological !esting" Computer-3ssisted s(chological testing" administered b( computer
Code(s)# '6&00
Instructor's Guide
Page 94 of 100
Chapter 3
Anesthesia
Case Studies
Case Study % 1
Patient admitted for uterine fibroids and d smenorrhea. The surgeon performs a 1aginal h sterectom . ;nde/# 3nesthesia" <(sterectom(" Haginal Code(s)# 00'.. 3nesthesia" for *aginal procedures+ *aginal h(sterectom(
Case Study % #
This is a #(- ear-old man !ith a chronic right-sided submandibular s!elling o1er the last fe! ears. The diagnosis of right sialoadenitis !as made. *n e,cision of right submandibular gland !as performed. ;nde/# 3nesthesia" 7ali*ar( Fland Code(s)# 00&00 3nesthesia for procedures on sali*ar( glands" including biops(
Case Study % .
The patient is a 75- ear-old male !ho !as recentl treated for lo! anterior resection for a stage // superior rectal cancer. *d:u1ant chemotherap + planned. Placement of long-term 1enous access de1ice !as reAuested. Surgeon inserts a Port-a-Cath. ;nde/# 3nesthesia" Central Henous Circulation Code(s)# 0050$ 3nesthesia for access to central *enous circulation
Case Study % 1
The patient is a 57- ear-old male !ho presented to the 3>T Clinic !ith a histor of left-sided nasal obstruction. The follo!ing procedures !ere performed: left ma,illar sinusotom + left anterior ethmoidectom + and remo1al of left nasal pol posis. ;nde/# 3nesthesia" Nose
Instructor's Guide
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Code(s)# 00&60 3nesthesia for procedures on nose and accessor( sinuses+ not otherwise specified
Case Study % 3
Patient has a diagnosis of urinar retention. The surgeon performs a transurethral resection of the prostate. ;nde/# 3nesthesia" !ransurethral rocedures" or 3nesthesia" !U> Code(s)# 00'&. 3nesthesia for transurethral resection of prostate
Instructor's Guide
Page 96 of 100
Chapter 14
;CPCS
Case Studies
/dentif the $e term from the inde, and assign codes from the #CPC$ %evel II to the follo!ing cases.
Case Study % 1
Clubfoot !edge to modif a shoe ;nde/# Clubfoot wedge Code(s)# :00%0 Clubfoot wedge
Case Study % #
Patient has e,treme dr e es. Ph sician inserts temporar + absorbable lacrimal duct implants in each e e. ;nde/# :acrimal duct implant" temporar( Code(s)# 3.$6$ / $ !emporar(" absorbable lacrimal duct implant" each
Case Study % .
*t-ris$ pre-natal assessment for patient !ho is 10 !ee$s pregnant ;nde/# renatal care
Code(s)# <&000 renatal care" at-ris) assessment
Case Study % 1
Screening mammograph + bilateral %direct digital image' ;nde/# 6ammograph( Code(s)# F0$0$ 7creening mammograph(" producing direct digital image" bilateral" all *iews
Case Study % 3
Instructor's Guide
Page 97 of 100
/B pole for infusion ;nde/# ;H ole Code(s)# 20776 ;H pole (Note in the infusion supplies section)
Instructor's Guide
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Chapter 11
"ei :urse ent in the A :ulatory Setting
Case Studies
Case Study % 1 * !edical ,ecessity
* #7- ear-old female patient is seen in an outpatient setting for a 1ariet of s mptoms+ including fatigue+ !ea$ness and insomnia. The ph sician orders the follo!ing tests:
8+S )S" 9+C '32'4 'S$
Instructor's Guide
Page 99 of 100
<hich test%s' does not meet medical necessit 6 3nswer# 73 ( rostate-7pecific 3ntigen) would not be appropriate for a female patient.
Instructor's Guide
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Case Study % # * !edical ,ecessity

8atch the follo!ing diagnoses&s mptoms !ith the appropriate test&procedure. 1. --". --5&? pregnanc (C) lo! bac$ pain (1) *. .. spirometr 3KF
3. --#. --5. --7. ---
hearing loss (2) C?P0 (3) coughing+ sneeDing+ runn nose (5) tach cardia (4)
C. 0. 3. 2.
=uman chorionic gonadotropin %hCF' osteopathic manipulati1e treatment t mpanometr allerg tests

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Instructor's Guide

AC210610: Basic CPT/HCPCS Exercises

Answer Key Chapter 1

AC210610: Basic CPT/HCPCS Exercises

AC210610: Basic CPT/HCPCS Exercises

*ppendi, * Patholog and 4aborator code

"eferencing CPT Assistant

AC210610: Basic CPT/HCPCS Exercises

Application of CPT Exercises

$6&05 $6&05 $6&05

AC210610: Basic CPT/HCPCS Exercises

.iops of lacrimal sac ;nde/# 4iops(" lacrimal sac Code# 6%5$5

AC210610: Basic CPT/HCPCS Exercises

Select the !odifier Exercise

AC210610: Basic CPT/HCPCS Exercises

AC210610: Basic CPT/HCPCS Exercises

AC210610: Basic CPT/HCPCS Exercises

Integu entary Syste

&.1' !edical Ter inology "e(iew

freeDe tissue remo1al of damaged tissue from !ound

basal cell carcinoma

AC210610: Basic CPT/HCPCS Exercises

remo1al of a piece of tissue for e,amination

malignant neoplasm benign neoplasm

5. --- lipoma (2)

&.2' Clinical Concepts

&.#' Integu entary Syste

AC210610: Basic CPT/HCPCS Exercises

1estruction" premalignant+ first lesion

AC210610: Basic CPT/HCPCS Exercises

Abstract from Documentation:

AC210610: Basic CPT/HCPCS Exercises

Post 8edical =istor : 8edications: *llergies: /mmuniDations: h(sical 2/amination#

= pertension9 dementia Colace+ iron+ h drochlorothiaDide+ Pa,il >one. >ot up to date.

Abstract from Documentation:

AC210610: Basic CPT/HCPCS Exercises

Source: >ational Cancer /nstitute. n.d. Bisuals?nline. ;n$no!n photographer&artist. http:&&1isualsonline.cancer.go1&details.cfm6imageidC1777.

AC210610: Basic CPT/HCPCS Exercises

&..' Crossword Pu//le

&.0' Clinical Concepts

8edial malleolus is located in the ------------ %$nee+ an)le'.

AC210610: Basic CPT/HCPCS Exercises

AC210610: Basic CPT/HCPCS Exercises

&.1' !usculos-eletal Syste

AC210610: Basic CPT/HCPCS Exercises

AC210610: Basic CPT/HCPCS Exercises

Abstract from Documentation:

AC210610: Basic CPT/HCPCS Exercises

Abstract from Documentation:

AC210610: Basic CPT/HCPCS Exercises

Abstract from Documentation:

AC210610: Basic CPT/HCPCS Exercises

Source: >ational Cancer /nstitute. n.d. Bisuals?nline. ;n$no!n photographer&artist. http:&&1isualsonline.cancer.go1&details.cfm6imageidC1775.

&.3' !edical Ter inology "e(iew

esophagus (C) bronchus (3) phar n, (4) ethmoid (1)

&.14' Clinical Concepts

AC210610: Basic CPT/HCPCS Exercises

AC210610: Basic CPT/HCPCS Exercises

AC210610: Basic CPT/HCPCS Exercises

&.12' Case Studies * "espiratory Syste "eports

0irect lar ngoscop and remo1al of pol ps from both cords

Abstract from Documentation:

AC210610: Basic CPT/HCPCS Exercises

ppendi, Patholog and 4aborator code