Answers To Chapter Review Exercises, Appendix D

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Appendix D textAC200610: Basic CPT and HCPCS CodingPage 1 of 26Answers to Chapter Review Exercises,Appendix DChapter 1: Introduction to Clinical CodingChapter 1 Review1.The American Medical Association (AMA) updates the CPT codes, and the Centers for Medicareand Medicaid Services (CMS) updates the HCPCS National Codes (Level II).2.Four3.ICD-9-CM and CPT/HCPCS4.a.Diagnosis: ICD-9-CMProcedure: CPT/HCPCSb. Diagnosis: ICD-9-CMProcedure: CPT/HCPCSc.UB-04 (CMS-1450)5.ICD-9-CM6.Procedure code 11440 is linked with diagnosis code #1 (216.3). Procedure code 82951 is linked withdiagnosis code #3 (790.29).Note: Depending on the carrier, you may link more than one reference number in block 24E, whereassome payers require just one. When reporting more than one code on a CMS-1500 claim, enter thecode with the highest fee in line 1 of block 24 and the remaining in descending order of charges.Chapter 2: Application of the CPT SystemExercise 2.1 Organization of CPT1.Surgery2.Evaluation and Management3.Pathology and Laboratory4.Category II codes5.Medicine6.Radiology7.Anesthesia8.Category III codes9.Maternity Care and Delivery10.StandbyServices

Appendix D text11.Radiation Oncology12.Surgical PathologyAC200610: Basic CPT and HCPCS CodingPage 2 of 26Exercise 2.2 CPT Conventions1.Repair blood vessel, direct; hand, finger2.Two3.Revised descriptor4.Esophagoscopy, rigid or flexible, with insertion of plastic tube or stent5.New descriptor6.No7.No8.13152, 131539.4081410.31578, 31576Exercise 2.3 Use of the Alphabetical Index1.23400Green operation, see scapulopexy2.10021Fine Needle Aspiration3.35556Graft, see Bypass graft, Femoral Artery or Popliteal Artery4.49555Hernia repair, femoral, recurrent5.26991Incision and drainage, bursa, hip6.01680Anesthesia, shoulder7.31525Laryngoscopy, direct8.72149MRI see magnetic resonance imaging, spine, lumbar9.11055Paring, skin lesion, benign hyperkeratotic, single lesion10.86701HIV-1, antibody11.41105Biopsy, tongue12.43239Esophagogastroduodenoscopies, see Endoscopy, gastrointestinal, upper, biopsy13.29881Arthroscopy, surgical, knee14.95827EEG, see Electroencephalography, sleep15.65220Removal, foreign body, cornea, without slit lamp16.58356 Endometrial Ablation (this exercise is difficult find in the alphabetic index, but a good lessonon how locating correct entries in the index is not a perfect science). Endometrial ablation directs coderto 58363, which is endometrial ablation (thermal). Alert students to look at the code below 58363—58356.17.4008F Beta-blocker therapy, see Performance Measures, Therapeutic, preventive or otherinterventions, Beta-Blocker therapy18.0184T Excision, Tumor, Rectum, Transanal Endoscopic19.77082DXA, see Dual X-ray Absorptiometry, vertebral fracture

Appendix D text20.25112AC200610: Basic CPT and HCPCS CodingPage 3 of 26Ganglion, Cyst, Wrist ExcisionExercise 2.4 CPT Coding Process1.Colonoscopy and polypectomy2.45384–453853.How was the polyp removed (hot biopsy forceps, snare, and so on)?4.“Was removed with hot biopsy forceps and retrieved”5.45384Exercise 2.5 CPT Coding Process1.Excision2.Can be located under Excision, lesion, skin; or Lesion, skin, excisionSelections: Benign11400–11471Malignant 11600–116463.Pathologic diagnosis indicates that the lesion was malignant (11600–11646).4.Documentation is needed to code malignant lesion, size of lesion margins (or size of excision)(2.0 cm 0.5 cm 0.5 cm 3.0 cm excision site) and site (arm).5.11603Exercise 2.6 CPT Coding Process1.2.Hernia repairIndex entries: Hernia repair, umbilicus; Repair, hernia, umbilical. Codes to review:49580–495873.Age of patient; incarcerated or strangulated hernia4.Review of documentation (38-year-old patient and no documentation for incarcerated/strangulatedhernia). Using the abstracted documentation and process of elimination, the correct code would be49585.5.Wound closure would be an integral part of the procedure and would not be assigned a CPT code.Exercise 2.7 Coding References1.453802.CPT Assistant, January 1996, page 7, instructs the coder to assign 45385. CPT Assistant, January2004, states that if a small polyp is removed via cold knife biopsy, the appropriate code is 45380.This is a good example of the need to research the most current coding advice.

Appendix D textAC200610: Basic CPT and HCPCS CodingPage 4 of 26Exercise 2.8 Coding References1.When a biopsy of a lesion is obtained and the remaining portion of the same lesion is thenexcised/fulgurated, only the code for the excision/fulguration should be used. When the biopsy istaken from a different lesion than the one excised, the biopsy code and an additional code for theremoval of the separate lesion are reported. It would be appropriate to append modifier 59 to thecode reported for the biopsy procedure.2.Reference: CPT Assistant, October 2004, Skin Biopsy Coding Guidelines.Exercise 2.9 Coding References1. No. Code 36479 would be reported only once. The code descriptor for code 36479 states, “second andsubsequent veins treated in a single extremity, each through separate access sites,” indicating thatthe second, third, fourth, etc. vein(s) are represented in code 36479. No additional reporting occursafter the second vein is treated.2.Reference: CPT Assistant, July 2012, pages 12-13 (Frequently Asked Questions)Exercise 2.10 Chapter 2 Review1.Bullet2.11100 and 111013.Category III4.423205.408436.Removal of less than 80% of vulvar area, and there was removal of skin and deep subcutaneoustissue. (See the note before CPT code 56405.)7.Method of removal8.No. Versed is a type of conscious sedation. The symbol appears before code 43235; therefore,administration/monitoring of conscious sedation would be inherent in the procedure.9.76857, based on the definitions provided in the note before code 7683010.11730, 11732, 11732Chapter 3: ModifiersExercise 3.1 Chapter 3 Review1.552.773.224.625.536.64721–50Carpal tunnel syndrome, decompression7.11730–FAAvulsion, nails

Appendix D textAC200610: Basic CPT and HCPCS Coding8.11043–73Debridement, muscle9.64611-52Chemodenervation, salivary glands10.19102–LTBiopsy, breast11.28485–RTFracture, metatarsal, open treatmentPage 5 of 26Note: –T9 is not applicable in this case because the procedure refers to the bones of the foot, not the toes.Chapter 4: SurgeryExercise 4.1 Integumentary System‐ Debridement1.11042 Debridement, skin, subcutaneous tissue2.11010 Debridement, skin, with open fracture3.11005 Debridement, skin, infected11008 Removal, mesh, abdominal wallExercise 4.2 Integumentary System ‐ Lesions1.11421Excision, skin, lesion, benign; or11402Lesion, skin, excision, benign2.17110Lesion, skin, destruction, benign3.11642Excision, skin, lesion, malignant; or Lesion, skin, excision, malignant4.11200Skin, tags, removal5.11403Lesion, skin, excision, benign6.11644Lesion, skin, excision, malignant7.11641Lesion, skin, excision, malignant11640Exercise 4.3 Integumentary System1.11442Excision, skin, lesion, benign; or Lesion, skin, excision, benignExercise 4.4 Integumentary System1.11308Lesion, skin, shavingExercise 4.5 Integumentary System – Wound Repairs1.12002Wound, repair; or Repair, wound, simple2.12032Wound, repair; or Repair, wound, intermediate3.12041Wound, repair; or Repair, wound, intermediate

Appendix D text12002AC200610: Basic CPT and HCPCS CodingPage 6 of 26Wound, repair; or Repair, wound, simple (sum of repairs)Exercise 4.6 Integumentary System1.12001Wound, repair; or Repair, wound, simpleExercise 4.7 Integumentary System1.1203212005Wound, repair; or Repair wound (simple and intermediate)Exercise 4.8 Integumentary System1.1312113122Wound, repair (complex)Exercise 4.9 Integumentary System1.11603Lesion, skin, excision, malignant12031Wound, repair (intermediate)Exercise 4.10 Integumentary System – Skin Grafts1.14021Skin Graft and Flap, tissue transfer2.1515015151Skin Graft and Flap, tissue-cultured3.15220Skin Graft and Flap, free skin graft, full thicknessExercise 4.11 Integumentary System1.15120Autograft, skin, epidermal11646Excision, skin, lesion, malignant; or Lesion, skin, excision, malignantExercise 4.12 Integumentary System1.15100Skin, grafts, freeExercise 4.13 Integumentary System1.19000–LTBreast, cyst, puncture aspirationExercise 4.14 Integumentary System1.19125–LTExcision, breast, cyst; or Breast, excision, lesion by needle localizationNote: The hospital also would assign 19290 for placement of the wire. The surgeon would not assign thiscode because the radiologist performed the procedure. In addition, a radiology code would besubmitted for both the facility and the radiologist. Radiology is introduced in chapter 5.Exercise 4.15 Integumentary System1.19120–RT Breast, excision, cyst; or Excision, breast, cystNote: The entire nodule was excised, not just a piece of tissue, which is implied with the term biopsy.

Appendix D textAC200610: Basic CPT and HCPCS CodingPage 7 of 26Exercise 4.16 Integumentary System Review Review1. 16020Burns, dressings2. 14020Skin Graft and Flap, tissue transferNote: Excision of lesion is included and should not be assigned an additional code.3. 12032Wound, repair, intermediateNote: Anatomic modifiers (LT, RT) are not appropriate.4. 19102–LT Breast, biopsy19295–LT Breast, metallic localization clip placement5.11606Lesion, skin, excision, malignant6.11770Pilonidal cyst, excision (Single-layer closure indicates “simple.”)7.11750–TA Nails, removal8.15781Dermabrasion9.17273Skin, destruction, malignant lesion10.11043Debridement, skin, subcutaneous tissueExercise 4.17 Musculoskeletal System ‐ Fractures1.25545–LTFracture, ulna, shaft, open treatment2.2180021800Fracture, rib, closed treatment3.23605–RT Fracture, humerus, closed with manipulation4.27532–RT Fracture, tibia, closed treatment (initial cast application included with treatment code)5.27562–RT Dislocation, patella, closed treatment6.27514–LT7.24516–RT Fracture, humerus, shaftFracture, femur, distalExercise 4.18 Musculoskeletal System1.29515–RT Splint, leg, shortNote: E/M code 99283–25 is applicable in this case.Exercise 4.19 Musculoskeletal System1.27788–LTFracture, fibula, closed treatment; or Fracture, fibula, with manipulation

Appendix D textAC200610: Basic CPT and HCPCS CodingExercise 4.20 Musculoskeletal System ‐ Arthroscopy1.29875–LTArthroscopy, surgical, knee2.29827–RT Arthroscopy, surgical, shoulder3.29846–LTArthroscopy, surgical, wrist4.29837–LTArthroscopy, surgical, elbowExercise 4.21 Musculoskeletal System1.29882–RT Arthroscopy, surgical, kneeExercise 4.22 Musculoskeletal System Review1.28475–LT Fracture, metatarsal, closed28475–LT2.28285–T1 Hammertoe repair3.27766–RT Fracture, ankle, medial4.20101Wound, exploration, penetrating, chest5.23030Hematoma, shoulder, drainage6.24343–RT Ligament, repair, elbow7.28740–LT Arthrodesis, tarsal joint8.29844–RT Arthroscopy, surgical, wrist9.28108–T2 Excision, cyst, phalanges, toe10.27372–RT Removal, foreign body, knee jointExercise 4.23 Respiratory System ‐ Endoscopy1.31255–50Ethmoidectomy, endoscopic2.31238–LT Endoscopy, nose, surgical; or Nose, endoscopy, surgical3.31233–50Sinusoscopy, sinus, maxillaryExercise 4.24 Respiratory System1.30520Septoplasty31267–50Endoscopy, nose, surgical30140–50Turbinate, excisionExercise 4.25 Respiratory System ‐ Laryngoscopy1.31540Laryngoscopy, direct2.31577Laryngoscopy, fiberoptic3.31510Laryngoscopy, indirectPage 8 of 26

Appendix D text4.31541AC200610: Basic CPT and HCPCS CodingLaryngoscopy, directExercise 4.26 Respiratory System1.31536Laryngoscopy, directExercise 4.27 Respiratory System ‐ Bronchoscopy1.31628Bronchoscopy, biopsy2.31641Bronchoscopy, removal, tumor3.31625Bronchoscopy, biopsy31623Bronchoscopy, brushingExercise 4.28 Respiratory System1.31623Bronchoscopy, brushingExercise 4.29 Respiratory System Review1.32666Thoracoscopy, surgical with wedge resection of lung2.30110Polyp, nose, excision, simple3.31625Bronchoscopy, biopsy4.30300Removal, foreign body, nose5.31237Endoscopy, nose, surgical6.30903–507.31540Laryngoscopy, direct8.32556Puncture, pleural cavity, drainage9.31576Laryngoscopy, fiberoptic10.30130Excision, turbinateEpistaxisExercise 4.30 Cardiovascular System1.33207Pacemaker, heart, insertion; or Insertion, pacemaker, heartExercise 4.31 Cardiovascular System1.36590Removal, venous access deviceExercise 4.32 Cardiovascular System1.36556Insertion, venous access device, centralExercise 4.33 Cardiovascular SystemReview1.33222Pacemaker, heart, revise pocket, chestPage 9 of 26

Appendix D textAC200610: Basic CPT and HCPCS CodingPage 10 of 262.36833Arteriovenous Fistula, Revision, with thrombectomy3.33824Ductus Arteriosus, repair4.36215Catheterization, brachiocephalic artery5.36582Venous Access Device, replacement6.36870Arteriovenous Fistula, thrombectomy, graft; or Thrombectomy, arteriovenous fistula, graft7.37224Angioplasty, Femoral artery, intraoperative8.33464Valvuloplasty, tricuspid valve9.33217Insertion, pacing cardio-defibrillator, leads10.37722–50Vein, stripping, saphenousExercise 4.34 Digestive System ‐ Endoscopy1.43202Endoscopy, esophagus, biopsy43217Endoscopy, esophagus, removal, polypNote: Modifier 59 would apply.2.45305Proctosigmoidoscopy, biopsy3.43258Endoscopy, gastrointestinal, upper, destruction of lesion4.45380Endoscopy, colon, biopsy5.43264Bile Duct, endoscopy, removal, calculiExercise 4.35 Digestive System1.43247Endoscopy, gastrointestinal, upper, foreign bodyExercise 4.36 Digestive System1.45384Colonoscopy, removal, polyp; or Endoscopy, colon, removal, polypExercise 4.37 Digestive System1.45330Sigmoidoscopy, explorationExercise 4.38 Digestive System – Hernia Repairs1.49500Hernia, repair, inguinal2.49561–RT Hernia, repair, incisional, incarcerated49568Implantation, mesh3.49651Laparoscopy, hernia repair, inguinal, recurrent4.49521Hernia, repair, inguinal, incarcerated5.49585Hernia, repair, umbilicus, reducible6.49656Hernia, repair, incisional, laparoscopicExercise 4.39 Digestive System

Appendix D text1.AC200610: Basic CPT and HCPCS CodingPage 11 of 2649505–LT Hernia, repair, inguinalNote: Mesh code is only coded with incisional and ventral hernia repairs.Exercise 4.40 Digestive System Review1.46930Hemorrhoids, destruction2.43644Laparoscopy, gastric restrictive procedures3.43245Endoscopy, gastrointestinal, upper, dilation4.42200Palatoplasty5.45383Colonoscopy, destruction, nia Repair, inguinal, recurrent, incarcerated8.49322Laparoscopy, aspiration9.46610Anoscopy, removal, polyp10.42809Removal, foreign body, pharynxExercise 4.41 Urinary System ‐ Cystoscopy1.52332Cystourethroscopy, insertion, indwelling ureteral stent2.52234Cystourethroscopy, with fulguration, tumor3.52353Cystourethroscopy, lithotripsy4.52282Cystourethroscopy, insertion, urethral stentExercise 4.42 Urinary System1.52352Cystourethroscopy, removal, calculus52332–51–RT Insertion, stent, ureteralNote: Because the stent was inserted at the conclusion of the procedure, one can presume it is anindwelling ureteral stent.Exercise 4.43 Urinary System1.52234Cystourethroscopy, with fulguration, tumorExercise 4.44 Urinary System Review1.51992Sling Operation, stress incontinence2.53260Excision, polyp, urethra3.52235Cystourethroscopy, with fulguration, tumor4.51525Cystotomy, excision, bladder diverticulum5.50200Kidney, biopsy6.52351Cystourethroscopy

Appendix D textAC200610: Basic CPT and HCPCS CodingPage 12 of 267.52290 Cystourethroscopy, with ureteral meatotomy (bilateral modifier not appropriate becausecode description specifies “unilateral” or “bilateral”)8.51785Electromyography, sphincter muscles, urethral, needle9.51701Insertion, catheter, urethral10.50920Fistula, ureterExercise 4.45 Male Genital System1.54057Lesion, penis, destruction, laser surgery2.10060Incision and drainage, abscess, skin3.55845Prostatectomy, retropubic, radical4.54861Epididymectomy, bilateral5.54150Circumcision, surgical excision, newbornExercise 4.46 Male Genital System1.55875Prostate, brachytherapy, needle insertionExercise 4.47 Male Genital System1.54520–LT Orchiectomy, simpleExercise 4.48 Male Genital System Review1.54840Spermatocele, excision2.54415Penile Prosthesis, removal, inflatable3.54690Orchiectomy, laparoscopic4.54322Hypospadias, one stage, meatal advancement5.54865Epididymis, exploration, biopsy6.55100Scrotum, abscess, incision and drainage7.54240Penis, plethysmography8.54060Penis, lesion, destruction, surgical excision9.54640–5010.55866Orchiopexy, inguinal approachLaparoscopy, prostatectomyExercise 4.49 Female Genital System1.58670Laparoscopy, oviduct surgery2.58120Dilation and curettage, corpus uteri3.59812Abortion, incomplete4.49322Laparoscopy, aspiration5.58545Laparoscopy, removal, leiomyomata

Appendix D text6.58262AC200610: Basic CPT and HCPCS CodingPage 13 of 26Hysterectomy, vaginal, removal tubes/ovariesExercise 4.50 Female Genital System1.57461LEEP ProcedureExercise 4.51 Female Genital System1.58558Hysteroscopy, surgical with biopsyExercise 4.52 Female Genital System Review1.57455Colposcopy, biopsy (range of codes)2.56620Vulvectomy, simple, partial (use definitions at beginning of section)3.58662Laparoscopy, destruction, lesion4.58150Hysterectomy, abdominal, total5.57023Incision and Drainage, hematoma, vagina6.56605Biopsy, vulva (external genitalia)57105Biopsy, vagina7.58554Hysterectomy, vaginal8.58561Hysteroscopy, removal, leiomyomata9.58290Hysterectomy, vaginal10.58356Ablation, endometrium, ultrasound guidanceExercise 4.53 Endocrine System Review1.60280Thyroglossal Duct, cyst, excision2.60650Laparoscopy, adrenal gland, excisionNote: There are several misleading index entries for this example. Adrenalectomy, laparoscopic, leads to50545. Same is true for Laparoscopy, adrenalectomy.3.60260–50Thyroid Gland, excision, total, removal of all thyroid tissue4.60300Thyroid gland, cyst, aspiration5.60500Parathyroid Gland, excisionExercise 4.54 Nervous System1.64445Injection, nerve, anesthetic2.64702–F8 Neuroplasty, digital nerve69990Operating microscope3.62281Epidural, injection4.64831–F5 Neurorrhaphy64832–F8

Appendix D textAC200610: Basic CPT and HCPCS CodingExercise 4.55 Nervous System1.63075DiscectomyExercise 4.56 Nervous System Review1.62220Creation, shunt, ventriculo2.64712Neuroplasty, peripheral nerve3.64782Excision, neuroma4.64840Suture, nerve5.63272Laminectomy6.62311Epidural, injection7.63688Neurostimulators, removal, pulse generator8.63706Myelomeningocele, repair9.64408Nerves, injection, anesthetic10.61312Craniotomy, surgeryExercise 4.57 Eye and Ocular Adnexa1.66984–LT Phacoemulsification, removal, extracapsular cataractExercise 4.58 Eye and Ocular Adnexa Review1.652222.67810–E1 Biopsy, eyelid3.681104.67800–E3 Chalazion, excision, single5.673116.67700–E3 Eyelid, abscess, incision and drainage7.67906–E1 Blepharoptosis, repair, superior rectus technique with fascial sling8.67961Eyelid, repair, excisional9.67914Ectropion, repair, suture10.Removal, foreign body, cornea with slit lampLesion, conjunctiva, excisionStrabismus, repair, one horizontal muscle67413–RT Orbitotomy, with removal of foreign bodyExercise 4.59 Auditory System1.69436–50 Tympanostomy (–50 for bilateral)Exercise 4.60 Auditory System Review1.69910Labyrinthectomy with mastoidectomy2.69205–LT Removal, foreign body, auditory canal, external, with anesthesia3.69636Tympanoplasty, with mastoidotomy, with ossicular chain reconstructionPage 14 of 26

Appendix D textAC200610: Basic CPT and HCPCS CodingPage 15 of 264.69005–LT Abscess, ear, external, complicated (would expect to see documentation to explain whythe procedure took an extensive amount of time)5.69401Eustachian Tube, inflation, without catheterizationExercise 4.61 Chapter 4 Review: Coding for Facility1.42305Incision and drainage, abscess, parotid gland2.69436–50 Tympanostomy3.57455Colposcopy, biopsy4.52234Cystourethroscopy, with fulguration, tumor5.19101–LT Biopsy, breast6.120517.26750–F5 Fracture, phalanges, closed treatment, distal8.31536Laryngoscopy, direct9.36569Catheter, venous, central line10.45333Sigmoidoscopy, removal, polyp11.49507–50 Hernia

code because the radiologist performed the procedure. In addition, a radiology code would be submitted for both the facility and the radiologist. Radiology is introduced in chapter 5. Exercise 4.15 Integumentary System 1. 19120–RT Breast, excision, cyst; or Excision, breast, cyst

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