ICD-10-CM Essential Exam Review

Guideline: Use the Most Specific Code Available

1. Coding Specificity:
o Always assign the most specific code that reflects the patient's
documented condition.
2. Diabetes Mellitus Example:
o If a patient has type 2 diabetes mellitus (DM) with diabetic
neuropathy, use:
 E11.40 (Type 2 diabetes mellitus with diabetic neuropathy,
unspecified)
o Do not use E11.9 (Type 2 diabetes mellitus without complications), as
it fails to capture the associated complication.
3. Key Point:
o Coding to the highest level of specificity ensures accurate
representation of the patient's condition, improves documentation
quality, and supports proper reimbursement.

Guideline: Code to the Highest Level of Certainty

1. When the Diagnosis is Probable:
o If the provider documents probable pneumonia (or any other
uncertain condition), code the symptoms instead of assigning a
definitive diagnosis.
o Example: For "probable pneumonia," code the symptoms of
pneumonia, such as R09.81 (Pleural effusion) or other relevant
respiratory symptoms, until a definitive diagnosis is made.
2. Importance of Coding Symptoms:
o When a diagnosis is not confirmed (e.g., described as "probable" or
"suspected"), coding symptoms ensures:
 Accuracy in reflecting the patient's current condition.
 Compliance with coding rules and guidelines.
3. Key Point:
 o Always wait for definitive documentation from the provider before
coding a condition as confirmed, but in cases of uncertainty, coding
symptoms maintains the integrity and accuracy of the clinical record.

Guideline: Sequence Codes Correctly

1. Sequencing Based on Primary Reason for Visit:
o If a patient presents with a primary diagnosis of I50.9 (Heart failure,
unspecified) and a secondary diagnosis of J44.9 (Chronic
obstructive pulmonary disease [COPD], unspecified), sequence
the codes as follows:
 I50.9 should be sequenced first if heart failure is the primary
reason for the visit.
 J44.9 should be sequenced second as it is the secondary
diagnosis.
2. Importance of Proper Sequencing:
o Correct sequencing ensures that the primary reason for the
patient's visit is accurately represented in the coding.
o This not only improves the accuracy of the medical record but also
helps with maximizing reimbursement compliance, as payers
typically reimburse based on the primary diagnosis.
3. Key Point:
o Always follow the provider’s documentation to determine the primary
reason for the visit and sequence codes accordingly. If there is any
uncertainty, clarify with the provider to ensure accurate coding.

Guideline: Acute vs Chronic Conditions

1. Sequencing Acute and Chronic Conditions:
o If a patient has both acute bronchitis (J20.9) and chronic
obstructive pulmonary disease [COPD] (J44.0), code the acute
condition first followed by the chronic condition.
 J20.9 (Acute bronchitis) should be sequenced first because it is
the acute condition.
 J44.0 (COPD with acute exacerbation) should be sequenced
second as it is chronic.
 2. Why Acute Conditions Are Prioritized:
o Prioritizing acute conditions reflects their immediate clinical
significance in the patient's care and treatment plan. Acute
conditions generally have a more urgent clinical impact, so they should
be coded first to reflect this in the medical record.
3. Key Point:
o Always code the acute condition first unless the acute condition is
resolved and the chronic condition is the primary focus of the visit.

Guideline: Laterality
1. Using Laterality Codes:
o For osteoarthritis of the right knee, use M17.11 (Unilateral
primary osteoarthritis, right knee), not just M17.9 (Osteoarthritis of
knee, unspecified).
o M17.11 specifies the laterality (right knee), providing more accurate
coding.
2. Importance of Laterality in Coding:
o Using codes that specify laterality (e.g., right vs. left side) ensures
precision in the medical record.
o It also helps to align with detailed documentation and accurately
represent the patient's condition.
3. Key Point:
o Always refer to documentation to determine the side of the body
affected, and select the correct laterality code to improve both the
accuracy and completeness of the diagnosis.

Guideline: Combination Codes

1. Using Combination Codes:
o For a patient with hypertension and heart disease, use I11.9
(Hypertensive heart disease without heart failure) instead of coding the
conditions separately.
o This combination code includes both the hypertension and heart
disease, simplifying the coding process.
2. Importance of Combination Codes:
 o Combining related conditions into one code avoids redundancy and
ensures that the documentation is concise and accurate.
o It aligns with coding guidelines, improving both the accuracy of the
record and the efficiency of the coding process.
3. Key Point:
o Always check for the presence of combination codes that encompass
multiple conditions, as this reduces the need for multiple codes while
maintaining coding accuracy.

Guideline: Manifestation Codes

1. Using Manifestation Codes:
o For diabetic retinopathy, code E11.319 (Type 2 diabetes mellitus
with unspecified diabetic retinopathy without macular edema) and add
the appropriate code to capture the manifestation of the condition
(e.g., H36.0 for diabetic retinopathy).
o Manifestation codes are necessary to provide a comprehensive view of
the condition and its complications.
2. Importance of Manifestation Codes:
o Adding manifestation codes helps to fully represent complex
conditions, as required by ICD-10. It ensures all aspects of the
condition, including both the underlying cause and its effects, are
accurately captured in the medical record.
3. Key Point:
o Always identify and add the appropriate manifestation code to
ensure complete and accurate coding, particularly when the condition
leads to additional complications or effects.

Guideline: Avoid Using Codes for Historical Conditions

1. Coding Historical Conditions:
o If a patient has a history of myocardial infarction but is now
asymptomatic, use Z86.74 (Personal history of sudden cardiac
arrest) instead of I21 (Acute myocardial infarction).
 o Z86.74 accurately reflects the patient’s personal history and
current asymptomatic status, while I21 would be incorrect as it
represents an acute event.
2. Importance of Differentiating Between Active and Historical
Conditions:
o Differentiating between active conditions and historical conditions
ensures clarity in coding and prevents misrepresentation of the
patient's current health status.
o Accurate coding ensures the clinical picture is correctly depicted for
both treatment and reimbursement purposes.
3. Key Point:
o Always review the documentation to determine whether the condition
is current or historical. Use Z codes for historical conditions when the
patient is no longer symptomatic.

Guideline: Compilation of Care

1. Post-Surgical Wound Infection:
o For a post-surgical wound infection, use T81.4XXA (Infection
following a procedure, initial encounter) as the primary code.
o This code captures the post-surgical complication and specifies the
timing of the care (initial encounter).
2. Importance of Correctly Coding Post-Surgical Complications:
o Appropriately coding post-surgical complications ensures
accurate representation of the patient's condition and the nature of
care required.
o It highlights both the type of complication and the timing of the
encounter (initial, subsequent, or sequela).

Guideline: Multiple Conditions

1. Coding Multiple Conditions:
o If a patient has both hypertension (I10) and diabetes (E11.9),
code both conditions.
o Documenting both conditions ensures that the healthcare provider has
a comprehensive understanding of the patient's health status.
2. Importance of Documenting and Coding Multiple Conditions:
 o Documenting all relevant conditions provides a thorough and
accurate picture of the patient's overall health, facilitating proper
treatment planning, care, and reimbursement.

Fever Coding Guidelines (R50.9):

1. R50.9 (Fever, unspecified):

o Use R50.9 when the fever is not attributed to a specific condition.
2. Fever due to an infection:
o Code the underlying infection as the primary diagnosis.
o Use R50.9 as a secondary code to capture the fever.

Example:

 For an unspecified viral infection causing fever, assign:

o B34.9 (Viral infection, unspecified) as the primary diagnosis.
o R50.9 (Fever, unspecified) as the secondary diagnosis.

Sepsis Coding Guidelines (A41.9):

1. Underlying Infection First:

o Code the underlying infection when the causative agent is
identified.

Example:

 For sepsis due to Staphylococcus aureus, assign:

o A41.01 (Sepsis due to Methicillin-susceptible Staphylococcus aureus).

2. A41.9 (Sepsis, unspecified organism):

o Use A41.9 if the type of infection or causative organism is
unknown or not documented.

AIDS/HIV Coding Guidelines (B20, Z21):

1. B20 (HIV):
o Use B20 for patients with symptomatic HIV/AIDS (i.e., those with
HIV-related illnesses).
o Once a patient has developed an HIV-related illness, always use B20
for subsequent encounters, even if the patient is asymptomatic.
2. Z21 (Asymptomatic HIV infection status):
 o Use Z21 for patients with asymptomatic HIV infection (i.e., no HIV-
related illness has been diagnosed).

Important Notes:

 If the documentation indicates that the patient is HIV-positive but does not
specify whether they are symptomatic or asymptomatic, query the provider
for clarification.
 Avoid using Z21 if the patient has ever been diagnosed with an HIV-related
illness—use B20 instead.

Kidney Stones Coding Guidelines (N20.0):

1. N20.0 (Calculus of kidney):

o Use N20.0 for kidney stones.
2. Associated Hydronephrosis:
o If kidney stones are associated with hydronephrosis, also code:
 N13.2 (Hydronephrosis with renal and ureteral calculous
obstruction).

Note: Ensure proper documentation supports the presence of hydronephrosis and

the calculous obstruction when coding both conditions.

Urinary Tract Infection (UTI) Coding Guidelines (N39.0):

1. N39.0 (Urinary tract infection, site not specified):
o Use N39.0 for a UTI when the specific site is not documented.
2. Specific Pathogen Identified:
o If the causative organism is identified, also code the pathogen.
o Example: For UTI caused by Escherichia coli, assign:
 N39.0 (Urinary tract infection, site not specified) as the primary
code.
 B96.20 (Unspecified Escherichia coli [E. coli] as the cause of
diseases classified elsewhere) as the secondary code.
Note: Always verify documentation for specificity regarding the infection site (e.g.,
bladder, kidneys) and the pathogen involved.

Hypertension Coding Guidelines (I10-I15):

1. I10 (Essential [Primary] Hypertension):
o Use I10 for uncomplicated hypertension (i.e., no associated
conditions like heart disease or chronic kidney disease).
2. Hypertension with Chronic Kidney Disease (CKD):
o Use I12.9 (Hypertensive chronic kidney disease with stage 1 through
stage 4 chronic kidney disease, or unspecified chronic kidney disease)
when:
  Hypertension and CKD are documented.
 The CKD is stage 1 through stage 4, or the stage is
unspecified.
Note:
 Assign an additional code from N18.1-N18.4 or N18.9 to identify the
specific stage of CKD when known (e.g., N18.3 for stage 3 CKD).
 Hypertension and CKD are assumed to be causally related unless explicitly
stated otherwise.

Diabetes Mellitus Coding Guidelines (E08-E13):

1. Type of Diabetes Mellitus:
o Use the appropriate code for the type of diabetes mellitus (e.g.,
type 1, type 2, or due to underlying conditions, drugs, or chemicals).
 Example for Type 2 Diabetes Without Complications:
 Assign E11.9 (Type 2 diabetes mellitus without
complications).
2. Diabetes with Complications:
o If the patient has complications, assign a code that specifies the type
of complication.
 Example for Type 2 Diabetes with Diabetic Retinopathy:
 Assign E11.21 (Type 2 diabetes mellitus with diabetic
retinopathy with macular edema or without further
specification).
3. Combination Codes:
o Use combination codes when available to identify both the diabetes
type and the specific complication in a single code.
Note:
 Always review documentation to confirm the type of diabetes, the presence
of complications, and any additional conditions requiring secondary
codes (e.g., hypertension or CKD).
 For conditions caused by diabetes, the causal relationship is assumed unless
documentation states otherwise.

Chronic Kidney Disease (CKD) Coding Guidelines (N18.1-N18.9):

1. Specific Stage of CKD:
o Assign a code from N18.1-N18.9 to identify the specific stage of CKD.
o Example: Use N18.5 for chronic kidney disease, stage 5.
2. CKD Due to Hypertension:
o If CKD is due to hypertension, use a combination code to capture
both the hypertension and CKD.
o Example:
 Assign I12.9 (Hypertensive chronic kidney disease with stage 1
through stage 4 CKD, or unspecified CKD) for CKD stages 1–4 or
unspecified CKD.
 Assign I13.2 (Hypertensive heart and chronic kidney disease
with stage 5 CKD or end-stage renal disease) if there is both
heart failure and CKD stage 5 or ESRD.
 3. Additional CKD Codes:
o Include an additional code from N18.1-N18.6 to specify the stage of
CKD, even when using a combination code.
 Example: For hypertensive CKD stage 5, assign:
1. I12.9 (Hypertensive CKD)
2. N18.5 (CKD, stage 5)
Note:
 Always confirm causation (e.g., CKD due to hypertension or diabetes) if not
explicitly stated in the documentation.
 Use N18.6 for end-stage renal disease (ESRD) when documented.

Pneumonia Coding Guidelines (J18.9):

1. Unspecified Pneumonia:
o Use J18.9 (Pneumonia, unspecified organism) when the causative
organism is not specified in the documentation.
2. Pneumonia Due to a Specific Organism:
o Assign the appropriate code for pneumonia caused by a specific
organism.
o Example:
 For pneumonia due to Streptococcus pneumoniae, use J13
(Pneumonia due to Streptococcus pneumoniae).
Important Notes:
 Always check the documentation for the specific organism responsible for the
pneumonia.
 If additional details (e.g., aspiration or hospital-acquired pneumonia) are
available, assign codes accordingly.

Acute Respiratory Failure Coding Guidelines (J96.0-J96.2)

1. Acute Respiratory Failure:
o Use J96.00 (Acute respiratory failure, unspecified whether with
hypoxia or hypercapnia) for unspecified acute respiratory failure
when the specific type of failure (hypoxia or hypercapnia) is not
documented.
2. Chronic Respiratory Failure:
o If the failure is chronic, use J96.10 (Chronic respiratory failure,
unspecified whether with hypoxia or hypercapnia).
o This code applies to chronic respiratory failure, regardless of whether it
is with hypoxia or hypercapnia, if the specific type is not stated.
3. Key Point:
o Always verify if the respiratory failure is acute or chronic and if
hypoxia or hypercapnia is documented to ensure the most accurate
code selection.

Chronic Obstructive Pulmonary Disease (COPD) Coding Guidelines (J44.9)

1. Unspecified COPD:
o Use J44.9 (Chronic obstructive pulmonary disease, unspecified) when
the documentation does not specify the type or severity of COPD.
 2. COPD with Acute Exacerbation:
o If the patient has an acute exacerbation of COPD, use J44.1 (COPD
with acute exacerbation).
o This code reflects the condition's acute worsening, distinguishing it
from the baseline COPD.
3. Key Point:
o Always verify the documentation to determine if the COPD is
unspecified or if there is an acute exacerbation, ensuring accurate
coding for the severity of the condition.

Asthma Coding Guidelines (J45.909)

1. Unspecified Asthma:
o Use J45.909 (Unspecified asthma, uncomplicated) when asthma is
documented without further specification regarding the severity or any
complications.
2. Asthma with Acute Exacerbation:
o If the asthma is in acute exacerbation, use J45.901 (Unspecified
asthma with acute exacerbation).
o This code reflects the presence of an acute exacerbation,
distinguishing it from the uncomplicated form of asthma.
3. Key Point:
o Always check the documentation for any mention of acute
exacerbation or further details on the asthma’s severity to ensure
accurate coding.

Congestive Heart Failure (CHF) Coding Guidelines (I50.9)

1. Unspecified Heart Failure:
o Use I50.9 (Heart failure, unspecified) when the type of heart failure is
not specified in the documentation.
2. Systolic Heart Failure:
o If the heart failure is systolic, use I50.20 (Unspecified systolic
[congestive] heart failure).
o This code specifically identifies systolic heart failure when further
details are not provided.
3. Key Point:
o Always look for more specific documentation (e.g., systolic, diastolic, or
mixed heart failure) to ensure the most accurate code is selected. If
only unspecified heart failure is mentioned, use I50.9.

Myocardial Infarction (MI) Coding Guidelines (I21-I22)

1. Acute Myocardial Infarction (MI):
o For an acute myocardial infarction (MI), use I21.3 (ST elevation
[STEMI] myocardial infarction of unspecified site).
o This code is used when there is an acute STEMI without a specified
site.
2. Subsequent Myocardial Infarction:
 o For a subsequent MI occurring within 28 days of the initial MI, use
I22.9 (Subsequent ST elevation STEMI myocardial infarction of
unspecified site).
o This code is used to indicate that the MI is a subsequent event after
the initial MI.
3. Key Point:
o Always check the timing of the MI (acute or subsequent) and whether a
specific site is documented. If the site is unspecified, use the
appropriate code for STEMI as listed above.

Stroke (Cerebrovascular Accident - CVA) Coding Guidelines (I63-I69)

1. Unspecified Ischemic Stroke:
o Use I63.9 (Cerebral infarction, unspecified) for an unspecified
ischemic stroke when the documentation does not specify the type
or location of the stroke.
2. Sequelae of Stroke (Cerebral Infarction):
o For sequelae (long-term effects) of a previous cerebral infarction,
use I69.3 (Sequelae of cerebral infarction).
o This code is used to capture the aftereffects or complications resulting
from the stroke.
3. Key Point:
o Ensure the documentation reflects whether the stroke is acute (use
I63.9) or whether it represents the sequelae of a previous stroke (use
I69.3).

Cancer Coding Guidelines (C00-D49)

1. Primary Malignancy:
o Always code the primary malignancy first. For example, use C34.90
(Malignant neoplasm of unspecified part of unspecified bronchus or
lung) to indicate the primary cancer site.
2. Metastasis (Secondary Malignancy):
o If there is metastasis (secondary cancer) to another site, add a
second code to represent the metastatic location. For example, use
C79.51 (Secondary malignant neoplasm of bone) for metastasis to the
bone.
3. Key Point:
o Primary cancer should always be coded first, followed by secondary
malignancy if applicable. This helps to properly document the spread
of cancer and the full extent of the patient's condition.

Anemia Coding Guidelines (D64.9)

1. Unspecified Anemia:
o Use D64.9 (Anemia, unspecified) when the type of anemia is not
specified in the documentation.
2. Iron Deficiency Anemia:
o For iron deficiency anemia, use D50.9 (Iron deficiency anemia,
unspecified).
o This code should be used when the anemia is due to iron deficiency,
but the specific details are not provided.
3. Key Point:
 o Always check for the specific type of anemia. If the type is not
mentioned, use the appropriate unspecified code (D64.9 for general
anemia or D50.9 for iron deficiency).

Fracture Coding Guidelines (S00-T88)

1. Seventh Character for Episode of Care:
o Always use a seventh character to indicate the episode of care for
fractures. This character helps specify whether the fracture is an initial
encounter, a subsequent encounter, or a sequela.
2. Example of Coding a Fracture:
o For an unspecified fracture of the lower end of the right radius
with an initial encounter for a closed fracture, use S52.509A
(Unspecified fracture of the lower end of the right radius, initial
encounter for closed fracture).
3. Key Point:
o The seventh character is essential for accurately representing the type
of encounter and tracking the patient's care stage.

Gastrointestinal Bleeding Coding Guidelines (K92.2)

1. Unspecified Gastrointestinal Bleeding:
o Use K92.2 (Gastrointestinal hemorrhaging, unspecified) when the
source of the gastrointestinal (GI) bleeding is not specified in the
documentation.
2. Gastrointestinal Bleeding with Known Source:
o If the source of the bleeding is identified, code it first. For example, for
a chronic or unspecified gastric ulcer with hemorrhage, use
K25.4 (Chronic or unspecified gastric ulcer with hemorrhage).
o This ensures the specific cause of the GI bleeding is accurately
represented.
3. Key Point:
o Always prioritize coding the source of the bleeding if known, as it
provides more specific information about the patient's condition.

Mental Health Conditions Coding Guidelines (F20-F48)

1. Specific Mental Health Condition:
o Always code the specific mental health condition first. For
example, for major depressive disorder, single episode,
unspecified, use F32.9 (Major depressive disorder, single episode,
unspecified).
2. Associated Symptoms:
o If there are associated symptoms, such as anxiety, code them as
well. For example, for generalized anxiety disorder, use F41.1
(Generalized anxiety disorder) in addition to the primary diagnosis.
3. Key Point:
o Accurately code both the primary mental health condition and any
associated symptoms to provide a complete picture of the patient’s
mental health status.
PROGRESS NOTE

This patient is a 50-year-old female who began developing bleeding, bright red
blood per rectum (Patient's presenting complaint.), approximately two weeks
ago. She is referred by her family physician. She states that after a bowel
movement she noticed blood in the toilet. She denied any prior history of bleeding
or pain with defecation. She states that she has had an external hemorrhoid
(This is reported by the patient, but not documented in the exam or
assessment, so it is not coded.) that did bleed at times but that is not where
this bleeding is coming from. She is presently concerned because a close friend of
hers was recently diagnosed with rectal carcinoma requiring chemotherapy that
was missed by her primary doctor. She is here today for evaluation for a
colonoscopy. Physical examination, she appears to be a well appearing 50-year-old,
white female. Abdomen is soft, non-tender, non-distended.

ASSESSMENT: 50-year-old female with rectal bleeding (Report the code

documented in the assessment.)

PLAN: We’ll schedule the patient for an outpatient colonoscopy. The patient was
made aware of all the risks involved with the procedure and was willing to proceed.
What diagnosis code(s) are reported

ICD-10-CM code for this case is K62.5.

Rationale:

 K62.5 is the code for rectal bleeding, which is the primary diagnosis
documented in the assessment. The patient presents with rectal bleeding as
a symptom, and the plan is to schedule her for a colonoscopy to investigate
the cause.
 Even though the patient mentions a history of external hemorrhoids, there is
no documentation or clinical confirmation of hemorrhoids causing the current
bleeding, so the focus remains on the rectal bleeding (K62.5).

PREOPERATIVE DIAGNOSIS: Bilateral profound sensorineural hearing loss.

POSTOPERATIVE DIAGNOSIS: Bilateral profound sensorineural hearing loss.

(Report the postoperative diagnosis.)

PROCEDURES PERFORMED:

1. Placement of left Nucleus cochlear implant.

2. Facial nerve monitoring for an hour.

3. Microscope use.

ANESTHESIA: General.

INDICATIONS: This is a 69-year-old woman who has had progressive hearing

loss (The diagnosis is documented as the indication for the surgery.) over
the last 10-15 years. Hearing aids are not useful for her. She is a candidate for
cochlear implant by FDA standards. The risks, benefits, and alternatives of
procedure were described to the patient, who voiced understanding and wished to
proceed.

PROCEDURE: After properly identifying the patient, she was taken to the main
operating room, where general anesthetic was induced. The table was turned to 180
degrees and a standard left-sided post auricular shave and injection of 1% lidocaine
plus 1:100,000 epinephrine was performed. The patient was then prepped and
draped in a sterile fashion after placing facial nerve monitoring probes, which were
tested and found to work well. At this time, the previously outlined incision line was
incised, and flaps were elevated. A subtemporal pocket was designed in the usual
fashion for placement of the device. A standard cortical mastoidectomy was then
performed and the fascial recess was opened exposing the area of the round
window niche. The lip of the round window was drilled down exposing the round
window membrane. At this time, the wound was copiously irrigated with bacitracin
containing solution, and the device was then placed into the pocket. A 1-mm
cochleostomy was made, and the device was inserted into the cochleostomy with
an advance-off stylet technique. A small piece of temporalis muscle was packed
around the cochleostomy, and the wound was closed in layers using 3-0 and 4–0
Monocryl and Steri-Strips. A standard mastoid dressing was applied. The patient
was returned to anesthesia, where she was awakened, extubated, and taken to the
recovery room in stable condition. What diagnosis code(s) are reported?

ICD-10-CM code for this case is H90.3.

Rationale:

 H90.3 is the code for bilateral sensorineural hearing loss.

 The preoperative diagnosis and postoperative diagnosis both confirm that the
patient has bilateral profound sensorineural hearing loss.
 This is a clear and documented diagnosis in the patient's case and is used for
reporting the diagnosis related to the procedure performed (placement of a
cochlear implant).

A patient is admitted to the hospital for repair of an open fracture, type I, of the
head of the left femur. The patient has been previously diagnosed with
symptomatic HIV. Applying the coding concept from icd-10-cm guidelines i.c.1.a.2.b,
what icd-10-cm code(s) is/are reported for the admission?

ICD-10-CM codes for this case are S72.052B and B20.

Rationale:

S72.052B is used for the open fracture, type I, of the head of the left
femur. This code is selected based on the ICD-10-CM guidelines that
the nature of the injury is the principal diagnosis, especially when the
injury is unrelated to the HIV condition.

 Code S72.052 indicates a fracture of the head of the femur,

with the 6th character "2" for the left femur.
 The 7th character "B" indicates the initial encounter for a
type I open fracture.

B20 is used to report symptomatic HIV disease, which is an additional

diagnosis as it is not the reason for the admission, but it is a significant
underlying condition that should be coded as well.

 Thus, S72.052B (for the open femur fracture) is the principal

diagnosis, and B20 (for symptomatic HIV) is coded as an
additional diagnosis.

A 22-year-old female is admitted to ICU for acute renal (kidney) failure due to sepsis
(casual organism unknown). Applying the coding concept form icd-10-cm guideline
i.c.1.d.1.b what icd-10-cm codes are reported (in the correct sequencing)?

ICD-10-CM codes for this case are A41.9, R65.20, and N17.9.

Rationale:

According to ICD-10-CM guideline I.C.1.d.1.b, when coding for severe sepsis, a

minimum of two codes are required:

1. Code for the underlying infection (sepsis)

2. Code from subcategory R65.2 for severe sepsis

In this case:

 A41.9 is used for sepsis, unspecified organism, as the causal organism is

unknown.
 R65.20 is used for severe sepsis without septic shock, indicating the
presence of organ dysfunction (acute), which, in this case, involves the
kidneys.
  N17.9 is used for acute renal failure, which is the associated acute organ
dysfunction due to the sepsis.

Thus, the correct sequencing is:

1. A41.9 (sepsis, unspecified organism)

2. R65.20 (severe sepsis without septic shock)
3. N17.9 (acute renal failure)

A 32-year-old female had a mastectomy for breast cancer. The mastectomy

completely removed the breast cancer with no further treatment. On a follow up
visit to her oncologist, it is determined the cancer has metastasized to the right
lung. The patient is now undergoing a lung resection for the lung cancer. What
codes are reported?

Correct Answer: C78.01, Z85.3

Metastasis to the Lung:

o The cancer has metastasized to the right lung, making it a secondary

malignant neoplasm.
o The correct code for secondary lung cancer involving the right lung is
C78.01. This should be listed first, as the metastasis is the current
reason for treatment.

Personal History of Breast Cancer:

o The primary breast cancer has been excised, and there is no evidence
of the original malignancy.
o When the primary malignancy has been removed and there is no
active disease, you should code it as a personal history of
malignant neoplasm using a Z85.- category code.
o For a personal history of breast cancer, the correct code is Z85.3.

Sequencing Guidelines:

o Per ICD-10-CM Guideline I.C.2.d., the secondary site (C78.01)

should be listed as the primary code when the patient is receiving
treatment for the metastasis.
o The personal history code (Z85.3) is used as a secondary diagnosis
to indicate the patient's past history of breast cancer.
A patient is admitted to the hospital with pneumonia. Testing indicates the patient's
pneumonia is due to staphylococcus aureus and is methicillin resistant (mrsa).
Applying the coding concept from icd-10-cm guidelines i.c.1.e.1.a, what icd-10-cm
codes are reported?
Correct Answer:
J15.212
This single code accurately captures the diagnosis: Pneumonia due to
Methicillin-resistant Staphylococcus aureus (MRSA).

The patient is diagnosed with pneumonia caused by Methicillin-resistant

Staphylococcus aureus (MRSA). To code this scenario accurately, we apply ICD-10-
CM Guideline I.C.1.e.1.a, which states:
 When a combination code exists that identifies both the infection and the
responsible organism (such as MRSA), only the combination code should
be assigned. Do not report a separate code for MRSA.
Steps to Determine the Correct Code:
1. Identify the condition: Pneumonia caused by MRSA.
o In the ICD-10-CM Alphabetic Index, look up Pneumonia, due to,
staphylococcus, aureus, methicillin-resistant (MRSA). This
directs you to J15.212.
2. Review the Tabular List:
o Code J15.212 is defined as "Pneumonia due to Methicillin-
resistant Staphylococcus aureus (MRSA)."
3. Combination Code Rule:
o Since J15.212 is a combination code that already captures both the
pneumonia and the methicillin-resistant organism, you do not need to
assign an additional code for MRSA (A49.02).

PREOPERATIVE DIAGNOSIS: Cataract, left eye
POSTOPERATIVE DIAGNOSIS: Cataract left eye, Presbyopia (Report the
postoperative diagnosis.)
PROCEDURE:
1. Cataract extraction with IOL implant
2. Correction of presbyopia (Patient is also diagnosed with presbyopia.) with lens
implantation
PROCEDURE DETAIL: The patient was brought to the operating room under
neuroleptic anesthesia monitoring. A topical anesthetic was placed within the
operative eye and the patient was prepped and draped in usual manner for sterile
ophthalmic surgery. A lid speculum was inserted into the right infrapalpebral space.
A 6-0 silk suture was placed through the episclera at 12 o'clock. A subconjunctival
injection of non-preserved lidocaine was given. A peritomy was fashioned from 11
o'clock to 1 o'clock with Westcott scissors. Hemostasis was achieved with the wet-
field cautery. A 3-mm incision was made in the cornea and dissected anteriorly with
a crescent blade The anterior chamber was entered at 12 o'clock and 2 o'clock with
a Supersharp blade. Non-preserved lidocaine was instilled into the anterior
chamber. Viscoelastic was instilled in the anterior chamber and using a bent 25-
guage needle, a 360-degree anterior capsulotomy was performed using Utrata
forceps. The capsulotomy was measured and found to be 5.5 mm in diameter. Using
an irrigating cannula, the lens nucleus was hydrodissected and loosened. Using the
phacoemulsification unit, the lens nucleus was divided and emulsified. The
irrigating/aspirating tip was used to remove the cortical fragments from the
capsular bag, and the posterior capsule was polished. Using a curette to polish the
anterior capsule, cortical fragments were removed from the anterior lens capsule for
270 degrees. The irrigating/aspirating tip was used to remove the capsular
fragments. The anterior chamber and capsule bag were inflated with viscoelastic
and using a lens inserter, a Cystalens was then placed within the capsular bag and
rotated to the horizontal position. The viscoelastic was removed with the
irrigating/aspirating tip and the lens was found to be in excellent position with a
slight posterior vault. The wound was hydrated with balanced salt solution and
tested and found to be watertight at a pressure of 20 mmHg. Topical Vigamox was
applied The conjunctiva was repositioned over the wound with a wet field cautery.
The traction suture and lid speculum were removed. A patch was applied. The
patient tolerated the procedure well and left the operating room in good condition.
What diagnosis code(s) are reported?

Final Answer:
 H25.812
 H52.4

Postoperative Diagnosis:

1. Cataract, left eye

o Look in the ICD-10-CM Alphabetic Index under Cataract, age-
related, nuclear sclerosis, which leads to category H25.81-.
o The specific code for cataract in the left eye is H25.812.
2. Presbyopia
o Look in the ICD-10-CM Alphabetic Index under Presbyopia, which
leads to H52.4.

Procedure Performed:

1. Cataract extraction with intraocular lens (IOL) implantation for the

cataract.
2. Correction of presbyopia with lens implantation.

 For the diagnosis, two ICD-10-CM codes must be reported to capture both
the cataract and presbyopia.
Correct Diagnosis Codes:

1. H25.812 – Age-related nuclear cataract, left eye.

2. H52.4 – Presbyopia.

Reasoning for Code Order:

 Per ICD-10-CM guidelines, the principal diagnosis (reason for the surgery) is
listed first. In this case, the cataract is the primary condition being treated,
so H25.812 is listed first, followed by H52.4 for presbyopia.

Subjective: Here to follow up on her atrial fibrillation. No new problems. Feeling

well. Medications are per medication sheet. These were reconstituted with the
medications that she was discharged home on. 0bjective: Blood pressure is 110/64.
Pulse is regular at 72. Neck is supple. Chest is clear. Cardiac normal sinus rhythm.

Assessment: Atrial fibrillation, currently stable

Plan:

1. Prothrombin time to monitor long term use of anticoagulant.

2. Follow up with me in one month or sooner as needed if she has any other
problems in the meantime. Will also check a creatinine and potassium today.

What diagnosis code(s) are reported?

Final Answer:

 I48.91 – Atrial fibrillation, unspecified.

 Z79.01 – Long-term (current) use of anticoagulants.
 Z51.81 – Encounter for therapeutic drug level monitoring.

1. Assessment:
o Atrial fibrillation, currently stable: This is the primary reason for
the follow-up visit.
o Long-term use of anticoagulants is being monitored, which needs to be
reported as a secondary diagnosis.
o Therapeutic drug level monitoring for prothrombin time is performed,
which also requires coding.
2. Plan:
 o Prothrombin time is monitored.
o Creatinine and potassium are checked, but these are part of the
anticoagulant monitoring and do not require separate diagnosis codes.

Diagnosis Code Selection:

Primary Diagnosis:

 Atrial Fibrillation (I48.91):

o In the ICD-10-CM Alphabetic Index, under Fibrillation, atrial, you
are directed to I48.91 for unspecified atrial fibrillation.

Secondary Diagnosis:

 Long-term (current) use of anticoagulants (Z79.01):

o In the ICD-10-CM Alphabetic Index, look for Long-term (current)
drug therapy/use of/anticoagulants, which directs to Z79.01.

Third Diagnosis:

 Encounter for therapeutic drug level monitoring (Z51.81):

o In the ICD-10-CM Alphabetic Index, look for Therapeutic/drug
level monitoring and find Z51.81.

Code Order:

 Per ICD-10-CM guidelines, the primary diagnosis should reflect the main
reason for the visit (atrial fibrillation), followed by codes for long-term drug
use and therapeutic monitoring.

Follow-up Visit: The patient has some memory problems. She is hard of hearing.
She is legally blind. Her pharmacist and her family are very worried about her
memory issues. She lives at home, family takes care of laying out her medications
and helping with the chores, but she does take care of her own home to best of her
ability.

Exam: Pleasant 85-year-old woman in no acute distress. She has postop changes of
her eyes. TMs are dull. Pharynx is clear. Neck is supple without adenopathy. Lungs
are clear. Good air movement. Heart is regular. She had a slight murmur. Abdomen
is soft. Moderately obese. Non-tender. Extremities; no clubbing or edema. Foot
exam shows some bunion deformity but otherwise healthy. Light touch is preserved.
There is no ankle edema or stasis change. Examination of the upper arms reveal
good range of motion. There is significant pain in her shoulder with rotational
movements. It is localized mostly over the deltoid. There is no other deformity.
There is a very slight left shoulder discomfort and slight right hip discomfort.

Impression:
1. Dementia

2. Right shoulder pain.

3. Benign hypertensive cardiovascular disease, a complication of diabetes.

4. Type 2 diabetes good control.

Most recent AlC done today 5.9%. Liver test normal. Cholesterol 199, LDL a little
high at 115.

Plans:

1. I offered her and her family neuropsychological evaluation to evaluate for

dementia. Her system complex is consistent with dementia, whether it be from
cerebral small vessel disease or Alzheimer’s is unknown. At this point, they would
much rather initiate treatment than go through an exhaustive neuropsychological
test.

2. For the shoulder we decided on right deltoid bursa steroid injection. She has had
injections for bursitis in the past and prefers to go this route. She will ice and rest
the shoulder after injection. Follow up in 3 months.

Procedure: Injection right deltoid bursa. The point of maximal tenderness was
identified, skin was prepped with alcohol. A 25-gauge, 1 ½-inch needle was
advanced to the posterolateral edge of the acromion and into the subacromial
space and then aspirated. 1 cc of 0.25% Marcaine mixed with 80 mg Depo Medrol
was deposited. The needle was withdrawn. Band-aid was applied. Post injection she
had marked improvement; increased range of motion consistent with good
placement of the medication. She was started on Cerefolin, plus NAC and Aricept
starter pack was given with email away script. Follow-up in 3 months and we will
reassess her dementia at that time. What diagnosis code(s) are reported?

Final Diagnosis Codes:

1. F03.90 – Dementia, unspecified, without behavioral disturbance.

2. M25.511 – Pain in right shoulder.
3. I11.9 – Hypertensive heart disease without heart failure.
4. E11.9 – Type 2 diabetes mellitus without complications.

Case Overview:

Visit Details:
  An 85-year-old woman presents for a follow-up visit with a history of memory
problems, right shoulder pain, benign hypertensive cardiovascular disease
(complicated by diabetes), and well-controlled type 2 diabetes.
 Her family assists with medications and household chores. Examination
reveals pain in the right shoulder, a slight murmur, and mild left shoulder and
right hip discomfort.
 A right deltoid bursa steroid injection is performed for pain relief. Treatment
for dementia is initiated, and her diabetes and cardiovascular conditions are
monitored.

Assessment:

1. Dementia: The cause is undetermined but likely due to cerebral small vessel
disease or Alzheimer's. Treatment is initiated with medications.
2. Right shoulder pain: Managed with a steroid injection.
3. Benign hypertensive cardiovascular disease (a complication of
diabetes): Evaluated as part of the follow-up.
4. Type 2 diabetes: Controlled, with a recent A1C of 5.9%.

Diagnosis Codes:

1. F03.90 – Dementia, unspecified, without behavioral disturbance:

o Dementia is the primary diagnosis, as the visit primarily addresses her
memory concerns and initiates treatment.
o In the ICD-10-CM Alphabetic Index, look under Dementia →
unspecified → F03.90. The absence of behavioral disturbances
confirms this code.
2. M25.511 – Pain in right shoulder:
o This code captures the right shoulder pain addressed with a steroid
injection.
o In the ICD-10-CM Alphabetic Index, look for Pain/joint/shoulder →
right → M25.511.
3. I11.9 – Hypertensive heart disease without heart failure:
o The patient has benign hypertensive cardiovascular disease as a
complication of diabetes, which is coded under I11.9.
o In the ICD-10-CM Alphabetic Index, look for Hypertension/with
heart disease → I11.9. The absence of heart failure supports this
code.
4. E11.9 – Type 2 diabetes mellitus without complications:
o Although the cardiovascular condition is related to diabetes, the
diabetes itself is listed separately as it is well-controlled without other
complications.
o In the ICD-10-CM Alphabetic Index, look for Diabetes/type 2 →
without complications → E11.9.
Code Order and Rationale:

1. F03.90: Dementia is the primary diagnosis, as it was the main focus of the
visit and treatment.
2. M25.511: Right shoulder pain is listed second, as it was treated with a
steroid injection.
3. I11.9: Benign hypertensive cardiovascular disease is third because it is a
chronic condition monitored during the visit.
4. E11.9: Type 2 diabetes is listed last as it is well-controlled and noted as part
of routine management.

S: The patient presents today for reevaluation and titration of carvedilol for his
coronary artery disease and hyperlipidemia. His weight is up 7 pounds. He has quit
smoking. He has no further cough, and he states he is feeling well except for the
weight gain. He states he doesn’t feel he’s eating more, but his wife says he’s
eating more. We’ve been attempting to titrate up his carvedilol to 25mg twice a day
from initially 6.25mg. He has tolerated the titration quite well. He gets cephalgias
on occasion. He states he has a weak spell but this is before he takes his morning
medicine. I updated his medical list here today. I gave him samples of Lipitor. O:
Weight is 217, pulse rate 68, respirations 16, and blood pressure 138/82. HEENT
examination is unchanged. His heart is a regular rate. His lungs are clear.

A:

1. CAD

2. Hyperlipidemia

P:

1. The plan is samples of Lipitor using the two months’ supply that I have given him.

2. We’ve increased his Coreg to 25mg

Final Diagnosis Codes:

1. I25.10 – Coronary Artery Disease Without Angina Pectoris.

2. E78.5 – Hyperlipidemia, Unspecified.
3. Z72.0 – Tobacco Use (History Of Smoking).
4. Z79.899 – Long-Term (Current) Use Of Other Specified Drugs.

Case Summary:
Subjective (S):

 The patient presents for reevaluation and titration of carvedilol for coronary
artery disease (CAD) and hyperlipidemia.
 Notable observations:
o Weight gain (+7 lbs).
o No further cough.
o Occasional cephalgias (headaches).
o Weakness spells occurring before morning medication.
o Smoking cessation.
 Medications:
o Carvedilol titrated to 25 mg twice daily.
o Samples of Lipitor provided for hyperlipidemia management.

Objective (O):

 Vital signs: Weight 217 lbs, pulse 68, respirations 16, blood pressure 138/82.
 Exam findings:
o HEENT unchanged.
o Heart: Regular rate.
o Lungs: Clear.

Assessment (A):

1. Coronary artery disease (CAD).

2. Hyperlipidemia.

Plan (P):

1. Provide two months' supply of Lipitor samples for hyperlipidemia.

2. Continue carvedilol titration (25 mg BID).
3. Follow-up in six months.

Diagnosis Codes:

1. I25.10 – Coronary artery disease without angina pectoris:

o CAD is listed as the first diagnosis.
o In the ICD-10-CM Alphabetic Index, look for Disease/coronary
(artery) → without angina pectoris → I25.10.
2. E78.5 – Hyperlipidemia, unspecified:
o Hyperlipidemia is documented and treated with Lipitor.
o In the ICD-10-CM Alphabetic Index, look for Hyperlipidemia →
E78.5.
3. Z72.0 – Tobacco use (history of smoking):
o The patient's recent smoking cessation is relevant for care
documentation.
o In the ICD-10-CM Alphabetic Index, look for Tobacco/use/history
of → Z72.0.
4. Z79.899 – Long-term (current) use of other specified drugs:
 o The patient’s long-term use of carvedilol is reported with this code.
o In the ICD-10-CM Alphabetic Index, look for Long-term (current)
(prophylactic) drug therapy → drug, specified NEC → Z79.899.

Rationale for Code Sequencing:

1. I25.10 (CAD): Listed first, as it is the primary diagnosis requiring

management with carvedilol.
2. E78.5 (Hyperlipidemia): Secondary, as it is also treated during this visit
with Lipitor.
3. Z72.0 (Tobacco use): Relevant due to the patient's smoking history and
recent cessation.
4. Z79.899 (Long-term drug use): Included to document continued carvedilol
therapy.

This combination reflects the patient’s active conditions, relevant history, and
current therapeutic interventions.

CPT CODING Guidelines and Sections

What does CPT stand for?

 Current Procedural Terminology (CPT): A standardized coding system

used by healthcare providers to describe medical, surgical, and diagnostic
services and procedures.
 Maintained by: American Medical Association (AMA).
 Purpose: Essential for billing, insurance claims, and accurate medical
documentation.

How many sections are there in the CPT manual?

 Six main sections.

What is the first section of the CPT manual?

 Evaluation and Management (E/M):

o Covers codes for patient assessment and management services.
o Includes services like office visits, consultations, hospital care, and
preventive care.

Primary Focus of CPT Codes

 Identification of Medical Services and Procedures:

o CPT codes are primarily used to describe medical, surgical, and
diagnostic services in a standardized manner.
 Facilitation of Billing and Documentation:
o These codes ensure consistency in communication between healthcare
providers, insurance companies, and government agencies.
 o Essential for accurate billing, claim submission, and medical
record documentation.

Bullet Symbol in CPT Manual

 What it indicates:
o A bullet symbol (●) placed before a CPT code signifies that the code
is new in the CPT manual for the current edition.
 Purpose:
o Highlights recently added codes, helping users quickly identify updates
and stay current with coding changes.

Code Range for Surgery in the CPT Manual

 The code range 10000–69999 covers procedures categorized under

Surgery in the CPT manual.

Sections Within This Range:

1. Integumentary System (10000–19999)

o Includes skin, nails, and breast procedures.
2. Musculoskeletal System (20000–29999)
o Covers bones, joints, and associated soft tissue surgeries.
3. Respiratory, Cardiovascular, Hemic, and Lymphatic Systems (30000–
39999)
4. Digestive System (40000–49999)
5. Urinary and Male Genital Systems (50000–59999)
6. Female Genital System and Maternity Care (59000–59999)
7. Endocrine System (60000–69999)

Triangle Symbol (▲) in CPT Manual

 What it indicates:
o A triangle symbol (▲) placed before a CPT code signifies that the
code's description has been revised in the current edition of the
CPT manual.
 Purpose:
o Highlights updates to existing codes, allowing users to quickly identify
changes in wording or scope.

Code Range for Radiology Services in the CPT Manual

 The code range 70000–79999 is designated for Radiology Services.

Sections Within Radiology Services:

1. Diagnostic Radiology (70000–70999)

o X-rays, fluoroscopy, and other imaging studies.
2. Diagnostic Ultrasound (76500–76999)
 o Includes ultrasound procedures.
3. Radiologic Guidance (77001–77022)
o Imaging guidance for procedures like biopsies.
4. Breast Mammography (77061–77067)
5. Bone/Joint Studies (77071–77086)
o Includes studies like bone density and joint imaging.
6. Radiation Oncology (77261–77999)
o Therapeutic radiology, including treatment planning and delivery.
7. Nuclear Medicine (78000–78999)
o Includes imaging studies using radioactive tracers.

Star Symbol (*) in the CPT Manual

 What it indicates:
o A star symbol (*) before a CPT code indicates that the code is
approved for telemedicine services.
o This symbol shows that the procedure or service can be provided
remotely through telehealth, in compliance with regulatory guidelines.
 Purpose:
o Helps healthcare providers identify which services are eligible for
telemedicine and can be billed when delivered via telehealth
platforms.

Code Range for Pathology and Laboratory Services in the CPT Manual

 The code range 80000–89999 is used for Pathology and Laboratory

Services.

Sections Within This Range:

1. Clinical Pathology (80000–89999)

o Includes tests related to chemistry, hematology, microbiology,
immunology, and other laboratory diagnostics.
2. Organ/Tissue Biopsy and Cytology (88000–88099)
o Covers laboratory tests related to biopsies and cytological evaluations.
3. Pathology Services (88000–89999)
o Includes histopathology, cytopathology, and related diagnostic tests.

Purpose of Modifiers in CPT Coding

 Indicating Alterations or Specifics:

o Modifiers are used to provide additional information about a
procedure or service that has been altered in some way but not
significantly enough to change the code itself.
 Examples of Alterations Indicated by Modifiers:
o Location of Service: If a service was performed in a different setting
(e.g., hospital vs. office).
 o Complexity or Extent of the Service: Indicates if a procedure was
more or less complex than typical.
o Repeat Procedures or Special Circumstances: Used when a
procedure is repeated or altered due to specific factors (e.g., patient
condition, complications).
 Purpose:
o Modifiers help ensure accurate billing, coding, and
reimbursement by specifying the context or circumstances under
which a service was delivered.

Section of the CPT Manual for Anesthesia Codes

 The code range 00100–01999 covers Anesthesia services in the CPT

manual.

Details within this Range:

 General Anesthesia (00100–01999)

o Includes codes for anesthesia services provided during various surgical
and diagnostic procedures.
 Examples:
o 00100–01999: Covers anesthesia for all types of surgeries, including
those for the head, neck, chest, abdomen, and extremities.
o Includes: Anesthesia for different specialties like orthopedics,
obstetrics, and cardiovascular procedures.

Plus Symbol (+) in CPT Coding

 What it indicates:
o The plus symbol (+) before a CPT code indicates that the code is an
add-on code.
o Add-on codes are used in conjunction with a primary procedure to
report additional services provided during the same session.
 Purpose:
o Add-on codes are not intended to be billed independently; they must
be linked to a primary procedure code to fully describe the services
rendered.
o These codes usually reflect extra procedures that complement the
main procedure, such as additional surgical steps, monitoring, or
diagnostic tests.

Code Range for Medicine Services in the CPT Manual

 The code range 90000–99999 is used for Medicine Services in the CPT
manual.

Sections Within This Range:

1. Immunization and Vaccination Services (90460–90474)

 o Includes codes for vaccines and immunization administration.
2. Endoscopy (92502–92700)
o Covers diagnostic and therapeutic procedures performed using an
endoscope.
3. Cardiology (93000–93999)
o Includes codes for cardiology services such as ECGs, echocardiograms,
and other cardiovascular tests.
4. Neurology (95800–95999)
o Covers neurological services including testing and diagnostic
procedures.
5. Other Specialized Medicine Services (90000–99999)
o Includes a variety of services, such as ophthalmology, sleep studies,
and other diagnostic tests.

Semicolon (;) in CPT Coding

 What it indicates:
o The semicolon (;) in CPT coding is used to separate the main
procedure from the additional descriptors in certain codes.
o It is commonly seen in indented codes under a primary procedure,
indicating that the indented codes share the same description as the
main code but have added details or variations.

Purpose:

 The semicolon is used to shorten descriptions for similar procedures and

prevent repetition. The indented codes under a main procedure can then be
read as having the same basic procedure but with additional, specified details
(such as the type of approach, site, or other variations).
 Example:
o Code 12345 might be the main procedure, with additional variations
like "12345; 12346" where the second code has a specific detail added
(e.g., different site or technique).

True Statement About CPT Category II Codes

 CPT Category II Codes are used primarily for tracking performance

measures.
o These codes are intended to assist in the collection of data for
quality reporting and to support performance measurement
initiatives, such as those related to healthcare quality improvement.
o They are optional codes and are not used for billing or
reimbursement but for tracking specific aspects of patient care,
such as adherence to clinical guidelines, preventive care services, or
other quality indicators.

Purpose of Category II Codes:

  They help in documenting the performance of specific processes or
outcomes in patient care.
 They are typically used in quality reporting programs like the Physician
Quality Reporting System (PQRS) or similar performance programs.

Main Difference Between CPT Category I and Category III Codes

1. Category I CPT Codes

o Purpose: Used for established procedures and services that are
widely accepted and have been in use for some time.
o Use: These codes represent standard medical practices, including
routine services and procedures for which there is sufficient clinical
evidence and consensus.
o Example: Codes for common procedures like surgery, office visits, or
diagnostic tests.
2. Category III CPT Codes
o Purpose: Used for new and emerging technologies, services, or
procedures that are not yet fully established.
o Use: These codes are used for tracking and reporting innovative or
experimental services that may not yet have widespread
acceptance or long-term data supporting their use.
o Example: Codes for new procedures, devices, or treatments that are
still being evaluated or have limited evidence.

Summary:

 Category I: For standard, well-established services.

 Category III: For new, emerging, or experimental technologies

CPT Code 80053: Comprehensive Metabolic Panel (CMP)

 Purpose:
o The Comprehensive Metabolic Panel (CMP) is a blood test that
measures various substances in the blood to evaluate the body's
chemical balance and metabolism.
 Includes:
o Glucose
o Calcium
o Proteins (total protein, albumin, globulin)
o Electrolytes (sodium, potassium, chloride, bicarbonate)
o Kidney function tests (blood urea nitrogen, creatinine)
o Liver enzymes (ALP, ALT, AST, bilirubin)
o Total bilirubin
 Use:
o It is commonly ordered as part of a routine checkup to assess kidney
and liver function, blood sugar levels, and electrolyte balance.

Lightning Bolt Symbol in CPT Coding

  The lightning bolt (⚡) symbol in the CPT manual indicates that the code
represents a new technology or a new procedure.
 Purpose:
o It is used to highlight emerging technologies, procedures, or
treatments that are new and may not yet have extensive clinical use
or long-term data but are being tracked and recognized for their
innovation.

CPT Code 80048: Basic Metabolic Panel (BMP)

 Purpose:
o The Basic Metabolic Panel (BMP) is a blood test used to measure
eight different substances in the blood to evaluate the body's basic
metabolic functions, including kidney function, blood sugar levels, and
electrolyte balance.
 Includes the following tests:

 Glucose – measures blood sugar levels.

 Calcium – important for bone health, nerve function, and
muscle function.
 Sodium – an electrolyte that helps regulate fluid balance and
nerve function.
 Potassium – another electrolyte vital for muscle and heart
function.
 Chloride – helps balance fluids and acid-base levels in the body.
 Carbon dioxide (CO2) – helps to assess the acid-base balance
in the blood.
 Blood Urea Nitrogen (BUN) – a waste product filtered by the
kidneys, which helps assess kidney function.
 Creatinine – a waste product from muscle metabolism, also
used to assess kidney function.

 Use:
o The BMP is often ordered as part of a routine checkup or to monitor
patients with conditions like kidney disease, diabetes, or
electrolyte imbalances.
o It provides important information about the kidney function, blood
sugar, and electrolyte balance in the body.

Deleted Codes Symbol in CPT Coding

 What it indicates:
o In the CPT manual, deleted codes are marked with a strike-through
symbol (a line through the code) to indicate that the code is no longer
valid or has been removed from the code set.
 Purpose:
o The strike-through symbol helps users quickly identify codes that are
no longer in use. This is especially important for updates in the CPT
 codebook, as it helps ensure that coders and healthcare providers do
not use outdated codes for billing or documentation purposes.
 Why Codes are Deleted:
o Codes may be deleted for a variety of reasons, such as:
 The service or procedure is no longer performed or is obsolete.
 The code is consolidated with another code.
 The code is replaced by a more accurate or specific code.

CPT Code 71045: Chest X-Ray, Single View

 Description:
o 71045 is the CPT code for a single view chest X-ray. This is a basic
radiologic procedure used to capture a single image of the chest area
to assess the lungs, heart, ribs, and other structures.
 Use:
o A single view chest X-ray typically provides an initial assessment for
conditions like pneumonia, lung infections, heart enlargement,
and broken ribs. It is often part of routine physical exams or to
investigate symptoms like cough, chest pain, or shortness of breath.
 Details:
o Single View: The image is taken from one angle, typically a
posterior-anterior (PA) view or an anteroposterior (AP) view,
depending on the patient's condition and the clinical need.

Hashtag Symbol (#) in CPT Coding: Resequenced Codes

 What it indicates:
o The hashtag symbol (#) is used to indicate resequenced codes in
the CPT manual.
o Resequenced codes are those that have been rearranged from their
original order for reasons such as maintaining logical groupings or
improving the flow of the code set.
 Purpose:
o The hashtag symbol helps users identify codes that are no longer in
numerical sequence and highlights where codes have been moved
to a different position in the code set. This often happens due to
updates or revisions in the CPT manual.
 Example:
o If a code was originally in one section and is moved to another due to
changes in classification or updates to the procedure, it will be marked
with the hashtag symbol to indicate its resequencing.

CPT Code 44970: Laparoscopic Appendectomy

 Description:
o 44970 is the CPT code for a laparoscopic appendectomy, which is a
minimally invasive surgical procedure to remove the appendix. The
procedure is performed using small incisions and a camera
(laparoscope) to guide the surgery.
Modifier 59 in CPT Coding

 What it indicates:
o Modifier 59 is used to indicate that a procedure or service is distinct
or independent from other services performed on the same day. It is
applied when multiple procedures are performed but are not part of
the same bundled or inclusive procedure.
 Purpose:
o Modifier 59 is used to avoid unbundling of procedures that are
separate and distinct from other services provided during the same
patient encounter. It helps ensure proper billing and reimbursement
when multiple services are performed that are not normally reported
together but are appropriate to be reported separately.
 When to Use Modifier 59:
o When a different anatomical site is involved (e.g., a procedure on
the left leg and right leg).
o When a different session or approach is used (e.g., a procedure
done in the morning and another in the afternoon).
o When a procedure is distinct and unrelated to the primary service
performed.

Example:

 If two procedures are performed, and one is a diagnostic test while the other
is a therapeutic procedure, and both are unrelated, Modifier 59 may be
applied to the therapeutic procedure.

CPT Code 45380: Colonoscopy with Biopsy

 Description:
o 45380 is the CPT code for a colonoscopy with biopsy. This
procedure involves the use of a flexible camera (colonoscope) inserted
into the colon to visually examine the colon and rectum for
abnormalities such as polyps, tumors, or inflammation. During the
procedure, a biopsy may be performed, meaning small tissue samples
are taken for laboratory analysis to check for conditions like cancer,
infection, or inflammatory bowel disease.

Modifier 25 in CPT Coding

 What it indicates:
o Modifier 25 is used to indicate that a significant, separately
identifiable Evaluation and Management (E/M) service was
provided by the same physician on the same day as another procedure
or service.
 Purpose:
o It allows the physician to report and receive reimbursement for an E/M
service in addition to a procedure or other service, as long as the E/M
 service is distinct and separate from the procedure or service
performed.
 When to Use Modifier 25:
o When a patient is seen for a distinct issue that requires a separate
E/M service (e.g., a patient is evaluated for a medical condition in
addition to a surgical procedure or diagnostic service).
o The E/M service must be medically necessary and not just routine
care related to the procedure performed.
o The E/M service should be documented thoroughly to show that it is
significant and distinct from the procedure or other service.

Example:

 If a patient is seen for a minor procedure, and the physician also evaluates
the patient for an existing medical condition unrelated to the procedure
(e.g., a follow-up for diabetes or hypertension), Modifier 25 would be used
to report the separate E/M service.

CPT Code 85025: Complete Blood Count (CBC) with Automated Differential

 Description:
o 85025 is the CPT code for a Complete Blood Count (CBC) with
Automated Differential. This test provides a comprehensive
overview of the blood's components, including the number of red
blood cells, white blood cells, platelets, hemoglobin levels, and
other important blood parameters.
 Key Components of the Test:
o CBC (Complete Blood Count):
 Red blood cells (RBC): Measures the amount of red blood
cells, which carry oxygen throughout the body.
 White blood cells (WBC): Measures the amount of white blood
cells, which help fight infections.
 Platelets: Measures the number of platelets, which help with
blood clotting.
 Hemoglobin: Measures the oxygen-carrying capacity of the
blood.
 Hematocrit: Measures the proportion of blood volume made up
of red blood cells.
o Automated Differential:
 The test automatically categorizes and counts different types of
white blood cells (such as neutrophils, lymphocytes, monocytes,
eosinophils, and basophils), helping to assess the body’s
immune response.
 Use:
o This test is commonly used to assess general health, diagnose
conditions such as anemia, infections, and blood disorders, and
monitor the status of patients undergoing treatments that affect blood
cell counts.
Modifier 26 in CPT Coding

 What it indicates:
o Modifier 26 is used to indicate the professional component of a
procedure, particularly when a service has both a professional and a
technical component.
 Purpose:
o The professional component refers to the part of the service
provided by the physician or healthcare professional, such as the
interpretation of diagnostic tests (e.g., radiology exams, laboratory
tests) or the professional skills used during a procedure.
o The technical component typically refers to the physical aspects of
the service, such as equipment usage, technician support, and facility-
related services.
 When to Use Modifier 26:
o When a procedure involves both a professional and technical
component, and the physician is only providing the professional part
(such as interpreting an X-ray or conducting a diagnostic test).
o It allows for billing and reimbursement for the professional
interpretation or analysis separately from the technical component.

Example:

 Radiology Services:
o If a radiologist interprets a chest X-ray (the professional component)
but does not perform the actual imaging (the technical component),
Modifier 26 would be applied to the radiology code to indicate that
only the professional interpretation is being billed.

CPT Code 70551: MRI Brain, Without Contrast

 Description:
o 70551 is the CPT code for an MRI of the brain without contrast.
This is a diagnostic imaging procedure that uses a magnetic field and
radio waves to create detailed images of the brain, without the use
of contrast material. It helps in evaluating brain structures and
detecting abnormalities such as tumors, strokes, or other neurological
conditions.

Modifier TC in CPT Coding: Technical Component

 What it indicates:
o Modifier TC is used to indicate the technical component of a
service. It is applied when a procedure or service includes both a
technical component (e.g., equipment use, technician support, or
facility-related services) and a professional component (e.g.,
interpretation, analysis, or expert judgment by a physician).
 Purpose:
 oThe technical component refers to the non-physician part of a
procedure, such as the actual performance of a diagnostic test, the use
of specialized equipment, or the facility's involvement in performing a
procedure. Modifier TC is used when the technical part of the service
is being billed separately from the professional services.
 When to Use Modifier TC:
o When the technical component of a service (like an X-ray, MRI, or
laboratory test) is provided but the professional component (like
interpretation of the test results) is not included in the billing.

Example:

 MRI Brain:
o If an MRI of the brain is performed in a facility, but the radiologist will
not interpret the results (perhaps the interpretation will be done by a
different physician), the facility may bill for the technical component
(e.g., using Modifier TC), while the radiologist would bill separately for
the professional component.

CPT Code 77067: Mammography, Bilateral, 2 View

 Description:
o 77067 is the CPT code for a bilateral mammography performed
with two views for each breast. This is a type of imaging used to
screen for breast cancer and other breast abnormalities. The two
views usually refer to the craniocaudal (CC) and mediolateral
oblique (MLO) projections.
 Details:
o The bilateral aspect means both the left and right breasts are being
imaged.
o The two views refer to two standard positions used to capture
detailed images of the breast tissue from different angles.

Modifier 50 in CPT Coding: Bilateral Procedure

 What it indicates:
o Modifier 50 is used to indicate that a bilateral procedure was
performed, meaning the procedure was done on both sides of the
body (e.g., both breasts, both knees, both eyes). This modifier tells the
payer that the service should be reimbursed as a bilateral procedure,
often at a higher rate due to the involvement of both sides.
 Purpose:
o The use of Modifier 50 ensures that the procedure is accurately
reported as being performed on both sides. It helps to distinguish the
service from two separate, unilateral procedures.
 When to Use Modifier 50:
 o When a procedure is performed bilaterally (on both sides of the
body), and the code does not specifically include a bilateral
designation (some codes already account for bilateral procedures).
o For procedures like knee surgeries, mammograms, cataract
surgeries, or any procedure that involves both sides of the body.

Example:

 Bilateral Knee Arthroscopy:

o If a patient has an arthroscopy performed on both knees, Modifier 50
would be used to report the bilateral nature of the procedure.

CPT Code 90686: Quadrivalent Influenza Vaccine, Intramuscular

 Description:
o 90686 is the CPT code for the quadrivalent influenza vaccine
administered intramuscularly. This vaccine protects against four
different strains of the influenza virus (two A strains and two B
strains), providing broader protection against seasonal flu.

Modifier 51 in CPT Coding: Multiple Procedures

 What it indicates:
o Modifier 51 is used to indicate that multiple procedures were
performed during the same session or encounter. It is applied when a
provider performs more than one distinct procedure during a single
visit, and these procedures are not bundled together.
 Purpose:
o Modifier 51 helps to ensure that each procedure is properly reported
and reimbursed, even if they were performed together. It often applies
to situations where more than one procedure is medically necessary
and distinct, but they are not typically billed together by default.
 When to Use Modifier 51:
o When multiple procedures are performed at the same time, but the
procedures are distinct and are reported separately.
o Modifier 51 is typically used when procedures are performed in
addition to the primary procedure. It indicates to the payer that the
additional procedures are eligible for reimbursement but should not be
paid at the full rate due to their performance as secondary services.

Example:

 If a physician performs a knee arthroscopy (CPT code 29881) and also

performs a meniscectomy (CPT code 29880) during the same session,
Modifier 51 would be used with the meniscectomy code to indicate that it
is a second, distinct procedure performed during the same visit.

Important Note:
  Modifier 51 should not be used for add-on codes (codes with a plus sign,
such as +31500), as these codes are always considered additional services
that are not subject to the same reimbursement rules.

CPT Code 82951: Glucose Tolerance Test

 Description:
o 82951 is the CPT code for a Glucose Tolerance Test (GTT), which is
used to measure the body's response to sugar (glucose) and assess
how well the body regulates blood sugar. It is commonly used to
diagnose diabetes mellitus and gestational diabetes.

Modifier 52 in CPT Coding: Reduced Services

 What it indicates:
o Modifier 52 is used to indicate that reduced services were provided.
This means that a service or procedure was performed, but not to its
full extent. The physician or healthcare provider may have performed a
partial procedure or made modifications due to various factors, such
as the patient's condition, circumstances, or clinical judgment.
 Purpose:
o Modifier 52 helps convey that the procedure was not fully
completed or was altered from the standard, but a reduced level of
service was still provided. It may be used when:
 The physician did not perform all components of a
procedure.
 The service was cut short due to medical necessity, patient
tolerance, or other reasons.
 When to Use Modifier 52:
o When a procedure or service was partially reduced or less
extensive than originally planned or described.
o The reduced services should be documented clearly in the patient's
medical record, explaining why the full procedure was not completed.

Example:

 Surgical Procedure:
o If a patient undergoes a procedure (e.g., a laparoscopic procedure) but
the surgeon is unable to complete it in full due to complications,
Modifier 52 may be added to the code to indicate that the procedure
was reduced or modified.

Important Note:

 Modifier 52 should not be used when the procedure itself is bundled with
other services or when the service is inherently considered "reduced." It
should also not be used when a service is not completed due to patient
refusal or other reasons not related to clinical discretion.
CPT Code 47562: Laparoscopic Cholecystectomy

 Description:
o 47562 is the CPT code for laparoscopic cholecystectomy, a
minimally invasive surgical procedure to remove the gallbladder. This
procedure is commonly performed to treat conditions such as
gallstones, gallbladder disease, and other gallbladder-related
issues.

Modifier 53 in CPT Coding: Discontinued Procedure

 What it indicates:
o Modifier 53 is used to indicate that a procedure was discontinued
after it had started, due to extenuating circumstances or conditions
that threatened the well-being of the patient. This modifier tells the
payer that the service was intended to be completed but was halted
for medical reasons before the procedure was finished.
 Purpose:
o Modifier 53 helps explain that the provider made the decision to stop
a procedure after initiation due to a patient's safety concerns,
unexpected complications, or other circumstances that prevented
the procedure from being completed as planned. This could involve
issues such as:
 Unanticipated medical complications during surgery.
 Patient intolerance to the procedure.
 Changes in the patient’s condition that make it unsafe to
continue.
 Anesthesia complications or other medical emergencies.
 When to Use Modifier 53:
o When a procedure was started but discontinued before completion
due to reasons beyond the provider's control.
o It must be documented in the medical record, explaining the reason for
discontinuation and any alternative interventions provided.

Example:

 Surgical Procedure:
o A patient undergoing laparoscopic surgery for gallbladder removal
(cholecystectomy) experiences cardiac complications during the
procedure, leading the surgeon to stop the surgery. Modifier 53
would be applied to indicate the surgery was halted due to the
patient’s condition.

Important Note:

 Modifier 53 is not used when a procedure is canceled before it begins, but

rather after it has started. It's used when the provider is unable to complete
the procedure safely.
CPT Code 45300: Digital Rectal Exam (DRE)

 Description:
o 45300 is the CPT code for a digital rectal examination (DRE), a
procedure performed to check for abnormalities in the rectum, anus,
and prostate (in males). This exam involves the healthcare provider
inserting a lubricated, gloved finger into the rectum to feel for
irregularities, masses, or signs of conditions like hemorrhoids,
prostate enlargement, or rectal cancer.

Modifier 54 in CPT Coding: Surgical Care Only

 What it indicates:
o Modifier 54 is used to indicate that the surgeon only provided the
surgical care for a procedure and that postoperative care was not
included in their services. This modifier is applied when a surgeon
performs the surgery but does not provide the follow-up care or
postoperative management, which may be handled by another
healthcare provider.
 Purpose:
o The use of Modifier 54 helps to specify that only the surgical
procedure was performed by the surgeon, and any follow-up care
(such as post-surgery visits, management of complications, and
recovery monitoring) is provided by another physician or healthcare
provider. This helps in proper billing and reimbursement.
 When to Use Modifier 54:
o When a surgeon performs the operative portion of a procedure, but
another provider manages the preoperative and/or postoperative
care.
o Common in cases where the surgical procedure is referred to a
specialist, and the patient continues with another provider for follow-up
care (e.g., general surgeons, orthopedic surgeons).

Example:

 Surgical Care Only:

o A cardiothoracic surgeon performs a heart surgery (such as
coronary artery bypass surgery), but the patient's postoperative
care (such as monitoring and wound care) is provided by the primary
care physician or another specialist. The surgeon would use Modifier
54 to indicate that they are only billing for the surgery, not the
postoperative care.

Important Note:

 Modifier 54 should be used in conjunction with the surgical procedure

code to distinguish between the surgical portion and the postoperative care,
which may be billed separately.
  Modifier 54 applies to surgical services only; it does not apply to
diagnostic or therapeutic procedures.

CPT Code 12001: Simple Repair of Superficial Wounds

 Description:
o 12001 is the CPT code for the simple repair of superficial wounds
that are 2.5 cm or less in length. This procedure involves the closure of
superficial lacerations or incisions on areas like the scalp, neck,
axillae (armpits), external genitalia, trunk, or extremities (arms
and legs). The repair involves only the skin and subcutaneous tissue
without significant underlying tissue involvement.
 Procedure Overview:
o Simple repair refers to a straightforward closure of a wound using
suturing or other methods that do not involve extensive tissue
manipulation. This code applies to repairs of superficial wounds that
do not extend deeply into the tissue layers beyond the skin and
subcutaneous tissue.
o Size of the wound must be 2.5 cm or less for this code to apply.
The wound must also be non-complex and not require advanced
techniques like those used in complex repairs.
 Indications for Use:
o This code is used for the closure of small, uncomplicated
superficial wounds. Examples include:
 Minor cuts or lacerations on the skin that do not involve
underlying structures (muscles, nerves, blood vessels).
 Wounds that are clean and do not require extensive
debridement or tissue manipulation.
 Commonly used for wounds on areas like the scalp, neck,
axillae, external genitalia, trunk, or extremities.
 Key Characteristics of a Simple Repair (for CPT Code 12001):
o The procedure involves a single layer closure of the wound.
o The wound is not complicated by factors like infection, tissue loss, or
significant cosmetic concerns.
o The wound does not require extensive manipulation of the underlying
tissue or additional resources.

Modifier 55 in CPT Coding: Postoperative Management Only

 What it indicates:
o Modifier 55 is used when the postoperative care (management) for
a procedure is provided by a healthcare provider other than the one
who performed the surgery. This modifier indicates that the surgeon
or physician performed the surgical procedure but not the
postoperative care, which is being handled by another provider.
 Purpose:
o Modifier 55 helps differentiate when a provider is responsible for only
the postoperative management of a patient after surgery, but not
the surgery itself. This can occur in situations where a specialist or
 surgeon performs the surgery, but follow-up care is managed by the
primary care physician or another healthcare provider.
 When to Use Modifier 55:
o The surgical procedure is performed by one provider (e.g., a surgeon),
but the postoperative care is provided by a different provider.
o The postoperative care includes services like monitoring recovery,
managing complications, or providing routine follow-up visits during
the recovery period.

Example:

 Postoperative Management Only:

o A general surgeon performs knee surgery on a patient, and then
the primary care physician manages the patient’s recovery, follow-
up visits, and any complications after the surgery. The primary care
physician would use Modifier 55 to indicate they are only billing for
the postoperative management of the patient after surgery.

Important Notes:

 Modifier 55 is used for postoperative management after a surgery is

performed. It does not apply to preoperative care or intraoperative
services.
 The postoperative period can vary depending on the procedure, but it
generally lasts for a period of 10 to 90 days after surgery.

Modifier 56 in CPT Coding: Preoperative Management Only

 What it indicates:
o Modifier 56 is used when the healthcare provider is responsible for
preoperative management only, meaning the provider handles the
preoperative care and preparation for a surgery, but does not
perform the actual surgical procedure or provide postoperative care.
The surgery itself is performed by a different physician or healthcare
provider.
 Purpose:
o Modifier 56 is used to indicate that the healthcare provider was
involved only in the preoperative phase of care, which includes
patient evaluation, diagnosis, and preparation for surgery, but was not
responsible for the surgery or any postoperative care.
 When to Use Modifier 56:
o When a provider is responsible for preoperative care (such as
assessing the patient, conducting necessary tests, and ensuring the
patient is ready for surgery) but does not perform the surgical
procedure itself or provide postoperative care.

Example:

 Preoperative Management Only:

 o A primary care physician evaluates and prepares a patient for
spinal surgery, performing tests, assessments, and ensuring that the
patient is medically optimized for surgery. However, the actual spinal
surgery is performed by an orthopedic surgeon. The primary care
physician would use Modifier 56 to indicate that they were
responsible only for the preoperative management.

Important Notes:

 Modifier 56 should be used when preoperative care is billed separately,

and the surgical procedure is billed separately by the surgeon who performed
the surgery.
 It does not apply to preoperative care related to diagnostic procedures,
routine visits, or care that is not part of the surgical preparation.

Modifier 57 in CPT Coding: Decision for Surgery

 What it indicates:
o Modifier 57 is used to indicate that an evaluation and
management (E/M) service led to the decision to perform
surgery. This modifier is applied when a physician's E/M service
(such as an office visit or consultation) results in a decision to proceed
with surgery on the same day.
 Purpose:
o Modifier 57 is used to separately report the E/M service that directly
resulted in the decision to perform a surgical procedure. It helps
distinguish when the E/M service is part of the surgical decision-
making process, ensuring that the provider is compensated for both
the decision-making and the procedure (if applicable).
 When to Use Modifier 57:
o The E/M service (such as an office visit or consultation) that took
place on the same day as surgery resulted in the decision to
proceed with the surgery.
o The decision for surgery should be documented in the patient's
medical record, showing that the E/M service directly led to the
decision to perform surgery.

Example:

 Decision for Surgery:

o A patient visits their physician for an evaluation regarding persistent
gallbladder pain. After assessing the patient's condition and
reviewing test results, the physician decides that the patient requires
gallbladder surgery. In this case, the E/M service (the office visit)
on the same day as the surgery decision would be billed with Modifier
57 to indicate that the decision for surgery was made during the visit.

Important Notes:
  Modifier 57 is applied to E/M services performed on the same day as the
decision to proceed with surgery, but it does not apply to routine visits or
follow-up appointments.
 The decision for surgery should be clearly documented in the patient’s
medical record to justify the use of Modifier 57.

SCENARIOS

Mohs surgery is performed on a patient with basal cell carcinoma on the neck. The
gross tumor is completely excised. Tissue is divided into two tissue blocks which are
mapped and color coded at their margins; frozen sectioning is performed. A full
thickness graft is used to harvest skin from the patient’s left axillae for an area of
10 sq cm on the neck. What CPT codes are assigned?

Case Explanation:

Scenario Summary:

 A patient undergoes Mohs micrographic surgery for basal cell carcinoma

on the neck.
 Tissue is divided into two tissue blocks, mapped, and color-coded. Frozen
sectioning is performed.
 Following tumor excision, a full-thickness skin graft is harvested from the
left axillae to repair a 10 sq cm defect on the neck.

Correct CPT Codes:

1. 17311 – Mohs micrographic surgery, including removal of all gross tumor and
surgical excision, first stage, up to 5 tissue blocks, head, neck, hands, feet,
genitalia:
o The Mohs technique was performed on the neck, which falls under the
head and neck category.
o Code 17311 is appropriate for up to 5 tissue blocks. Since the
procedure involved two tissue blocks, this code is applicable.
2. 15240 – Full-thickness graft, free, including direct closure of donor site, neck,
hands, feet, and/or eyelids; 20 sq cm or less:
o A full-thickness graft was performed on the neck using skin harvested
from the left axillae, covering an area of 10 sq cm.
o Code 15240 applies to 20 sq cm or less in the neck, making it the
correct choice for this procedure.

A 4-year-old is seen in the ER as she cannot bend her right arm after her older
brother pulled on her arm while playing. The physician reviews the X-ray and the
diagnosis is a dislocated nursemaid’s elbow. The ER physician reduces the elbow
successfully. The patient can move her arm again. She will follow-up with an
orthopedic physician. What CPT® code is reported?

Final Answer:

24640-54 – Closed treatment of radial head subluxation (nursemaid

elbow), with manipulation.
This code accurately represents the diagnosis and procedure performed, with
modifier 54 indicating the ER physician provided only the surgical portion of care.

 This CPT code is specific to the reduction (manipulation) of a

nursemaid’s elbow and accurately reflects the service performed.
 Modifier 54 is added to indicate that the ER physician provided only the
surgical portion of the treatment, and the patient will follow up with
another provider (orthopedist) for further care.

Case Explanation:

Scenario Summary:

 A 4-year-old child presents with a dislocated nursemaid’s elbow caused

by traction during play.
 The ER physician reviews an X-ray, confirms the diagnosis, and reduces
the dislocation successfully.
 Post-reduction, the child can move her arm again. Follow-up care will be
provided by an orthopedic physician.

A cardiologist performed an angioplasty and atherectomy on the right popliteal

artery by percutaneous approach from the left femoral artery. What is the CPT®
coding?

Final Answer:

37225 – This code appropriately describes the atherectomy and angioplasty

performed on the right popliteal artery via a percutaneous approach.

Case Explanation:

Scenario Summary:

 A cardiologist performs angioplasty and atherectomy on the right

popliteal artery via a percutaneous approach.
 The access site for the procedure is the left femoral artery.
43-year-old female patient is in the surgical suite to have an incarcerated hernia of
her belly button repaired with an implantation of a mesh. What is the correct
CPT® coding for the hernia repair?

Final Answer:

49587 – This code correctly describes the repair of an incarcerated umbilical

hernia in a patient aged 5 years or older, and it includes the mesh implantation
as part of the procedure.

Case Explanation:

Scenario Summary:

 The patient is a 43-year-old female.

 She has an incarcerated umbilical hernia.
 Mesh implantation is performed during the hernia repair.

The patient presents with a recurrent cyst of the Bartholin’s gland which has
previously been treated with antibiotics and I&D. At this visit her gynecologist
incises the cyst, draining the material and tacks the edges of the cyst creating an
open pouch to prevent recurrence. What is the correct CPT® code?

Final Answer:

56440 – This code accurately describes the marsupialization procedure for a

Bartholin’s gland cyst, which involves incising the cyst, draining it, and creating
an open pouch to prevent recurrence.

Case Explanation:

Scenario Summary:

 The patient presents with a recurrent Bartholin’s gland cyst.

 The gynecologist performs marsupialization of the cyst, where the cyst is
incised, the material is drained, and the edges are tacked to create an open
pouch to prevent recurrence.

A 45-year-old male patient with chronic lumbago is seen by the physician to have
an epidural injection at the sacral level. What CPT® code is reported for this
procedure?
Final Answer:

62322 – This code correctly describes the single epidural injection at the sacral
level for this patient with chronic lumbago. Injection, epidural or spinal (caudal
or sacral), single level, sacral.

Case Explanation:

Scenario Summary:

 A 45-year-old male patient with chronic lumbago (lower back pain) is

undergoing an epidural injection at the sacral level.

New patient visit primary care physician comprehensive history and exam,
,medical decision making of moderate complexity what is the correct code

CPT code 99204:

 A new patient requiring a comprehensive evaluation and

moderate complexity in decision-making. This could be for
conditions that require careful consideration but are not highly
complicated or requiring urgent interventions.

An established patient visits to a specialist problem focused history and

exam medical decision making of low complexity

CPT code 99212:

 An established patient who presents with a problem-focused

concern that requires a low level of complexity in both history and
examination. This might include a follow-up visit for a stable
condition or a minor issue that doesn’t require extensive decision-
making or intervention.

Initial consultation visits for a new patient, detailed history and exam,
medical decision making of high complexity.

CPT Code 99244:

 This code applies to an initial consultation for a new patient

where the provider performs a detailed history and
examination and the medical decision making is high
complexity. It is typically used in cases where the patient's
 condition is serious, involves multiple diagnoses or treatment plans,
or requires a comprehensive approach.

Example Scenario:

 A new patient presents to a specialist with a complex medical

issue that requires a detailed history and examination (such as a
complex case of a chronic condition or a new, serious diagnosis).
The physician needs to consider multiple treatment options or may
need to gather extensive test results or consultations before
making a decision.

A Patient undergoes an open repair of an inguinal hernia, initial

CPT 49505:
 Procedure: This code is used when the surgeon performs an
open surgical procedure to repair an inguinal hernia in a
new patient (first-time procedure).
 Initial repair of an inguinal hernia via an open surgical
approach, whether or not mesh is used.
 This code is used only for open repairs. If the repair is done
via a laparoscopic approach, a different code (e.g., 49650)
would be used.

A patient has a Laparoscopic appendectomy

CPT 44970:

 Laparoscopic appendectomy is performed for an acute, chronic, or

recurrent appendicitis, or for other medical indications where the
appendix needs to be removed via a laparoscopic technique.
 This code applies to the laparoscopic approach specifically. If an open
appendectomy is performed,

Patient with a Total knee arthroplasty

CPT 27447:
 Total knee arthroplasty (replacement of the knee joint with a
prosthetic) performed for conditions such as severe arthritis,
degenerative joint disease, or knee deformities.
 The code can be used whether or not the patella is resurfaced
during the surgery.

Left off on page 260 question 57

 Anesthesia CPC Guidelines

ANESTHESIA TYPE

GENERAL-complete unconsciousness

REGIONAL-numb large part of the body

MONITORED ANESTHESIA CARE (MAC)- conscious sedation with a focus

on patient safety and comfort.

LOCAL ANESTHESIA- numb a small area

REPORTING BASED ON ANESTHESIA TIME

START TO END: Time is reported from when the anesthesiologist begins preparing
the patient to when the patient is no longer under the provider’s care.

MINUTES: Anesthesia time is documented in minutes.