CH5- CPT Concepts

Question 1

A patient comes into the office for follow up of neck pain. The provider documents a medically appropriate history and exam. The medical decision making was of low complexity. What E/M code is reported for this visit?

Answer 1

99213

Response Feedback:
The patient is seen in the office and is being seen for follow-up of neck pain making it an established patient. For an established patient, the criteria of the E/M visit is based on the E/M Guidelines. The provider documented a medically appropriate history and exam. The medical decision making was of low complexity making this a 99213.

Question 2

A patient sees his primary care doctor for calluses on his feet. The provider uses a scalpel to pare down six calluses (benign hyperkeratotic lesions) on his feet. How is this reported?

Answer 2

11057

Response Feedback:
Look in the CPT Index for Paring/Skin Lesion/Benign Hyperkeratotic 11055-11057. In the Integumentary Section, the codes are determined based on the number of lesions removed. 11057 reports more than four lesions. This code is only reported once anytime more than 4 lesions are removed by paring or cutting.

Question 3

A 5 year-old fell on broken glass and required suturing of a laceration. Due to the age and combative behavior of the patient, the provider utilized moderate sedation while repairing the laceration. The provider gave the child 50 mg of Ketamine IM. A nurse monitored the patient during the procedure which took 30 minutes. What CPT® code is reported for moderate sedation?

Answer 3

99152, 99153

Response Feedback:
Moderate sedation is often used for pediatric patients in situations not normally requiring sedation. In this case, the provider administered sedation with a nurse assisting in monitoring the patient. In the CPT® Index look for Sedation/Moderate/with Independent Observation and you are directed to code range 99151-99153. Code selection is based on age of the patient and the length of time. Code 99152 describes an encounter using moderate sedation, and the physician or other qualified healthcare professional rendering the diagnostic or therapeutic service also manages the sedation. This code is specific for the age of the patient and up to 15 minutes of time. Add-on 99153 is for each additional 15 minutes of intraservice time.

Question 4

A child with suspected sleep apnea was given an apnea monitoring device to use over the next month. The device was capable of recording and storing data relative to heart and respiratory rate and pattern. The pediatric pulmonologist reviewed the data and reported to the child’s primary pediatrician. What CPT® code(s) is/are reported for the monitor attachment, download of data, provider review, interpretation and report?

Answer 4

94774

Response Feedback:
In the CPT® Index look for Monitoring/Pediatric Apnea and you are directed to code range 94774-94777. Code selection is based on the components of the test performed. In this case, code 94774 describes the data storage capability, including the provider or other qualified health care professional interpretation and report. The code is to be reported each 30-day period.

Question 5

When tissue glue is used to close a wound involving the epidermis layer how is it reported?

Answer 5

as a simple closure

Response Feedback:
Rationale: The Guidelines for Repair (Closure) include tissue adhesive along with sutures and staples, either singly or in combination with each other can be reported with the repair codes. In this case the tissue glue (adhesive) is a one-layer closure and can be reported with a simple repair code. Wound closure utilizing adhesive strips as the sole repair material is coded using the appropriate E/M code.

Question 6

Mr. Bowen is having a pre-employment physical (screening). His doctor ordered the following serum blood tests: CBC (automated), comprehensive metabolic panel, automated differential WBC count and a thyroid stimulating hormone (TSH) assay. Code the services for these labs.

Answer 6

80050

Response Feedback:
Rationale: Organ or Disease-Oriented Panels guidelines preceding the panel codes indicate, “The tests listed with each panel identify the defined components of that panel.” In addition to the tests listed under the Comprehensive metabolic pane (80053), an automated CBC and an automated differential WBC count (85025), and TSH (84443) are part of 80050 General health panel and are not coded separately. In the CPT® Index, look for Blood Tests/Panels/General Health directing you to 80050.

Question 7

A 56 year-old patient who has been admitted requires a tunneled CV catheter insertion. The physician uses ultrasound guidance to perform the insertion. The physician documented vessel patency and that permanent recordings are in the patient’s record. What CPT® codes are reported for the physician’s services?

Answer 7

36558, 76937-50

Response Feedback:
The physician inserts a tunneled CV catheter (central venous). The patient is 56 years-old and there is no indication that a port or pump is involved. In the CPT® Index look for Central Venous Catheter Placement/Insertion/Central/Tunneled without Port or Pump 36557-36558, 36565. The correct code is 36558. The physician uses ultrasound guidance, which is reported with 76937. In the coding guidelines for Central Venous Access Procedures, it states that imaging can be reported separately. The codes you are referred to are 76937 and 77001. Because the imaging used is ultrasound, report with 76937. Note that 76937 is an add-on code and it can only be reported if the physician documents selected vessel patency and permanent ultrasound recordings are in the patient’s record. Modifier 26 is appended to report the professional component.

Question 8

A 6 year-old female with prominent ears undergoes a bilateral otoplasty. Surgeon makes an incision just behind the ear in the natural fold where the ear is joined to the head exposing the cartilage. Cartilage is trimmed and shaped and the incision is closed. Temporary sutures are placed to secure the ear until healing is accomplished. The procedure is repeated on the other ear. What CPT® code is reported?

Answer 8

69300-50

Response Feedback:
Rationale: In the CPT® Index look for Otoplasty which directs you to code 69300, Auditory System numeric section. The parenthetical note beneath 69300 instructs us to report the code with modifier 50 for a bilateral procedure.

Question 9

Vasectomy reversal is performed, bilaterally, using the operating microscope. Choose the procedure code(s).

Answer 9

55400-50, 69990

Response Feedback:
Rationale: In the CPT® Index look for Vasectomy/Reversal which refers you to see Vasovasorrhaphy - code 55400. There are two parenthetical instructions beneath the code instructing us to use modifier 50 for a bilateral procedure and to use 69990 when an operating microscope is used.

Question 10

A patient presents for epicardial lead placement via median sternotomy to the right atrium and right ventricle. A dual pacemaker generator is then inserted subcutaneously. The patient has bundle branch block and sinoatrial node dysfunction. What CPT® code(s) are reported?

Answer 10

33202, 33213-51

Response Feedback:
Rationale: Because leads were placed on the right atrium and right ventricle, it is a dual chamber system. Two codes are necessary to report placement of an epicardial system. The parenthetical note under 33203 directs the coder to report codes 33202 and 33203 with 33212, 33213, 33221, 33230, 33231, and 33240. Look in the CPT® Index for Pacemaker, Heart/Insertion/Pulse Generator Only. You are referred to 33212, 33213, and 33221. For the placement of the epicardial electrodes look in the CPT® Index for Pacemaker, Heart/Insertion/Electrode, and you are referred to 33202-33203.

Question 11

Codes for surgery include the performance of the surgery as well as which of the following?

Answer 11

Local anesthesia, including digital nerve blocks

Response Feedback:
Post-operative days range from 0-90 days depending on the surgery performed. Codes for surgery includes only typical post-operative care and does not include care provided for post-operative complications as part of global care. One E/M encounter on the day of, or immediately preceding the date of surgery (unless the decision for surgery was made at that visit, in which case it may be claimed separately) is included.

Question 12

A Medicare patient presents to the ER for chest pain. An internal medicine provider is called to evaluate the patient. A medically appropriate history and exam is documented. The provider orders an EKG, chest X-ray, and lab work and requests a consultation by cardiology. The documentation supports a high MDM. The internal medicine provider admits the patient. What is the correct billing for the admission?

Answer 12

99223, R07.9
Response Feedback:
Internal Med is called to evaluate the patient, and this does not meet the definition of a consult. Admissions are reported from initial hospital inpatient or observation care. Code 99223, Initial hospital inpatient or observation care is reported for a high MDM.

According to ICD-10-CM guideline, I.B.18, when a confirmed diagnosis is not available, it is appropriate to report the signs and symptoms. Look in the ICD-10-CM Alphabetic Index for Pain/chest (central) R07.9. Verify code selection in the Tabular List.

Question 13

What is the CPT® code for an appendectomy?

Answer 13

44950
Response Feedback:
Look in the CPT® Index for Appendectomy which directs you to 44950, 44955, 44960, 44970. Code choice is based on the method of removal and additional procedures performed at the same time. Verify code in the numerical section.

Question 14

What is the CPT® code for a diagnostic amniocentesis?

Answer 14

5900
Response Feedback:
Look in the CPT® Index for Amniocentesis, Diagnostic and you are referred to 59000. Verify code in the numerical section.

Question 15

Patient presents for ultrasound (US) of thyroid for nontoxic multinodular goiter. US is performed with small parts linear probe at 3.3 cm depth. Images taken show a slightly hypoechoic solid mass noted on the right lobe of the thyroid inferiorly measuring 1.44 cm transversely and 1.54 transversely. Which CPT® code is used?

Answer 15

76536
Response Feedback:
Look in the CPT® Index for Ultrasound/Neck referring you to 76536. CPT® code is selected by location and the radiology method. Verify code in the numerical section.

Question 16

A 68-year-old Medicare patient presented for an annual examination and had no complaints. Her claim, billed as 99387, was denied. Was this billed correctly? If not, what is needed to bill this encounter correctly?

Answer 16

It will depend on the documentation
Response Feedback:
The code selection is based on the documentation. CPT® code 99387 will not be paid by Medicare. Medicare uses codes G0438 for initial and G0439 for subsequent annual wellness visits. G0101 and Q0091 is billed with modifier GA if an Advanced Beneficiary Notice (ABN) was completed and documentation indicates the patient has a breast and pelvic exam with a screening pap.

Question 17

What is the CPT® code for an arthrocentesis wrist (intermediate joint)?

Answer 17

20605
Response Feedback:
Look in the CPT® Index for Arthrocentesis/Intermediate Joint referring to codes 20605 and 20606. The code choice is specific to if ultrasound guidance is or is not performed. There is no indication in the question that ultrasound guidance was used. The correct code is 20605.

Question 18

What is the correct CPT® code to use for testing stool for occult blood by guaiac for a patient presenting with a chronic gastric ulcer and the provider takes two specimens as part of the digital examination?

Answer 18

82272
Response Feedback:
Since the patient is not being tested for a colorectal neoplasm screening, do not report code 82270. Code 82272 is reported when a single, two or three specimens are obtained from a digital rectal examination to be tested; do not report code 82272 twice. In the CPT® Index look for Occult Blood leads you to 82270-82272.

Question 19

Patient is seen for destruction of 2 skin lesions that were diagnosed as actinic keratosis (AK). Which of the following is the correct billing for removal of skin lesions?

Answer 19

17000, 17003
Response Feedback:
Actinic keratosis is a premalignant lesion. Look in the CPT® Index for Destruction/Lesion/Skin/Premalignant and you are referred to codes 17000-17004, 96567, 96573, and 96574. Codes 96567, 96573, and 96574 are for reporting photodynamic therapy. The correct code is based on the number of lesions. Code 17000 is reported for the first lesion. Code 17003 is reported once for the second lesion. Code 17003 is an add-on code and used in conjunction with 17000 only. Add-on codes cannot be reported with modifier 51, they are exempt. Code 17004 is only reported, by itself, if 15 or more lesions were destroyed. There is a parenthetical note under code 17004 that indicates not to report 17004 with 17000-17003.

Question 20

A 2-year-old is brought to the ER by EMS for near drowning. EMS had gotten a pulse. The ER physician performs endotracheal intubation, blood gas, and a central venous catheter placement. The ER physician documents a total time of 30 minutes on this critical infant in which the physician already subtracted the time for the other billable services. What is the E/M service and procedure code(s) to report for the ER physician?

Answer 20

99291-25, 36555, 31500
Response Feedback:
According to the CPT® subsection guidelines for Inpatient Neonatal and Pediatric Critical Care: To report critical care services provided in the outpatient setting (example, emergency department or office) for neonates and pediatric patients of any age, see the Critical Care codes 99291, 99292; do not report 99475. There is documentation in which the ER physician spent a total of 30 minutes on a critical patient; report 99291 for the critical care; do not report 99285. Blood gas (82803) is a lab procedure that is not separately reported when billing for critical care. A list of services included in reporting critical care is found in the subsection guidelines under Critical Care Services. Modifier 25 needs to be appended to 99291 because it is an evaluation and management service in which billable procedures were performed on the same date of service. Code 36556 for the catheter placement and code 31500 for the intubation are billable codes and should be reported separately.

Question 21

A 62-year-old woman presents for sigmoidoscopy. The physician inserts a flexible scope into the patient’s rectum and determines the rectum to be clear of polyps. The scope is advanced to the sigmoid colon and a total of 3 polyps are found. Using a snare technique, the polyps are removed. The flexible scope is withdrawn. The pathology report later indicates the polyps are benign. The claim was billed with 45388. Is this correct? If not, what code should be billed?

Answer 21

No, 45338 should be reported.
Response Feedback:
CPT® code 45388 is for a colonoscopy with ablation which is incorrect. Look in the CPT® Index for Sigmoidoscopy/Removal/Polyp which refers you to codes 45333 and 45338. Code 45338 is selected based on use of the snare technique. CPT® code 45309 is used for a proctosigmoidoscopy where a rigid scope is used. CPT® code 44100 is for a biopsy only, without the use of a scope.

Question 22

A claim is submitted for an assistant surgeon. What modifier would NOT be used for an assistant surgeon?

Answer 22

Modifier 62
Response Feedback:
Modifier 62 is used when two surgeons are involved but they meet the definition of co-surgeons and not assistant surgeons. Modifiers 80, 82, and AS can all be used for an assistant surgeon depending on the payer and the provider. Modifier 80 is used for an assistant surgeon during the procedure. AS is used for non-physician assistant-at-surgery services for Medicare beneficiaries. Modifier 82 is used by a physician in a teaching facility when a qualified resident is not available.

Question 23

Sally is a 45-year-old female, established patient seen for an annual gynecological exam. The physician performs a comprehensive history and a detailed exam. During the exam, a cervical polyp is seen, and the decision is made to remove the polyp with ring forceps. What code(s) are reported?

Answer 23

99396-25, 57500
Response Feedback:
The polyp is an incidental finding during the preventive service. A separate problem E/M would not be reported. Look in the CPT® Index for Evaluation and Management/Preventive Services referring you to 99381-99429. Code selection is based on the age of the patient and whether the patient is new/established. The removal of the polyp is a biopsy. Look in the CPT® Index for Cervix/Biopsy and you are referred to codes 57500 and 57520. The correct code to report is 57500. Modifier 25 would be appended to the E/M code to report it is separately identifiable.

Question 24

The patient is a female with a long history of chronic intractable pain secondary to myofascial pain syndrome, scoliosis, and has four back surgeries. She also has piriformis muscle syndrome. The patient was injected with five trigger points using a total of 33 cc. of 0.25% Marcaine and 40 mg. The muscles injected were two muscles in her lumbar paraspinous and two muscles in her piriformis. What is the appropriate CPT® code(s) for the procedure?

Answer 24

20553
Response Feedback:
Trigger point injections were given. Code 20610 is not reported because this was not performed into a major joint. Trigger point injections are reported by the number of muscles that are injected not the number of injections. There were four muscles injected (two muscles in the lumbar paraspinous and two muscles in the piriformis) directing you to code 20553. Code 20553 is only reported once because the code description indicates “muscle(s),” which means this code is reported once when three or more muscles are injected. Look in the CPT® Index for Trigger Point/Injection/Two or More muscles, leads you to 20553.

Question 25

Claim is sent for biopsy of soft tissue of flank with code 21920. Is this code correct? If not, what code is reported?

Answer 25

Yes, this code is correct.
Response Feedback:
Look in the CPT® Index for Biopsy/Back/Flank referring you to codes 21920-21925. Code 21920 is reported for soft tissue biopsy of the back/flank. Codes 20200, 20205 and 20206 are reported for excisional biopsies of muscle and are incorrect.

Question 26

What is the full CPT® code description for 00846?

Answer 26

Anesthesia for intraperitoneal procedures in lower abdomen including laparoscopy; radical hysterectomy
Response Feedback:
Code 00846 is an indented code, which means the description from parent code 00840 up to the semicolon is the beginning of the full description for code 00846. The full code description is: Anesthesia for intraperitoneal procedures in lower abdomen including laparoscopy; radical hysterectomy. You can also refer to the Introduction section in front of the CPT® codebook and look for the subheading Format of the Terminology to indicate this.

Question 27

A claim is reported for bilateral knee injections with Kenalog 40 mg per joint with CPT® codes 20610, 20610, J3301x80. Is this coded correctly and if not, how should it be coded?

Answer 27

No, 20610-50, J3301x8 should be reported.
Response Feedback:
CPT® code 20610 is for a unilateral procedure. The procedure was performed bilateral and should be reported as 26010-50. When performed bilaterally Modifier 50 is used with one-line item. HCPCS Level II code J3301 is reported per 10 mg unit of Kenalog. In this case, 40 mg was injected into each joint for a total of 80 mg. The Kenalog is reported with J3301 x 8. Some payers may allow use of Modifier 51 for the second procedure.

Question 28

Patient with multilevel disk degeneration with stenosis has consented to have a steroid injection for pain management into the right L5-S1 paravertebral facet joint. The needle is inserted under fluoroscopic guidance and a steroid mixture was then injected. The same procedure was performed on the left L5-S1 facet joint without complications. How is this procedure reported?

Answer 28

64493-50
Response Feedback:
In the CPT® Index, look for Injection/Paravertebral Facet Joint/Nerve/with Image Guidance which leads you to codes 64490-64495. Because injections were performed on the right and left side of the paravertebral facet joint, report modifier 50. The code description for code 64493 indicates “with image guidance (fluoroscopy or CT)”, which means fluoroscopy code 77003 is not reported separately.

Question 29

Newborn male is scheduled for a circumcision. He is sterilely prepped and draped. A penile nerve block is performed. The circumcision is performed by a ring device. Hemostasis is achieved. Vaseline Gauze dressing applied. Patient tolerated the procedure well. How is this encounter coded?

Answer 29

54150
Response Feedback:
In the CPT® Index look for Circumcision/Surgical Excision/Neonate referring you to codes 54150 and 54160. The patient is having the circumcision performed with a ring device (other device), selecting code 54150. It is inappropriate to code 64450 with 54150 because a penile block is included and stated in the code description.

Question 30

When a patient is seen for evaluation and the decision is made for a minor procedure that is performed on the same day, which modifier is appended to the claim to allow reimbursement for the E/M and the procedure?

Answer 30

Modifier 25
Response Feedback:
Modifier 57 is used for procedures with more than 10 global days. For minor procedures performed on the same day as an E/M service, use Modifier 25.

Question 31

The patient is a 52-year-old man with a large right inguinal hernia. He is brought to the operating room to have it repaired for the first time. The hernia is reduced, and a mesh is placed over the area. What CPT® code(s) is (are) reported for the surgery?

Answer 31

49505
Response Feedback:
In the CPT® Index look for Hernia Repair/Inguinal/Initial, Child 5 Years or Older, which leads you to codes 49505 and 49507. This is the first time the patient has the inguinal hernia, report code 49505 for an initial hernia repair.

Question 32

An 18-year-old male is taken to the operating room to resolve a urethral stricture. A cystoscope was passed through the urethra and bladder and a series of urethral dilators up to 20 French were then placed, dilating the stricture. What CPT® code is used for this procedure?

Answer 32

52281
Response Feedback:
Be careful to read the code descriptions because the procedure is for the urethra not ureter. Do not report 52341. Because a cystoscope is used for the procedure, do not report code 53600. The procedure is for a urethral stricture, not for interstitial cystitis, do not report code 52260. In the CPT® Index look for Stricture/Urethra and there is a note to See Urethral Stenosis. Look for Urethral/Stenosis/Dilation referring you to 52281. Verify the code in the numerical section.

Question 33

Laparoscopic cholecystectomy is performed for a patient with RUQ pain and abnormal ultrasound. Which code is used for this procedure?

Answer 33

47562
Response Feedback:
Indexing for Cholecystectomy/Laparoscopic leads to 47562-47564. Code 47562 is for a laparoscopic cholecystectomy.

Question 34

A 68-year-old female with end-stage-renal disease is having a non-tunneled central venous catheter placed. Patient is placed under moderate conscious sedation and needle punctured the internal jugular vein in which a guide wire was inserted. A catheter was inserted over the guidewire and the final catheter tip resided in the superior vena-cava. The patient was monitored by nurse and the patient was under sedation for 30 minutes. The codes reported are 36556, 99152, 99153. Are these codes reported correctly? If not, what code(s) are used for this procedure?

Answer 34

Yes, the codes are reported correctly.
Response Feedback:
This is a non-tunneled catheter being inserted, code 36558 is for a tunneled catheter and it is not reported. In the CPT® Index look for Central Venous Catheter Placement/ Insertion/Central/Non-tunneled, leads you to 36555-36556. For the conscious sedation, look in the Index for Sedation/Moderate/with Independent Observation and you are directed to 99151-99153. Because the patient is over 5 years old, 99152 is reported for the first 15 minutes and 99153 is reported for the additional 15 minutes.