CPC Chapter 10- Cardiovascular System Review Questions

Question 1

The __________ is a fist-sized, cone-shaped muscle sitting between the lungs and behind the sternum.
A. Aortic valve
B. Heart
C. Capillary bed
D. Coronary artery

Answer 1

B. Heart

Rationale: The heart is a fist-sized, cone-shaped muscle sitting between the lungs and behind the sternum.

Question 2

What type of circulation refers to the movement of blood through tissues of the heart?
A. Pulmonary
B. Systemic
C. Arterial
D. Coronary

Answer 2

D. Coronary

Rationale: Coronary circulation refers to the movement of blood through the tissues of the heart.

Question 3

What term refers to a rapid heartbeat?
A. Tachycardia
B. Cardiomegaly
C. Bradycardia
D. Tachypnea

Answer 3

A. Tachycardia

Rationale: Tachy = fast and cardia = heart.

Question 4

Which valves are the semilunar valves?
A. Tricuspid and Aortic
B. Pulmonary and Mitral
C. Tricuspid and Mitral
D. Pulmonary and Aortic

Answer 4

D. Pulmonary and Aortic

Rationale: The tricuspid and mitral valves are the atrioventricular valves. The pulmonary and aortic valves are the semilunar valves because of their shape, a half moon or crescent shaped.

Question 5

Where can codes relating to the cardiovascular system be found in CPT®?
A. 30000s
B. 70000s
C. 90000s
D. All the above

Answer 5

D. All the above

Rationale: CPT® codes for the Cardiovascular System are found in multiple sections of CPT® (30000, 70000, and 90000).

Question 6

A patient presents to his physician’s office for a follow-up visit and review of test results. Previously, the patient complained of shortness of breath and chest pain during exercise and the physician ordered an echocardiogram. The physician documents aortic valve stenosis. What ICD-10-CM code is reported?
A. I08.0
B. Q23.0
C. I35.0
D. I06.0

Answer 6

C. I35.0

Rationale: No mention was made of a congenital condition or rheumatic condition. In the ICD-10-CM Alphabetic Index look for Stenosis, stenotic/aortic (valve), referring you to I35.0. Verify the code in the Tabular List.

Question 7

A patient presents to the ED and is subsequently admitted on the same day diagnosed with an acute anteroapical wall infarction. What ICD-10-CM code is reported?
A. I21.19
B. I21.09
C. I22.9
D. I21.4

Answer 7

B. I21.09

Rationale: Look in the ICD-10-CM Alphabetic Index for Infarct, infarction/myocardium, myocardial (acute) (with stated duration of 4 weeks or less)/ST elevation (STEMI)/anterior (anteroapical) referring you to I21.09. There is no listing for anteroapical. Under category code I21 in the Tabular List, you are referred to the Official Guidelines, I.C.9.e.1, for Type 1 ST elevation myocardial infarction (STEMI) and non-ST elevation myocardial infarction (NSTEMI). The definition of a STEMI includes “myocardial infarction specified as acute.” Look in the Alphabetic Index for Infarct, infarction/myocardium, myocardial (acute)/ST elevation (STEMI)/anterior (anteroapical) (anterolateral) (anteroseptal) (Q wave) (wall) referring you to I21.09. The Tabular List verifies code choice.

Question 8

A patient is diagnosed as having chronic renal failure with hypertension. He is end stage, receiving dialysis. What ICD-10-CM codes are reported?
A. I10, N18.6, Z99.2
B. I12.9, N18.6, Z99.2
C. I12.0, N18.6, Z99.2
D. I13.0, N18.6, Z99.2

Answer 8

C. I12.0, N18.6, Z99.2

Rationale: According to the ICD-10-CM guideline I.C.9.a.2., a relationship is assumed between hypertension and chronic kidney disease. Look in the ICD-10-CM Alphabetic Index for Hypertension, hypertensive/kidney/with/stage 5 chronic kidney disease (CKD) or end stage renal disease (ESRD) referring you to I12.0. Verify in the Tabular List. An instructional note indicates to use additional code to identify the stage of chronic kidney disease (N18.5, N18.6). Code N18.6 is reported for the end stage renal failure. There is an instructional note to use additional code to identify dialysis status (Z99.2).

Question 9

A patient is diagnosed with acute on chronic diastolic congestive heart failure (CHF). Report the ICD-10-CM code(s).
A. I50.33
B. I50.31, I50.32
C. I50.43
D. I50.32

Answer 9

A. I50.33

Rationale: There is a combination code for acute on chronic diastolic congestive heart failure. Look in the ICD-10-CM Alphabetic Index for Failure, failed/heart/diastolic (congestive)/acute/and (on) chronic (congestive) referring you to I50.33. Always verify your codes in the Tabular List.

Question 10

Patient presents to the physician’s office after a syncopal episode. An EKG is performed in the office and the patient is diagnosed with a Mobitz type I AV block. What ICD-10-CM code is reported?
A. I44.0
B. R55
C. I44.1
D. I44.2

Answer 10

C. I44.1

Rationale: The syncope is a sign/symptom of the AV block and is not reported. Mobitz I is a second-degree block. Look in the ICD-10-CM Alphabetic Index for Mobitz heart block (atrioventricular) or Block, blocked/atrioventricular/types I and II referring you to I44.1. Verification in the Tabular List confirms the correct code choice.

Question 11

Patient undergoes a 3 venous, 2 arterial CABGs using the saphenous vein, femoropopliteal vein, and the radial artery, harvested by the surgeon performing the grafts. The venous grafts were procured using endoscopic harvesting techniques. What CPT® codes are reported?
A. 33534, 33512, 35572
B. 33534, 33519, 35572, 35600, 33508
C. 33514, 35572, 35600
D. 33533, 33521, 35572, 35600, 33508

Answer 11

B. 33534, 33519, 35572, 35600, 33508

Rationale: 33534 is used for the two arterial grafts. Because a combination of AV grafts is used, instead of using a code from 33510-33516 for the venous grafts, we use add-on codes +33517-+33523. There are three venous grafts (+33519). Code +35572 is for procurement of the femoropopliteal vein, +35600 is for harvesting the radial artery, and +33508 is the add-on code for endoscopic harvesting of the saphenous vein. Look in the CPT® Index for Coronary Artery Bypass Graft (CABG)/Arterial Bypass 33533-33536, and Arterial-Venous Bypass 33517-33519, 33521-33523. See the notes above these sections for coding +35572 and +35600. Highlight these codes for easy reference in your code book. All the codes except 33534 are add-on codes and are modifier 51 exempt.

Question 12

Patient presents for removal and replacement of her permanent dual chamber transvenous pacemaker system (generator and leads). What CPT® codes are reported?
A. 33213, 33234-51, 33233-51
B. 33206, 33207-51, 33233-51, 33235-51
C. 33235, 33208-51, 33233-51
D. 33240, 33235-51, 33233-51

Answer 12

C. 33235, 33208-51, 33233-51

Rationale: Multiple codes are needed to show the entire procedure. 33235 is for removing the electrodes, 33208 is for putting in the new system, and 33233 is for removing the pacemaker pulse generator. These codes are all found under Cardiac Assist Devices/Pacemaker System in the CPT® Index. Modifier 51 reports multiple procedures performed during the same session.

Question 13

Patient has mitral valve prolapse. A mitral valve ring is inserted with cardiopulmonary bypass. What CPT® code is reported?
A. 33426
B. 33464
C. 33425
D. 33430

Answer 13

A. 33426

Rationale: The mitral valve was repaired, not replaced. Look in the CPT® Index for Repair/Heart/Mitral Valve 0345T, 33418-33420, 33422, 33425-33427 Code 33426 Valvuloplasty, mitral valve, with cardiopulmonary bypass; with prosthetic ring, is correct. Cardiopulmonary bypass is included in the code description and not coded separately.

Question 14

Catheter advanced from the left femoral artery into the aorta, manipulated into both the left and right renal arteries for imaging. What CPT® code(s) is/are reported?
A. 36245, 36245-59
B. 36252
C. 36245, 36245-59, 36252
D. 36251

Answer 14

B. 36252

Rationale: Look in the CPT® Index for Angiography/Renal Artery referring you to 36251-36254. Code 36252 includes selective catheter placement (first-order) of the main renal artery and any accessory artery(s) for renal angiography, including arterial puncture, catheter placement(s), fluoroscopy, contrast injection(s), image postprocessing, permanent recording of images, and radiological supervision and interpretation, including pressure gradient measurements when performed, and flush aortogram when performed; bilateral.

Question 15

During an inpatient stay, a patient is taken to the cath lab. A catheter is placed in the aortic arch, right and left vertebral arteries, and right and left common carotids. Imaging with interpretation and report is performed in each location. What CPT® codes are reported?
A. 36247, 36246-59, 36245-59, 36222-50-51, 36226-50-51
B. 36217, 36216-59, 36215-59, 36218, 36222-50-51, 36226-50-51
C. 36226-50, 36222-50-51
D. 36224-50, 36228-50-51

Answer 15

C. 36226-50, 36222-50-51

Rationale: Three separate vascular families are catheterized; however, the codes for angiography of the common carotids and the vertebrals include selective catheterization. Report 36222 for the selective catheter placement and angiography of the right and left common carotid arteries. This code includes arch aortography. For the selective bilateral vertebral angiography report 36226. Both procedures are performed bilaterally with modifier 50. Some payers may require RT and LT modifiers or modifier 59 appended to the second code. Always check with your carriers. In the CPT® Index, look for Angiography/Carotid Artery; also look for Angiography/Vertebral Artery. Code 36226 is listed first, followed by 36222, which is less work-intensive. Modifier 51 is appended to the second procedure.

Question 16

A 5-French pigtail catheter was placed in the abdominal aorta and a run-off was performed following injection of 80 cc of contrast. Oblique DSA images of the iliofemoral circulation were performed following two injections, each 15 cc. The catheter was not moved to another position within the aorta for the additional injections. What CPT® codes are reported?
A. 36200, 75630-26
B. 36215, 32615-59, 75630-26
C. 36215, 36215-59, 36200, 75630-26
D. 36200, 75716-26

Answer 16

A. 36200, 75630-26

Question 17

A catheter was advanced into the left and right renal artery and the superior mesenteric artery (SMA), and imaging was performed in all vessels. What CPT® codes are reported?
A. 36245-RT, 36245-LT, 36245-59, 36252-59, 75726-26
B. 36245-RT, 36245-LT-59, 36245-59, 75726-26
C. 36252, 36245-59, 75726-26
D. 36245, 36248 x 2, 75726-26

Answer 17

C. 36252, 36245-59, 75726-26

Rationale: Look in the CPT® Index for Angiography/Renal Artery referring you to 36251-36254. Code 36252 includes selective catheter placement (first-order) of the main renal artery and any accessory artery(s) for renal angiography, including arterial puncture, catheter placement(s), fluoroscopy, contrast injection(s), image postprocessing, permanent recording of images, and radiological supervision and interpretation, including pressure gradient measurements when performed, and flush aortogram when performed, bilateral. For the selective catheterization code for the SMA look in the CPT® Index for Artery/Abdomen/Catheterization referring you to 36245-36248. The SMA is considered a visceral artery. Look in Appendix L and you will see the SMA is a first-order vessel. For the radiology code look in the CPT® Index for Angiography/Abdomen referring you to 74174, 74175, 74185, 75635, 75726. The correct code is 75726. Modifier 26 denotes the professional service.

Question 18

A catheter is placed at the level of the renal arteries for abdominal aortography and then moved to the level of the bifurcation of the aorta for pelvic angiography, demonstrating stenosis in the left external iliac. The right external iliac, femoral, and popliteal arteries are normal. What CPT® codes are reported?
A. 36245, 36245-59, 75630-26
B. 36245, 36245-59, 75716-26, 75625-26
C. 36245, 36200, 75716-26
D. 36200, 75716-26, 75625-26

Answer 18

D. 36200, 75716-26, 75625-26

Rationale: The catheter was placed at the level of the renals or renal arteries, not in the renal arteries, so this is a nonselective catheterization. Nonselective catheter placement in the aorta is reported with 36200. Look in the CPT® Index for Aorta/Catheterization/Catheter or Catheterization/Aorta. Because the catheter was repositioned and separate studies were performed, both the aortography and the extremity angiography are reported. In the CPT® Index, look for Aorta/Aortography referring you to 75600, 75605, 75625, 75630. For angiography of the lower extremities look in the CPT® Index for Angiography/Leg Artery referring you to 73706, 75635, 75710-75716. Modifier 26 reports the professional service.

Question 19

Left and right heart catheterization, selective coronary angiogram, left ventriculogram, ascending aortogram to assess the aortic root, descending aortogram, right iliac angiogram, Perclose closure. Access is from the right femoral artery and right femoral vein. What CPT® codes are reported for the physician’s services in a facility?
A. 93454-26, 93565, 75625-26
B. 93458-26, 93567, 75600-26, 75625-26, 75710-RT
C. 93460-26, 93567
D. 93460, 93567, 75600-26, 75625-26, 75710-RT

Answer 19

C. 93460-26, 93567

Rationale: Cardiac catheterization code 93460 reports right and left heart catheterization, selective coronary angiography with imaging interpretation and reporting, as well as left ventriculography. The cardiac catheterization code includes injection procedures and radiologic S &I (Supervision & Interpretation). The ascending aortography to review the aortic root is reported with add-on code +93567. Aortography is always included in cardiac catheterizations unless it is performed for a specific purpose, such as to study an aortic aneurysm or occlusive disease.

The right iliac angiogram is not reported. It was performed to assess the femoral artery for the Perclose device. The Perclose closure is not reported; it is bundled with the cardiac catheterization procedure. Modifier 26 is required to indicate the professional services only for 93460. The add-on code for the injection service is a professional service; a modifier is not required. In the CPT® Index, look for Cardiac Catheterization/Combined Left and Right Heart/with Left Ventriculography directing you to 93453, 93460, 93461. Check the numeric listing and 93460 is correct. Look In the CPT® Index for Cardiac Catheterization/Injection for the list of injection codes.

Question 20

Angioplasty of the diagonal branch with intravascular ultrasound (IVUS). What CPT® codes(s) should be reported?
A. 92920-LD, 92978-26
B. 92920-LC, 92978-26
C. 92920-26, 92979-26
D. 92920-LC

Answer 20

A. 92920-LD, 92978-26

Rationale: IVUS is separately reportable. For the angioplasty code look in the CPT® Index for Percutaneous Transluminal Angioplasty/Artery/Coronary referring you to 92920-92921. The diagonal branch is a branch of the left anterior descending and modifier LD is appended. For IVUS look in the CPT® Index for Vascular Procedures/Intravascular Ultrasound/Coronary Vessels referring you to 92978-92979. Modifier 26 denotes the professional service.

Question 21

A patient presents for a cardiac stress test at the hospital. The same physician supervises the test, interprets the study, and documents the official report. What CPT® code(s) should be reported for the physician who is not employed by the hospital?
A. 93015
B. 93015-26
C. 93016, 93017, 93018
D. 93016, 93018

Answer 21

D. 93016, 93018

Rationale: Because the study was performed in the hospital, the physician bills for the professional services. Look in the CPT® Index for Stress Tests/Cardiovascular referring you to 93015-93024. Modifier 26 is not required, because these services are professional services. These codes do not have a professional and technical component.

Question 22

The EP specialist documented that a comprehensive electrophysiologic evaluation was performed in the hospital, including induction of arrhythmia, right atrial pacing, and bundle of His recording. The specialist documented the study and wrote a report. What CPT® code(s) should be reported?
A. 93619
B. 93620-26
C. 93618-26, 93610-26, 93600-26
D. 93620-26, 93621

Answer 22

C. 93618-26, 93610-26, 93600-26

Rationale: Although the surgeon documented a “comprehensive” study, it does not include all components listed in CPT® for 93619 or 93620; therefore, the individual procedures are reported. The only procedures performed were 93618 (induction of arrhythmia), 93610 (intra-atrial pacing), and 93600 (bundle of His recording). Look in the CPT® Index for Electrophysiology Procedure referring you to 93600-93660. The procedure was performed in the hospital; the physician must report only the professional service with modifier 26 appended to all the codes.

Question 23

A complete transthoracic echocardiography (TTE) was performed with spectral Doppler and color flow. For the global service, what CPT® code(s) should be reported?
A. 93307, 93320, 93325
B. 93306
C. 93312, 93320, 93325
D. 93312

Answer 23

B. 93306

Rationale: A combination code exists to bundle the Doppler and color flow. Look in the CPT® Index for Echocardiography/Transthoracic referring you to 93306-93308, 93350-93352. Code 93306 is correct.

Question 24

A physician places a centrally inserted, tunneled central venous access device with a subcutaneous pump in a 7-year-old patient.
A. 36558
B. 36560
C. 36563
D. 36561

Answer 24

C. 36563

Rationale: Look in the CPT® Index for Venous Access Device/Insertion/Central referring you to 36560-36566. The code for insertion of a tunneled central venous access device with a subcutaneous pump is 36563.

Question 25

How many layers of tissue does an artery have?
A. Two
B. One
C. Three
D. Four

Answer 25

C. Three

Rationale: An artery has three layers: an outer layer of tissue, a muscular middle and an inner layer of epithelial cells.

Question 26

A patient suffering from an abdominal aortic aneurysm involving a renal artery undergoes endovascular repair deploying a fenestrated visceral autograft using two visceral artery endoprostheses. Radiological supervision and interpretation were performed. Select the CPT® code for this procedure.
A. 34701
B. 34842
C. 34841
D. 34703

Answer 26

B. 34842

Rationale: Look in the CPT® Index for Repair/Aorta/Visceral/Endovascular directing you to code 34841-34848. Code 34842 is correct to report because two visceral artery endoprostheses were used.

Question 27

What part of the cardiovascular system is responsible for the one-way flow of blood through the chambers of the heart?
A. Septum
B. Heart valves
C. Atria
D. Bundle of His

Answer 27

B. Heart valves

Rationale: Heart valves are made of flaps (cusps/leaflets) opening and closing like one way swinging doors, preventing blood from flowing back.

Question 28

Repair of coronary vessel is called:
A. Endovascular
B. Endarterectomy
C. Aortic
D. Angioplasty

Answer 28

D. Angioplasty

Rationale: Angio = vessel, plasty = repair

Question 29

In the cath lab a physician places a catheter in the aortic arch from a right femoral artery puncture to perform an angiography. Fluoroscopic imaging is performed by the physician. What CPT® code(s) is/are reported?
A. 36221
B. 36222
C. 36215, 75605-26
D. 36200, 75605-26

Answer 29

A. 36221

Rationale: The aorta is the trunk of the system, so this is a non-selective catheterization. Look in the CPT® Index for Angiography/Cervicocerebral Arch. Only one code is reported for the catheterization and fluoroscopic imaging which is 36221.

Question 30

A PICC with a port is placed under fluoroscopic guidance for a 45-year-old patient for chemotherapy infusion by a physician. The procedure was performed in the hospital. Report the codes for the physician.
A. 36571, 77001-26
B. 36568
C. 36571
D. 36570, 77001-26

Answer 30

A. 36571, 77001-26

Rationale: Look in the CPT® Index for Central Venous Catheter Placement/Insertion/Peripheral/with Port referring you to 36570-36571. The age of patient is 45; therefore, report 36571. Fluoroscopic guidance for central venous access is reported with 77001 and can be found by looking in the CPT® Index for Fluoroscopy/Venous Access Device directing you to 36598, 77001. The correct code for fluoroscopy is 77001. Modifier 26 is necessary to show the professional service only.

Question 31

Patient is diagnosed with acute systolic heart failure due to hypertension with CKD stage 4. What ICD-10-CM codes are reported?
A. I10, I12.9, I50.21, N18.4
B. I13.0, I50.21, N19
C. I13.0, I50.21, N18.4
D. I11.0, I12.9, I50.21, N18.4

Answer 31

C. I13.0, I50.21, N18.4

Rationale: There is a causal connection with hypertension and heart failure, and one is assumed with CKD, so combination code I13.0 is required. The type of heart failure and stage of CKD are also needed to complete the coding. In the ICD-10-CM Alphabetic Index look for Hypertension/cardiorenal (disease)/with heart failure/with stage 1 through stage 4 chronic kidney disease referring you to I13.0. In the Tabular List there is a note below I13.0 to use additional code to identify the type of heart failure. Look in the Alphabetic Index for Failure/heart/systolic (congestive)/acute referring you to I50.21. Instructions further indicate to also code for the stage 4 chronic kidney disease. Look in the Alphabetic Index for Disease, diseased/kidney/chronic/stage 4 (severe) referring you to N18.4. Verify code selection in the Tabular List.

Question 32

Due to infections from hemodialysis, the physician replaces a dual chamber implantable defibrillator system with a multi-lead system with an epicardial lead and transvenous dual chamber lead defibrillator system. The original dual leads are extracted transvenously. The generator pocket is relocated. What CPT® codes are reported?
A. 33243, 33202-51, 33263-51, 33223-59
B. 33241, 32330-51, 33263-51, 33223-59
C. 33244, 33220-51, 33264-51, 33223-59
D. 33244, 33202-51, 33264-51, 33223-59

Answer 32

D. 33244, 33202-51, 33264-51, 33223-59

Rationale: When a new system is placed after removal of an old system, report the codes for removal of the components and insertion of the new system. This is a transvenous system. The removal of the dual chamber implantable defibrillator electrodes is reported with 33244. Look in the CPT® Index for Cardiac Assist Devices/Implantable Defibrillators/Transvenous Implantable Pacing Defibrillator (ICD)/Removal/Electrodes referring you to 33244. The insertion of the epicardial electrode is reported with 33202. In the CPT® Index look for Cardiac Assist Device/Implantable Defibrillators/Transvenous Implantable Pacing Defibrillator (ICD)/ Insertion/Electrode referring you to 33202-33203, 33216-33217,33224-33225. The dual defibrillator generator was replaced with a multi-lead defibrillator generator 33264. Look in the CPT ® Index for Cardiac Assist Devices/ Transvenous Implantable Pacing Defibrillator (ICD)/ Replacement, Pulse Generator referring you to 33262-33264. Code 33264 describes the removal and replacement of an implantable defibrillator pulse generator. Two leads were replaced. Look in the CPT® Index for Cardiac Assist Devices/Implantable Defibrillators/ Transvenous Implantable Pacing Defibrillator (ICD)/ Insertion/Electrode referring you to 33202, 33203, 33216, 33217, 33224, 33225. Code 33217 describes the insertion of two transvenous electrodes for an implantable defibrillator; however, the notes under 33264 tell you not to report 33217. Code 33217 is bundled with 33264. The notes for this section of CPT® tell you to use 33223 for the relocation of the skin pocket for clinical situations such as infection. Modifier 51 is needed on 33202 and 33264. Modifier 59 is needed on 33223 to show that it is separate from 33244.

Question 33

What information is needed to accurately code hypertension retinopathy in ICD-10-CM?
A. The stage of retinopathy
B. The affected eye(s)
C. Which side of the heart is affected?
D. Whether the hypertension is malignant or benign

Answer 33

B. The affected eye(s).

Rationale: Hypertensive retinopathy for ICD-10-CM needs a 6th character that specifies the laterality of the retinopathy. Look in the ICD-10-CM Alphabetic Index for Retinopathy/hypertensive which directs you to H35.03-.

Question 34

Procedure: Right femoral angiography, percutaneous transluminal tibioperoneal angioplasty and stenting.

Description of Procedure: The patient was premedicated and brought to the cardiovascular laboratory. The right inguinal region is prepped and draped in the usual sterile fashion. Local cutaneous anesthesia was obtained with 1% Lidocaine. A 6 French sheath was inserted antegrade into the right femoral artery. It was kinked and was replaced with a 6 French Arrow sheath.
Findings: Selective injections into the right femoral artery revealed diffuse irregularities of the superficial femoral artery with a 95 percent mid to distal stenosis and a 60 percent distal stenosis. The distal popliteal artery had an eccentric 60 percent stenosis. The tibial peroneal trunk was diffusely diseased with sequential 95 percent stenosis present. The anterior tibial and posterior tibial arteries are both occluded. We gave intravenous heparin 2,500 units. The distal vessel was wired with a V18 wire. We then dilated both superficial femoral artery lesions with a 5 x 4 Diamond balloon and achieved good angiographic result. We then elected to approach the tibial peroneal trunk that was a high-grade stenosis leading into the only remaining circulation. This was dilated with a 3 x 4 Diamond balloon. This had satisfactory results, but we elected to stent this for a better long-term patency. We exchanged out the V18 wire for a coronary extra support wire and deployed a 3.5 x 40 mm GR2 coronary stent. This was then post-dilated to high pressures with a 3.5 x 40 mm NC Bandit balloon. We then performed inflations in the popliteal artery with a 4 x 2 Symmetry balloon, also achieving a satisfactory angiographic result. The balloon catheter was then withdrawn. The final angiographic result was excellent, with wide patency from the superficial femoral artery into the peroneal down to the ankle. Following the procedure, an ACT was obtained. The sheath was removed. A strong popliteal pulse was obtained. The patient was transported in stable condition to the recovery unit.

Impression:
1. Successful percutaneous transluminal angioplasty of sequential 95 and 60 percent mid and distal superficial femoral artery lesions.
2. Successful percutaneous transluminal angioplasty of a 60 percent popliteal lesion.
3. Successful percutaneous transluminal angioplasty of diffuse 95 percent tibial peroneal trunk stenosis with stenting producing a residual stenosis to 0 percent.

Which angioplasty codes are correct to report?
A. 37230, 37232-51
B. 37236, 37224-51, 37230
C. 37230, 37224-51
D. 37221, 37230-51

Answer 34

C. 37230, 37224-51

Rationale: Treatment of lesions in the femoral popliteal artery and stenosis in the tibial peroneal trunk to restore blood supply (revascularization) using angioplasty with placement of a stent in the tibial peroneal trunk is being performed. 37224 is coded for the angioplasty in the femoral-popliteal artery. Look in the CPT® Index for Revascularization/Artery/Femoral-Popliteal referring you to 37224-37227. Angioplasty was performed in the femoral artery and in the popliteal artery; therefore, the correct code is 37224. Look in the CPT® Index for Revascularization/Artery/Tibial/Peroneal referring you to 37228-37235. Angioplasty and stent placement were performed; therefore, the correct code is 37230. Modifier 51 denotes additional procedures performed during the same session.

Question 35

An arterial catheterization is performed by cutdown for transfusion. What CPT® code is reported?
A. 36640
B. 36600
C. 36625
D. 36620

Answer 35

C. 36625

Rationale: The answer is found in the CPT® Index by referencing Catheterization/Arterial System/Cutdown directing you to 36625.

Question 36

A physician states he performed a comprehensive EP study with induction of arrhythmia in the hospital. The report shows bundle of His recording, pacing and recording of the right atrium, and induction of arrhythmia by electrical pacing. What CPT® coding is reported?
A. 93620-26, 93621-26
B. 93619-26
C. 93620-26
D. 93600-26, 93602-26, 93610-26, 93618-26

Answer 36

D. 93600-26, 93602-26, 93610-26, 93618-26

Rationale: Although the physician stated a comprehensive EP study was performed, the right ventricular pacing and recording, and left atrial pacing and recording from the coronary sinus or left atrium were not done. The components must be billed separately. Look in the CPT® Index for Electrophysiology Procedure directing you to 93600-93660. The procedure was performed in the hospital; therefore, modifier 26 is appended to all the codes to report the professional service.

Question 37

Physician replaces a single chamber permanent pacemaker with a dual chamber permanent pacemaker. What CPT® code(s) is/are reported?
A. 33213, 33233-51
B. 33214
C. 33213, 33233-51, 33235-51
D. 33212, 33233-51

Answer 37

B. 33214

Rationale: Code 33214 is used for the conversion of a single chamber system to a dual chamber system which includes removal of the previously placed pulse generator, testing of existing lead, insertion of new lead and insertion of new pulse generator. Look in the CPT® Index for Cardiac Assist Device/Pacemaker System/Upgrade referring you to code 33214.

Question 38

A patient presents to the outpatient surgery department for revision to his autogenous radiocephalic fistula so he can continue his hemodialysis. What is the correct CPT® code?
A. 36831
B. 36825
C. 36832
D. 36904

Answer 38

C. 36832

Rationale: The patient is undergoing revision of the arteriovenous (radiocephalic) fistula. Look in the CPT® Index for Arteriovenous Fistula/Revision/without Thrombectomy referring you to code 36832.

Question 39

What is included in all vascular injection procedures?
A. Just the procedure itself
B. Selective catheterization
C. Necessary local anesthesia, introduction of needles or catheters, injection of contrast media with or without automatic power injection and/or necessary pre-and post-injection care specifically related to the injection procedure.
D. Catheters, drugs and contrast material

Answer 39

C. Necessary local anesthesia, introduction of needles or catheters, injection of contrast media with or without automatic power injection and/or necessary pre-and post-injection care specifically related to the injection procedure.

Rationale: CPT® guidelines for Vascular Injection Procedures indicate the above listed in D as being included.

Question 40

MAZE procedure is performed on a patient with atrial fibrillation. The physician isolates and ablates the electric paths of the pulmonary veins in the left atrium, the right atrium and the atrioventricular annulus while on cardiopulmonary bypass. What CPT® code is reported?
A. 33254
B. 33255
C. 33256
D. 33259

Answer 40

C. 33256

Rationale: The procedure described above is extensive according to CPT® definition. Look in the CPT® Index for Maze Procedure/Open referring you to 33254-33256. The patient was on bypass; therefore, the correct code is 33256.

Question 41

During an inpatient hospitalization, a patient who suffered myocardial infarction had a combined right and left heart catheterization. Access was achieved through the right femoral artery and the right femoral vein. Selective catheterization of the coronary arteries and selective catheterization of the left ventricle were followed by injections of contrast and angiography. During right heart catheterization, angiography of the right atrium was performed. Imaging supervision, interpretation and report for all angiography was performed during the cardiac catheterization. Select the CPT® coding for this procedure by the cardiologist.
A. 93460, 93565
B. 93460-26, 93566
C. 93460
D. 93453-26

Answer 41

B. 93460-26, 93566

Rationale: There are three parts to cardiac catheterization: selective catheter placement, injection of contrast, and radiologic supervision and interpretation and report which are included in most of the cardiac catheterization codes. In the CPT® Index look for Cardiac Catheterization/Combined Left and Right Heart/with Left Ventriculography referring you to 93453, 93460-93461. Code 93460 includes right and left heart catheterization, coronary angiography, and left ventriculography. None of the combined right and left heart catheterizations include right atrial angiography; therefore, the add-on code +93566 is reported. Modifier 26 is required to report the professional service. The add-on code +93566 for the injection procedure is a professional service, and modifier 51 is not required.

Question 42

A 35-year-old patient presented to the outpatient hospital for PTA of an obstructed hemodialysis AV graft in the venous anastomosis and the immediate venous outflow. The procedure was performed under moderate sedation administered by the physician performing the PTA. The physician performed all aspects of the procedure, including radiological supervision and interpretation. Code for all services performed.
A. 36901, 36905
B. 36905
C. 36902
D. 36901, 36902

Answer 42

C. 36902

Rationale: PTA is the abbreviation for percutaneous transluminal angioplasty. This procedure involves the peripheral dialysis segment, which in the upper extremity extends through the axillary vein or the entire cephalic vein in the case of cephalic venous outflow. The correct code is 36902, which includes angioplasty and all radiological supervision and interpretation. Moderate sedation is not included in this code; however, 99152 is not reported, because the documentation does not indicate who monitored the patient, the medication, the dosage, or the time of the moderate sedation.

Question 43

Patient undergoes a mitral valve repair with a ring insertion and an aortic valve replacement, on cardiopulmonary bypass. Which CPT® codes are reported?
A. 33464, 33406-51
B. 33468, 33426-51
C. 33430, 33405-51
D. 33426, 33405-51

Answer 43

D. 33426, 33405-51

Rationale: 33426 reports mitral valve valvuloplasty with a prosthetic ring, and 33405 reports an aortic valve replacement with cardiopulmonary bypass. Modifier 51 is required on the second procedure to indicate multiple procedures performed during the same setting. Look in the CPT® Index for Valvuloplasty/Mitral Valve or Mitral Valve/Repair referring you to 33425-33427. Look in the in the CPT® Index for Replacement/Aortic Valve. Allograft is not indicated in the question, selecting 33405.

Question 44

Catheter advanced from the right femoral vein into the left and right pulmonary artery. The catheter was further negotiated into the right lung lower lobe. Pulmonary angiography performed in all locations including radiologic supervision and interpretation. What CPT® codes are reported?
A. 36014-50, 75741, 75774-26
B. 36015, 36014-59, 75741-26, 75741-59
C. 36015-RT, 36014-LT, 75743-26, 75774-26
D. 36015-50, 36014, 75743-26

Answer 44

C. 36015-RT, 36014-59-LT, 75743-26, 75774-26

Rationale: Look in the CPT® Index for Pulmonary Artery/Catheterization referring you to 36013-36015. 36015-RT reports the second order selective catheterization of the right pulmonary artery; 36014-59-LT reports the first order selective catheterization in a different family of the left pulmonary artery. Look in the CPT® Index for Angiography/Pulmonary referring you to 75741-75746, 93568. Code 75743-26 reports bilateral pulmonary angiography, and 75774 reports the additional angiography after the basic study of the right and left pulmonary arteries. Look in the CPT® Index for Angiography/Other Artery referring you to 75774.

Question 45

PREOPERATIVE DIAGNOSIS: Heart Block
POSTOPERATIVE DIAGNOSIS: Heart Block
ANESTHESIA: Local anesthesia
NAME OF PROCEDURE: Reimplantation of dual chamber pacemaker
DESCRIPTION: The chest was prepped with Betadine and draped in the usual sterile fashion. Local anesthesia was obtained by infiltration of 1% Xylocaine. A subfascial incision was made about 2.5 cm below the clavicle, and the old pulse generator was removed. Using the Seldinger technique, the subclavian vein was cannulated and through this, the old atrial lead was removed, and a new atrial lead (serial # 6662458) was placed in the right atrium and to the atrial septum. Thresholds were obtained as follows: The P-wave was 1.4 millivolts, atrial threshold was 1.6 millivolts with a resultant current of 3.5 mA and resistance of 467 ohms.
Using a second subclavian stick in the Seldinger technique, the old ventricular lead was removed and a new ventricular lead (serial # 52236984) was inserted and placed into the right ventricular apex. The thresholds were obtained and were as follows: R-wave was 23.5 millivolts. The patient was pacing at 100% at 0.5 volts, with resultant current of 0.8 mA and resistance of 480 ohms. When we were satisfied with the thresholds, the leads were connected to the pacemaker generator (serial # 22561587), which was inserted into the previously created pocket.
The wound was thoroughly irrigated with antibiotic solution and hemostasis was obtained. The incision was closed in layered fashion with 2-0 Dexon. A compressive dressing was applied, and the patient tolerated the procedure very well. He was taken to the recovery room in satisfactory condition. What CPT® codes are reported?
A. 33207, 33206-51, 33236-51
B. 33208, 33238-51, 33241-51
C. 33235, 33208-51, 33233-51
D. 33202, 33233-51

Answer 45

C. 33235, 33208-51, 33233-51

Rationale: Look for Cardiac Assist Devices/Pacemaker System/Removal. Code 33235 reports removal of the electrodes of a dual pacemaker lead system. Next, look for Cardiac Assist Devices/Pacemaker System/Insertion/System. Code 33208 reports replacement of permanent pacemaker generator with transvenous electrodes to the right atrium and right ventricle. Code 33233 reports the removal of a pacemaker generator and is indexed - Cardiac Assist Devices/Pacemaker System/Removal. Modifier 51 reports multiple procedures performed during the same session.

Question 46

A patient presents for extremity venous study. Complete noninvasive physiologic studies of both lower extremities were performed. Which CPT® code is reported?
A. 93970
B. 93970-50
C. 93922
D. 93923

Answer 46

A. 93970

Rationale: Code 93970 reports a complete bilateral noninvasive physiologic study of extremity veins. This study is found in the CPT® Index by looking for Vascular Studies/Venous Studies/Extremity referring you to 93970-93971. Modifier 50 is not appended because the term bilateral is included in the code description for 93970.

Question 47

Patient undergoes a three artery CABG. A surgical assistant procures the artery used for the grafts. What CPT® coding is reported for the assistant surgeon.
A. 33535-80
B. 33510-80
C. 33517-80, 35600-80
D. 33533-80, 35600-80

Answer 47

A. 33535-80

Rationale: Procurement of the arterial conduit is bundled into 33535 and reported with modifier 80 for the surgical assistant according to the guidelines. 35600 is used for harvesting an artery of the upper extremity; however, there is no mention of this in the report. The guidelines in the codebook above 33535 instruct you to use modifier 80 when a surgical assistant performs an arterial graft procurement. Look in the CPT® Index for Coronary Artery Bypass Graft (CABG)/Arterial Bypass referring you to 33533-33536. There are three arterial grafts; therefore, 33535 is correct.

Question 48

Preoperative Diagnosis: Aortic valve stenosis with coronary artery disease associated with congestive heart failure
Postoperative Diagnosis: Same
Procedure: Aortic valve replacement, coronary artery bypass graft with harvesting of the saphenous vein and the radial artery.
Anesthesia: General endotracheal
Incision: Median sternotomy
Description of Procedure: The patient was brought to the operating room and placed in supine position. After the patient was prepared, median sternotomy incision was carried out and conduits were taken from the left arm as well as the right thigh. She was cannulated after the aorta and atrium were exposed and after full heparinization.

She went on cardiopulmonary bypass, and the aortic cross-clamp was applied. Cardioplegia was delivered through the coronary sinuses in a retrograde manner. The patient was cooled to 32 degrees. Iced slush was applied to the heart. The aortic valve was then exposed through the aortic root by transverse incision. The valve leaflets were removed, and the 23 St. Jude mechanical valve was secured into position by circumferential pledgeted sutures. At this point, aortotomy was closed.

Attention was turned to the coronary arteries. The first obtuse marginal artery was a very large target and the saphenous vein graft to this target indeed produced an excellent amount of flow. Proximal anastomosis was then carried out to the foot of the aorta. The radial artery was anastomosed to the left anterior descending artery target in an end-to-side manner. The proximal anastomosis was then carried out to the root of the aorta.

The patient came off cardiopulmonary bypass after aortic cross-clamp was released. She was adequately warmed. Protamine was given without adverse effect. Sternal closure was then done using wires. The subcutaneous layers were closed using Vicryl suture. The skin was approximated using staples. What CPT® codes are reported?
A. 33405, 33533-51, 35600, 33517
B. 33405, 33533-51, 33510, 35500
C. 33390, 33533-51, 33510
D. 33411, 33533-51, 35600, 33517

Answer 48

A. 33405, 33533-51, 35600, 33517

Rationale: The patient had an aortic valve replacement using a mechanical valve (which is considered a prosthesis). The median sternotomy incision indicates an open procedure. Look in the CPT® Index for Aortic Valve Replacement/Open/with Prosthesis and you are referred to 33405. The patient also had a cardiopulmonary bypass graft on one vein and one artery. Look in the CPT® Index for Coronary Artery Bypass Graft/Arterial-Venous Bypass which refers you to 33517-33519, 33521-33523. Look at the first set of codes, 33517-33519. These codes fall within the subcategory for Combined arterial-venous grafting for coronary bypass. The instructions say to report two codes: 1) a code from 33517-33523 for the combined arterial-venous graft code (33517-33523) and 2) the appropriate arterial graft code (33533-33536). 33517-33523 are add-on codes to report the venous portion of the graft. In this case, one vein was grafted making +33517 correct. Below +33517, there is a parenthetic instruction to report +33517 in conjunction with 33533-33536. Code selection is based on the number of arterial grafts. In this case, one artery was grafted making 33533 the correct code. The instructions for arterial grafting for coronary artery bypass indicate that the procurement (harvesting) of the arterial grafts is included in this set of codes except when an upper extremity artery is harvested. In this case, the radial artery was used, which is an upper extremity artery. To report this, 33509 or 35600 is reported depending on if the procedure is open or endoscopic. The radial artery was harvested in an open procedure making 35600 the correct code. CPT® code 33517 is an add-on codes, so modifier 51 is not appended. CPT® codes 35600 is modifier 51 exempt. Modifier 51 is appended to 33533 to indicate multiple procedures were performed.