CPC Chapter 13- Reproductive System Review Questions

Question 1

The uterine adnexa refers to which two structures of the female reproductive system?
A. Vulva and perineum
B. Vagina and uterus
C. Uterus and fallopian tubes
D. Fallopian tubes and ovaries

Answer 1

D. Fallopian tubes and ovaries

Rationale: The word adnexa means appendages. Uterine appendages are the tubes and ovaries.

Question 2

Which of the following are also known as the greater vestibular glands?
A. Bartholin’s glands
B. Skene’s glands
C. Ovaries
D. None of the above

Answer 2

A. Bartholin’s glands

Rationale: Bartholin’s glands are the large glands located on either side of the vaginal introitus or opening. Another name for these glands is greater vestibular glands.

Question 3

The two structures that make up the uterus are:
A. The uterus and uterine tubes
B. The cervix and uterine fundus
C. The vulva and corpus uteri
D. The vagina and cervix

Answer 3

B. The cervix and uterine fundus

Rationale: The uterine tubes, vulva, and vagina are not part of the uterus. The uterus is made up of the cervix (cervix uteri) and the fundus (corpus uteri).

Question 4

If you know that the suffix -scopy means to use a scope to examine a body structure, what word means a scope procedure to examine the vagina?
A. Hysteroscopy
B. Laparoscopy
C. Colposcopy
D. Enteroscopy

Answer 4

C. Colposcopy

Rationale: The root word colp/o means vagina; colposcopy is examination of the vagina using a scope.

Question 5

Which of the following structures in the female reproductive system is not bilateral?
A. Ovaries
B. Bartholin’s glands
C. Cervix
D. Salpinx

Answer 5

C. Cervix

Rationale: The ovaries and salpinges (fallopian tubes) are found on both sides of the uterus. The Bartholin’s glands are found on both sides of the vaginal introitus. The cervix is singular, connecting the uterus to the vagina.

Question 6

Choose the code for VIN III.
A. N90.0
B. N90.1
C. D07.1
D. D07.2

Answer 6

C. D07.1

Rationale: VIN III is coded as cancer in situ and VIN indicates a vulvar lesion. Look in the ICD-10-CM Alphabetic Index for VIN and you are directed to see Neoplasia, intraepithelial, vulva. Look in the Alphabetic Index for Neoplasia/intraepithelial/vulva/grade III referring you to D07.1. Verify in the Tabular List.

Question 7

Which one of the following is not part of the definition of code O80?
A. Live-born
B. With episiotomy
C. With forceps
D. Spontaneous

Answer 7

C. With forceps

Rationale: Code O80 is for a normal delivery requiring minimal or no assistance, with or without episiotomy, without fetal manipulation [eg, rotation version] or instrumentation [forceps] of a spontaneous, cephalic, vaginal, full-term, single, live-born infant. Forceps delivery is found in the ICD-10-CM Alphabetic Index under Delivery/failed/forceps directing you to O66.5.

Question 8

A pregnant patient presents to the ED with cramping and bleeding. On examination, the cervix is dilated and there are no retained products of conception. The physician documents an abortion at 10 weeks. What is the type of abortion?
A. Missed abortion
B. Spontaneous abortion
C. Induced abortion
D. None of the above

Answer 8

B. Sponraneous abortion

Rationale: ICD-10-CM and CPT® recognize three types of abortions, spontaneous (also called a miscarriage), induced or therapeutic (TAB) caused by a deliberate procedure, or missed. A missed abortion occurs when the fetus dies but the products of conception are retained.

Question 9

A woman with a long history of essential hypertension is managed throughout her pregnancy and delivers today. The hypertension has not resolved after the delivery. How is this coded?
A. I10
B. O13.3
C. O10.03
D. O10.03, I10

Answer 9

C. O10.03

Rationale: It is important to assess if a condition existed prior to pregnancy, developed during, or due to the pregnancy in order to assign the correct code. In this case, the hypertension is pre-existing. Look in the ICD-10-CM Alphabetic Index for Hypertension/complicating/puerperium, pre-existing/pre-existing/essential O10.03. Puerperium is the time period immediately after the birth of the baby and up to six weeks following childbirth. Hypertension (I10) is not reported separately; it is included in O10.03.

Question 10

A 68-year-old female presents with vaginal bleeding. It has been five years since her last period. Choose the code to describe her bleeding.
A. N92.5
B. N92.3
C. N92.4
D. N95.0

Answer 10

D. N95.0

Rationale: This bleeding is after the end of the woman’s menses and is described as postmenopausal. Look in the ICD-10-CM Alphabetic Index for Bleeding/postmenopausal N95.0. Verify in the Tabular List.

Question 11

Physician performs an incision and drainage of an abscess located on the labia majora. What CPT® code is reported?
A. 10060
B. 56405
C. 56420
D. 53060

Answer 11

B. 56405

Rationale: The vulva consists of the external female genitalia, which includes the labia minora and majora, clitoris, and vestibule. Code 56405 reports the I&D of the abscess of the vulva or perineal abscess. Because there is a specific code for an I&D of an abscess of the vulva, do not code 10060. Look in the CPT® Index for Incision and Drainage/Abscess/Vulva 56405 Verify in the numeric section.

Question 12

Patient comes in with uterine bleeding. Physician performs a diagnostic dilation and curettage by scraping all sides of the uterus. What CPT® code is reported?
A. 58100
B. 59160
C. 57505
D. 58120

Answer 12

D. 58120

Rationale: The D&C is performed in the uterus. Look in the CPT® Index for Dilation and Curettage/Corpus Uteri 58120. There is no mention that the patient is postpartum, so you do not report 59160. Verify in the numeric section.

Question 13

A patient delivers twins at 32 weeks gestation for her first pregnancy. The first baby is delivered vaginally, but during the delivery, the second baby turns into a breech position. The physician decides to perform a cesarean delivery for the second baby. The physician also provided antepartum and postpartum care. How would the deliveries be reported?
A. 59400, 59409-51
B. 59510-22
C. 59510, 59409-51
D. 59618, 59612-51

Answer 13

C. 59510, 59409-51

Rationale: Only one baby is delivered vaginally making 59400, 59409-51 incorrect. Only one baby was delivered by cesarean section making 59510 incorrect. Because this is the patient’s first pregnancy, do not report codes 59618, 59612. Look in the CPT® Index for Cesarean Delivery/Routine Care 59510 and Vaginal Delivery/Delivery Only 59409. Modifier 51 is appended to indicate additional procedures during the same session. The code with the highest value is sequenced first. Verify codes in the numeric section.

Question 14

A 52-year-old patient is scheduled for surgery for a right ovarian mass. Through an open incision, the surgeon finds a healthy left ovary. A right ovarian mass is visualized, and the decision is made to remove the mass and the right ovary. What CPT® code is reported?
A. 58940
B. 58925
C. 28920
D. 58720

Answer 14

A. 58940

Rationale: The right ovary was removed which is an oophorectomy. Code 58925 reports removal of an ovarian cyst. Code 58920 reports removal of a wedge (triangular piece) of an ovary or of both ovaries. Code 58720 reports the removal of tube and ovary, unilateral or bilateral. Look in the CPT® Index for Ovary/Excision/Total 58940-58943. Code 58940 is reported for the removal of an ovary. Verify in the numeric section.

Question 15

A 63-year-old patient has severe intramural fibroids. The surgeon performs an open total abdominal hysterectomy with removal of the fallopian tubes and ovaries. What CPT® code is reported?
A. 58200
B. 58150
C. 58548
D. 58262

Answer 15

B. 58150

Rationale: This is an open total abdominal hysterectomy, not a vaginal hysterectomy 58262. The procedure was not performed laparoscopically 58548. It does not mention that a partial vaginectomy with para-aortic and pelvic lymph node sampling was performed 58200. Look in the CPT® Index for Hysterectomy/Abdominal/Total 58150, 58200, 58956. The correct code is 58150. Verify in the numeric section.

Question 16

What ICD-10-CM code is reported for VIN III?
A. D07.0
B. N87.1
C. N90.1
D. D07.1

Answer 16

D. D07.1

Rationale: Look in the ICD-10-CM Alphabetic Index for VIN – See Neoplasia, intraepithelial, vulva. Look in the Alphabetic Index for Neoplasia/vulva/grade III (severe dysplasia) referring you to D07.1. Verify in the Tabular List. The Alphabetic Index listing for Dysplasia/vulva/severe NEC also directs you to D07.1. VIN III is listed as carcinoma in situ in the Tabular List.

Question 17

Patient has TAH-BSO. What CPT® code is reported?
A. 58200
B. 58152
C. 58180
D. 58150

Answer 17

D. 58150

Rationale: TAH-BSO stands for Total Abdominal Hysterectomy – Bilateral Salpingo-oophorectomy. In the CPT® Index look for Hysterectomy/Abdominal/Total, directing you to 58150, 58200, 58956. A bilateral salpingo-oophorectomy is the removal of the tubes and ovaries. CPT® code 58150 includes with or without removal of the tubes and ovaries.

Question 18

A 40-year-old presents with vaginal bleeding for several weeks. The gynecologist orders an ultrasound to obtain more information for a diagnosis. What diagnosis code is appropriate for this encounter?
A. N92.5
B. N93.9
C. N92.6
D. N92.4

Answer 18

B. N93.9

Rationale: There is no indication that the vaginal bleeding is associated with her menstrual cycle and there is no indication of menopause. Look in the ICD-10-CM Alphabetic Index for Bleeding/vagina, vaginal (abnormal) directing you to N93.9.

Question 19

What ICD-10-CM category is used to report the weeks of gestation of pregnancy?
A. I24
B. E11
C. O20
D. Z3A

Answer 19

D. Z3A

Rationale: When a code from Chapter 15 is reported, an additional code is reported to identify the specific week of the pregnancy. This is reported from category Z3A Weeks of gestation.

Question 20

If a woman is hospitalized with severe pre-eclampsia in the 30th week of her pregnancy what is the diagnosis code for her daily visits?
A. O14.13
B. 014.03, Z3A.30
C. O14.13, Z3A.30
D. O14.10, Z3A.00

Answer 20

C. O14.13, Z3A.30

Rationale: In the ICD-10-CM Alphabetic Index look for Pre-eclampsia/severe directing you to O14.1-. Verification in the Tabular List indicates that a 6th character is reported for the trimester of the pregnancy. 30 weeks of pregnancy places the patient in her third trimester reporting O14.13. The Tabular List at the beginning of Chapter 15 defines how many weeks are in the first, second and third trimesters. You will also see an instructional note to report a code from category Z3A to indicate the weeks of pregnancy. In the Alphabetic Index look for Pregnancy/weeks of gestation/30 weeks referring you to Z3A.30. Verify in the Tabular List.

Question 21

Procedures involving which of the following structures found in the vulva are NOT coded in the female reproductive system section of CPT®?
A. Introitus
B. Clitoris
C. Skene’s Gland
D. Hymen

Answer 21

C. Skene’s Gland

Rationale: Procedures on the Skene’s glands are coded in the urinary system

Question 22

What procedure is performed to treat vaginal prolapse?
A. Colpectomy
B. Colpopexy
C. Colpotomy
D. Colposcopy

Answer 22

b. Colpopexy

Rationale: Vaginal prolapse occurs when the vaginal wall is stretched out and there is no support in the pelvic structure and the pelvic organs fall downward protruding through the vaginal canal. To correct this disorder, a suturing of the prolapsed vagina to its surrounding structures is performed.
All the choices have the prefix colpo- which means vagina. The suffix –pexy means surgical fixation. The suffix –scopy means examination of. The suffix –ectomy means removal of. The suffix –otomy is to make an incision or cut into. The correct answer is colpopexy.

Question 23

Vulvar cancer in situ can also be documented as:
A. VIN II
B. Adenocarcinoma of the vulva
C. VIN III
D. VIN I

Answer 23

C. VIN III

Rationale: Vulvar intraepithelial neoplasia stage III or VIN III is coded as cancer in situ. The other VINs listed are coded as hyperplasia and adenocarcinoma is a primary malignancy. In ICD-10-CM Alphabetic Index go to the Table of Neoplasms and look for Neoplasm, neoplastic/vulva/Ca in situ column directing you to D07.1. Verification of this code in the Tabular List confirms D07.1 is reported for VIN III.

Question 24

If a non-Medicare patient has an age and gender appropriate preventive medicine exam (i.e., a breast and pelvic exam) this is coded with the age appropriate Preventive Medicine codes from the E/M chapter of CPT®. If a Medicare patient has a breast and pelvic exam, how is this coded?
A. 99387
B. G0101
C. 99387 or 99397
D. None of the above, preventive services are free for Medicare patients

Answer 24

B. G0101

Rationales: Medicare Part B requires that for pelvic examination (including clinical breast examination), use HCPCS Level II code G0101 when ordered by a physician. This information can be found on the CMS website at this link: https://www.cms.gov/regulations-and guidance/guidance/manuals/downloads/clm104c18pdf.pdf#page=82. In your HCPCS Level II Index look for Screening/cancer/cervical or vaginal and you are directed to code G0101.

Question 25

If a physician obtains a Pap smear specimen from a non-Medicare patient and incurs the cost for it to be transferred to an outside laboratory. How is this coded?
A. 99000
B. This service is NOT billed separately
C. 88164
D. Q0091

Answer 25

A. 99000

Rationale: Look to the CPT® Index for Specimen Handling and you are directed to 99000, 99001. CPT® code 99000 is reported when the physician incurs cost for collection, handling and/or conveyance of a specimen for transfer from the office to a laboratory. This is a non-Medicare patient, the HCPCS Level II code Q0091 is only reported for a Medicare patient.

Question 26

A diabetic woman delivered her child and now returns to obstetrician’s office for follow up. She has had type 1 diabetes controlled with insulin for most of her life. Her obstetrician will monitor her closely for several weeks to be sure her pregnancy does not cause her permanent problems. What diagnosis code is used for her visit 2 weeks after her delivery?
A. O24.03
B. O24.33
C. O24.019, E10.9
D. P70.1

Answer 26

A. O24.03

Rationale: Pregnancy codes will continue to be used during the postpartum (puerperal) period. In the ICD-10-CM Alphabetic Index look for Puerperal, puerperium (complicated by, complications)/ diabetes/pre-existing/type 1 directing you to O24.03. Verification in the Tabular List shows O24.03 indicates pre-existing type 1 diabetes mellitus in the puerperium (post-partum) period. Code P70.1 is reported on the newborn’s record not the mother’s record. Code O24.03 is a com-bination code in which Type 1 diabetes E10.9 is already noted in O24.03, so it is not reported. Only report E10 category when there are diabetic manifestations as indicated in the Tabular List, for exam diabetic neuropathy or diabetic ketoacidosis.

Question 27

A pregnant patient presents to the hospital in active labor. The obstetrician providing her prenatal care is contacted to perform the delivery. The provider delivers twins vaginally. The obstetrician will also provide the postnatal care. What CPT® code(s) describe this procedure?
A. 59430
B. 59400, 59409-51
C. 59510 X 2
D. 59409 X 2

Answer 27

B. 59400, 59409-51

Rationale: The delivery is vaginal. Look in the CPT® Index for Vaginal Delivery directing you to codes 59400, 59610-59614. As the physician has provided the prenatal care and will provide the postpartum care, the vaginal delivery for twin A is the global service described by 59400. The delivery of twin B is coded with 59409 with modifier 51 appended indicating this is a multiple procedure. Prenatal and postpartum care applies to the total care of the patient and not to both deliveries.

Question 28

How is a visit for supervision of normal pregnancy coded in ICD-10-CM according to the coding guidelines and instructional note?
A. A code from category Z34 is reported without a code from category Z3A.
B. A code from category O80 is reported with a code from category Z3A.
C. A code from category Z34 is reported with a code from category Z3A.
D. A code from category O80 is reported with a code from category Z37.

Answer 28

C. A code from category Z34 is reported with a code from category Z3A.

Rationale: Z codes for pregnancy are for use when none of the complications or problems listed in the codes from Chapter 15: Pregnancy, Childbirth and the Puerperium exist. Codes in category Z34 for supervision of pregnancy are always first listed and are not to be used with any other code from the OB chapter. Coding guideline I.C.21.c.11 indicates that code Z3A is not reported with abortive outcomes (O00-O08), elective of termination of pregnancy (Z33.2), or for postpartum conditions. There is also a code first note listed with the Z3A- codes that specifies Z3A is reported with obstetric conditions or encounter for delivery (O09-O60, O80-O82).

Question 29

Ultrasound indicates a 20-week fetus has a distended bladder and the decision is made to perform vesicocentesis. The procedure is successful and the bladder is emptied. What CPT® is code reported for this procedure?
A. 51100
B. 59074
C. 59001
D. 51102

Answer 29

B. 59074

Rationale: In the CPT® Index look for Fetal Procedure/Fluid Drainage directing you to 59074. Verify in the numeric section.

Question 30

What modifier is appropriate for a separately billable antenatal service during the global OB package period?
A. 25
B. No modifier is needed
C. 57
D. 24

Answer 30

B. No modifier is needed

Rationale: An antenatal service is performed before the baby is delivered. According to the notes in the Maternity Care and Delivery subsection in the CPT® codebook “Antepartum care includes the initial prenatal history and physical examinations; recording of weight, blood pressures, fetal heart tones, routine chemical urinalysis, and monthly visits up to 28 weeks gestation; biweekly visits to 36 weeks gestation; and weekly visits until delivery.”

Question 31

An 88-year-old widow with uterine prolapse and multiple comorbid conditions has been unsuccessful in the use of a pessary for treatment elects to receive colpocleisis (LeFort type) to prevent further prolapse and avoid more significant surgery such as a hysterectomy. The treatment is successful. What are the CPT® and ICD-10-CM codes reported for this procedure?
A. 59320, N81.3
B. 57120, N81.4
C. 57130, N88.3
D. 57020, N81.2

Answer 31

B. 57120, N81.4

Rationale: This surgical procedure of a colpocleisis is performed to prevent uterine prolapse. In this procedure, the walls of the vagina are sewn together. This obliterates the vagina and prevents uterine prolapse. It is only performed in patients not sexually active. In the CPT® Index, look for Colpocleisis or LeFort Procedure/Vagina referring you to code 57120.
The reason for the operation is uterine prolapse. In the ICD-10-CM Alphabetic Index look for Prolapse, prolapsed/uterus (with prolapse of vagina) referring you to code N81.4. Verify in the Tabular List.

Question 32

A patient with severe adenomyosis has a vaginal hysterectomy with bilateral salpingo-oophorectomy. After the uterus is removed it is weighed at 300 grams. What is the CPT® code reported for this procedure?
A. 58291
B. 58262
C. 58290
D. 58292

Answer 32

A. 58291

Rationale: A vaginal hysterectomy code can be selected based on the weight of the uterus and additional procedures included with the hysterectomy. In the CPT® Index look for Hysterectomy/Vaginal/Removal Tubes/Ovaries directing you to codes 58262, 58263, 58291, 58292, 58552, 58554. A vaginal hysterectomy for a uterus greater than 250 grams is reported from code range 58290-58294. Further selection of removal of tubes and ovaries defines code 58291.

Question 33

A 26-year-old gravida 2 para 1 female has been spotting and has been on bed rest. She awoke this morning with severe cramping and bleeding. Her husband brought her to the hospital. After examination, it was determined she has an incomplete early spontaneous abortion. She is in the 12th week of her pregnancy. She was taken to the OR and a dilation and curettage (D&C) was performed. There were no complications from the procedure. She will follow-up with me in the office. She has had four antepartum visits during her pregnancy.
A. 59812, 59425, O03.4
B. 58120, 59425, O03.1
C. 59812, 59425, O03.9
D. 58120, 59425, O03.9

Answer 33

A. 59812, 59425, O03.4

Rationale: This procedure was performed on a pregnant patient (obstetrical) for an incomplete spontaneous abortion. The first procedure to report is the dilation and curettage (D & C). Look in the CPT® Index for Abortion/Incomplete referring you to 59812. Report the antenatal care service because the patient had four antepartum visits before the abortion occurred. In the CPT® Index look for Obstetrical Care/Antepartum Care referring you to 59425, 59426. 59425 is correct for 4-6 prenatal visits.

Look in the ICD-10-CM Alphabetic Index for Abortion/incomplete (spontaneous) referring you to O03.4. Weeks of gestation would not be coded. ICD-10-CM guideline 1.C.21.c.11, category Z3A codes should not be assigned for pregnancies with abortive outcomes (categories O00-O08).

Question 34

A 56-year-old woman with biopsy-proven carcinoma of the vulva with metastasis to the lymph nodes has complete removal of the skin and deep subcutaneous tissues of the vulva in addition to removal of her inguinofemoral, iliac and pelvic lymph nodes bilaterally. The diagnosis of carcinoma of the vulva with 7 of the nodes also positive for carcinoma is confirmed on pathologic review. What are the CPT® and ICD-10-CM codes reported for this procedure?
A. 56633, 38765-50, C51.9, C77.4, C77.5
B. 56632-50, D07.1
C. 56640-50, C51.9, C77.4, C77.5
D. 56637, C51.9, C79.89

Answer 34

C. 56640-50, C51.9, C77.4, C77.5

Rationale: The patient has her vulva removed to treat malignancy (vulvectomy, radical complete). She also has removal of inguinofemoral, iliac and pelvic lymph nodes. In the CPT® Index, look for Vulvectomy/Radical/Complete/with Inguinofemoral, Iliac, and Pelvic Lymphadenectomy referring you code 56640. All areas removed are listed in the code description for code 56440. There is a parenthetical note under this code to report 56640 with modifier 50 for a bilateral procedure.

This scenario needs three ICD-10-CM codes. The first one is to show the carcinoma of the vulva. Look in the ICD-10-CM Alphabetic Index for Carcinoma – see also Neoplasm, malignant by site. Go to the ICD-10-CM Table of Neoplasms and look for Neoplasm, neoplastic/vulva/Malignant Primary column referring you to C51.9.

The second diagnosis code is for the metastasis of the cancer to the lymph nodes. Look in the Table of Neoplasms for Neoplasm, neoplastic/lymph, lymphatic channel NEC/gland (secondary)/inguina, inguinal/Malignant Secondary column, guiding you to code C77.4. Also look under gland (secondary) in the Malignant Secondary column for iliac C77.5 and pelvic C77.5. Verify all codes in the Tabular List.

Question 35

A patient with a previous low transverse incision cesarean delivery is attempting VBAC (vaginal birth after cesarean), also known as TOLAC (trial of labor after cesarean) with her second child. During labor her uterus ruptured. She had an emergency cesarean section followed immediately by hysterectomy to remove her ruptured uterus. Mother and baby survived. The same obstetrician provided her antepartum and postpartum care. What are the CPT® and ICD-10-CM codes reported for this service?
A. 59614-22, 59525, O71.1, Z3A.00, O34.212
B. 58150, 59514-51, O71.1, Z3A.00, Z37.0
C. 59618, 59525, O71.1, O34.211, Z3A.00, Z37.0
D.
59510, 58150-51, O71.1, Z3A.00, Z37.0

Answer 35

A. 59618, 59525, O71.1, O34.211, Z3A.00, Z37.0

Rationale: This patient has a previous history of caesarean delivery and is attempting to deliver her second child vaginally (VBAC). Due to her uterus rupturing, the planned vaginal delivery was changed to a caesarean delivery. Look in the CPT® Index for Cesarean Delivery/Previous Cesarean/Unsuccessful Attempted Vaginal Delivery/Routine Care referring you to code 59618. After the delivery a hysterectomy was performed. The procedure is located in the CPT® Index by looking for Cesarean Delivery/with hysterectomy referring you to 59525. Modifier 51 is not appended to this code, because it is an add-on code.

The first-listed diagnosis will reflect the rupture of the uterus during labor which is the reason for the cesarean. Look in the ICD-10-CM Alphabetic Index for Rupture/uterus/during or after labor O71.1. Next look for Delivery/cesarean (for)/previous/cesarean delivery/low transverse scar, O34.211. Notes at the beginning of Chapter 15 states to use an additional code from category Z3A to identify the weeks of gestation. The weeks of gestation are not provided. In the ICD-10-CM Alphabetic Index look for Pregnancy/weeks of gestation/not specified and you are referred to Z3A.00. The last code to report is the outcome of the delivery. In the Alphabetic Index look for Outcome of delivery/single NEC/live born, referring you to Z37.0. Verify the codes in the Tabular List.

Question 36

A 62-year-old woman with a history of urinary incontinence and incomplete bladder emptying presents for sling urethropexy and repair of a cystocele. The sling urethropexy is performed using a prosthetic mesh. The anterior repair is also performed without difficulty and both repairs are performed vaginally. What are the CPT® codes reported for this service?
A. 53440, 57240-51, 57267
B. 53440, 57240
C. 57288, 57267, 57240-51
D. 57288, 57240-51

Answer 36

D. 57288, 57240-51

Rationale: The patient has urinary incontinence and her bladder is bulging downward through the anterior vaginal wall (cystocele). First a sling is placed under the junction of the urethra and bladder for suspension to correct the urinary incontinence. Look in the CPT® Index for Sling Operation/Vagina referring you to 57287, 57288. 57288 is correct as 57287 is for removal or revision of the sling. Next is the repair of the cystocele by tightening the front (anterior) wall of the vagina (colporrhaphy or anterior repair). Look in the CPT® Index for Vagina/Repair/Cystocele referring you to 57240, 57260. The insertion of the mesh, code 57267, is not coded for this scenario because it was used for the sling operation not the colporrhaphy. It is included in 57288. Modifier 51 is appended to 57240 to indicate additional procedures performed during the same session.

Question 37

A woman presents for hysterectomy after ECC (endocervical curettage) and EMB (endometrial biopsy) indicates endometrial cancer. Transabdominal approach (incision) is chosen for exposure of all structures possibly affected. The abdomen is thoroughly inspected with no gross disease outside the enlarged uterus but several lymph nodes are enlarged and the decision is made to perform a hysterectomy with bilateral removal of tubes and ovaries and bilateral pelvic lymphadenectomy with periaortic lymph node sampling. Specimens sent to pathology confirm endometrial cancer but find normal tissue in the lymph nodes. What are the CPT® and ICD-10-CM codes reported for this service?
A. 58210, C54.1
B. 58210, C55, C77.5
C. 58548, C54.1
D. 58150, 38770-51, C54.1, C77.5

Answer 37

A. 58210, C54.1

Rationale: An open approach is performed to remove the uterus, cervix, tubes, ovaries and bilateral pelvic lymph nodes along with sampling (biopsy) the peri-aortic lymph nodes. In the CPT® Index look for Hysterectomy/Abdominal/Radical referring you to 58210. The key to choosing this code from the other choices is the removal of the pelvic lymph nodes and a biopsy of the peri-aortic lymph nodes (radical procedure) which is located in the description for code 58210.
Because the lymph nodes were benign, the endometrial cancer is the only diagnosis to report. Look in the ICD-10-CM Table of Neoplasms for Neoplasm, neoplastic/endometrium/Malignant Primary column referring you to C54.1. Verify in the Tabular List.

Question 38

A patient with a long history of endometriosis has an open surgical approach to perform an exploratory laparotomy for an enlarged right ovary seen on ultrasound with other possible masses on the uterus and in the peritoneum. Exploration reveals these masses to be endometriosis including a chocolate cyst (endometrioma) of the right ovary, right fallopian tube and peritoneum. The endometriomas are all small, less than 5 cm, and laser is used to ablate them, except the ovarian cyst, which is excised. During the procedure the patient also has a tubal ligation. What are the CPT® and ICD-10-CM codes reported for this service?
A. 49000, 58662-51, 58925-51, 58671-51, N80.111, N80.211, N80.311, Z30.2
B. 49203, 58671-51, N80.8
C. 49203, 58611, N80.111, N80.211, N80.30, Z30.2
D. 58662, 58600-51, N80.111, N80.211, N80.30, Z30.2

Answer 38

C. 59203, 58611, N80.111, N80.30, Z30.2

Rationale: The exploratory laparotomy is not a separately billable service because it is no longer just examination of the intraabdominal organs; it became a surgical procedure in which the endometriomas were destroyed by laser. Remember a surgical laparotomy always includes a diagnostic (exploratory) laparotomy. Look in the CPT® Index for Endometrioma/Abdomen/Destruction/Excision referring you to 49203-49205. 49203 is correct for destruction for 1 or more tumors with the largest less than 5 cm in diameter.
The second procedure is a tubal ligation (female sterilization in which the fallopian tubes are sealed or severed). Look in the CPT® Index for Fallopian tube/Ligation referring you to 58600, 58611. Add-on code 58611 is correct to report because the tubal ligation was performed at the same time as another intra-abdominal surgery. Modifier 51 is not appended because 58611 is an add-on code.
The endometriosis included the ovary and the right fallopian tube. Look in the ICD-10-CM Alphabetic Index for Endometriosis/ovary/superficial guiding you to code N80.11-. Next look in the Alphabetic Index for Endometriosis/fallopian tube/superficial referring you to code N80.21-. Both codes will report the 6th character 1. Then look for Endometriosis/peritoneal directing you to code N80.30. Reporting a diagnosis for the tubal ligation is found by looking in the Alphabetic Index for Encounter (with health service) (for)/sterilization guiding you to code Z30.2. Verify all codes in the Tabular List.

Question 39

A 27-year-old woman’s regular obstetrician delivers twins by cesarean delivery. Both are delivered without complications. Patient will have postpartum care in two weeks. What is/are the CPT® code(s) reported for this service?
A. 59510, 59514-51
B. 59510, 59510-51
C. 59510
D. 59400

Answer 39

C. 59510

Rationale: When reporting a procedure code for an uncomplicated twin delivery by cesarean delivery, you code the global cesarean code once, because there is only one incision to deliver both babies by a cesarean delivery. Many payers will not provide additional reimbursement for a twin delivery by cesarean. Look in the CPT® Index for Cesarean Delivery/Routine Care referring you to 59510. Verify in the numeric section.

Question 40

A 32-year-old woman with a previous vertical incision for cesarean delivery presents in spontaneous labor with the baby in cephalic presentation. She has had an uneventful pregnancy and after laboring for 10 hours she delivers a single female child with brief use of a vacuum extractor over an episiotomy that is repaired by the delivering physician. There are no complications. What are the diagnosis codes for this delivery?
A. O80, Z3A.00, Z37.0
B. O75.9, O70.9, O82, Z3A.00, Z37.0
C. O66.5, O34.212, Z3A.00, Z37.0
D. O80, O70.9, O66.5, Z3A.00

Answer 40

C. O66.5, O34.212, Z3A.00, Z37.00

Rationale: Rationale: You do not code a normal delivery, code O80, because a vacuum extractor is used to deliver the baby. In the ICD-10-CM Alphabetic Index look for Delivery/complicated/by/attempted vacuum extraction and forceps referring you to code O66.5. ICD-10-CM guidelines, I.A.14., state the word “and” should be interpreted as “and” or “or” when appearing in the title. The second code reports the previous cesarean delivery. In the Alphabetic Index look for Delivery/cesarean (for)/previous/cesarean delivery/classical (vertical) scar, guiding you to code O34.212. Instructional note in the beginning of Chapter 15 indicates a code from Z3A is reported with the pregnancy codes. Z3A.00 indicates unspecified weeks. This is found in the Alphabetic Index by looking for Pregnancy/weeks of gestation/not specified. Your last code to report is the outcome of the delivery. Look in the Alphabetic Index for Outcome of delivery/single NEC/liveborn referring you to code Z37.0. Verify all codes in the Tabular List.