a b x 5 c , d Todd had a tumor removed from his left temporal bone. How would you report this service? a.

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1 1. An infant born at 33 weeks underwent five photocoagulation treatments to both eyes due to retinopathy of prematurity at six months of age. The physician used an operating microscope during these procedures. These treatments occurred once per day for a defined treatment period of five days. How would you report all of these services? a b x 5 c , d Todd had a tumor removed from his left temporal bone. How would you report this service? a b c , d Jennifer was admitted to the hospital for an aspiration of two thyroid cysts. Her physician completed this procedure with CT guidance of the needle including interpretation and report. How would you report the professional services? a , b x 2, c , , d Baby Smith was diagnosed with meningitis. His physician placed a needle through the fontanel at the suture line to obtain a spinal fluid sample on Monday. The needle was withdrawn and the area bandaged. The baby required another subdural tap bilaterally on Wednesday. How would you report Wednesday s service? a b , 61001

2 c d Max had a bilateral revision fenestration operation. How would you report this procedure? a b c d. Both a and c 6. Dr. Martin performed an excision at the middle cranial fossa for a vascular lesion. This procedure was completed in an intradural fashion with dural repair and graft. His partner, Dr. Sutter, performed an infratemporal approach with decompression of the auditory canal. How should Dr. Martin report her services? a , b c d After a snow skiing accident, Barry had a cervical laminoplasty to four vertebral segments. How should you report this procedure? a x 4 b , c , 63045, d How is a neuroplasty procedure described in the CPT Professional Edition?

3 a. The decompression or freeing of intact nerve from scar tissue, including external neurolysis and/or transposition b. The surgical repair of nerves using only microscopic techniques c. The position of nerves tested one or more anatomic digits d. The decompression or freeing of an intact vein from scar tissue, including external neurolysis and/or transposition 9. Phyllis fell down on the ice and fractured her leg. The fall also caused severe injury to the muscles and tore several nerves. Her physician completed suturing of two major peripheral nerves in her leg without transposition and shortened the bone. After the surgery she was seen by a physical therapist for ongoing treatment and gait training. How would you report the surgical procedure? a , , b , c , 64859, d , 64857, 64859, John was hospitalized for a repair of a laceration to his left conjunctiva by mobilization and rearrangement. How should you report this procedure? a LT b c d LT 11. The patient is a 64-year-old female who is undergoing a removal of a previously implanted Medtronic pain pump and catheter due to a possible infection. The back was incised; dissection was carried down to the previously placed catheter. There was evidence of infection with some fat necrosis in which cultures were taken. The intrathecal portion of the catheter was removed. Next the pump pocket was opened with evidence of seroma. The pump was dissected from the anterior fascia. A 7-mm Blake drain was placed in the pump pocket through a stab incision and secured to the skin with interrupted Prolene. The pump pocket was copiously irrigated with saline and closed in two layers. What are the CPT and ICD-9-CM codes for this procedure?

4 A , , , V53.09 B , 62355, C , , D , , The patient is a 73-year-old gentleman who was noted to have progressive gait instability over the past several months. Magnetic resonance imaging demonstrated a ventriculomegaly. It was recommended that the patient proceed forward with right frontal ventriculoperitoneal shunt placement with Codman programmable valve. What is the correct code for this surgery? A B C D What is the CPT code for the decompression of the median nerve found in the space in the wrist on the palmar side? A B C D year-old Hispanic male has a chalazion on both upper and lower lid of the right eye. He was placed under general anesthesia. With an #11 blade the chalazion was incised and a small curette was then used to retrieve any granulomatous material on both lids. What code should be used for this procedure? A B C D MRI reveals patient has cervical stenosis. It was determined he should undergo bilateral cervical laminectomy at C3 through C6 and fusion. The edges of the laminectomy were then cleaned up with a Kerrison and foraminotomies were done at C4, C5, and,,c6. The stenosis is central: a facetectomy is performed by using a burr. Nerve root canals were freed by additional resection of the facet, and compression of the spinal cord was relieved by removal of a tissue overgrowth around the foramen. Which CPT codes should be used for this procedure? A , B , , C D , x An extracapsular cataract removal is performed on the right eye by manually using an iris expansion device to expand the pupil. A phacomulsicfication unit was used to remove the nucleus and irrigation

5 and aspiration was used to remove the residual cortex allowing the insertion of the intraocular lens. What code should be used for this procedure? A B C D An infant who has chronic otitis media was placed under general anesthesia and a radial incision was made in the posterior quadrant of the left tympanic membrane. A large amount of mucoid effusion was suctioned and then a ventilating tube was placed in both ears. What CPT and ICD-9-CM codes should be reported: A , B , C , D , A craniectomy is being performed on a patient who has Chiari malformation. Once the posterior inferior scalp was removed a C-1 and a partial C-2 laminectomy was then performed. The right cerebellar tonsil was dissected free of the dorsal medulla and a gush of cerebrospinal fluid gave good decompression of the posterior fossa content. Which CPT code should be used? A B C D Under fluoroscopic guidance an injection of a combination of steroid and analgesic agent is performed on T2-T3, T4-T5, T6-T7 and T8-T9 on the left side into the paravertebral facet joints. The procedure was performed for pain due to thoracic root lesions. What are the procedure codes? A , 64480x3, B , 64491, 64492x2, C x4, D , 64491, 64492

6 20. An entropian repair is performed on the left lower eyelid in which undermining was performed with scissors of the inferior lid and inferior temporal region. Deep sutures were used to separate the eyelid margin outwardly along with stripping the lateral tarsus to provide firm approximation of the lower lid to the globe. The correct CPT code is: A E4 B E2 C E2 D E1 21. The patient was taken to the procedure room and placed prone and the L4 L5 interspace was identified using fluoroscopy to determine the injection site. The patient was prepped in routine sterile fashion with Betadine and covered in sterile drape. 1% lidocaine was used to anesthetize the skin, subcutaneous tissue, and muscle. Once the proper anesthesia was obtained, a 3 inch, 20 gauge Tuohy needle was inserted and slowly advanced towards the L4-L5 interspace. Using a 6 cc glass syringe and the loss-of-resistance technique the epidural space was identified. After aspiration revealed no blood or cerebrospinal fluid return, the syringes were then changed and 80 mg/ml preservative-free Depo Medrol and 2 cc of 1% methylparaben free lidocaine were injected in slow incremental fashion. After aspiration, all needles were removed intact, the skin was cleaned and a Band-Aid was applied. Code this encounter. A B , C , D , A 65-year-old patient presented with ectropion of the right lower eyelid. Repair with tarsal wedge excision is performed for correction. Attention was then directed to the left eye. The patient also had an ectropion of the left lower lid which was repaired by suture repair. Code this procedure. A B E4, E2 C D E4, E2 23. A 42-year-old patient returns to the hospital neurology clinic for follow-up. He was checked three days prior to this visit where a lumbar puncture was done to find the etology of the patient s headaches. The headaches have increased in intensity over the past three days. The neurologist examines the patient and finds a CSF leak from the lumbar puncture. A blood patch by epidural injection is performed to repair the leak. Code the services for today s visit. A B C , D , 62287

7 24. A 63-year-old woman presented to the eye clinic as a new patient with symptoms of flashing lights and floaters in the right eye for two days duration. The ophthalmologist does a general evaluation of the complete visual system, including dilating her eyes and checking her with the indirect ophthalmoscope, revealing peripheral retinal tear. The physician explains to the patient that if left untreated, there is a high likelihood of retinal detachment. The patient agrees to the procedure. The physician lasers the retinal tear and tells the patient to come back in 24 hours for follow-up. Code this visit. A , B , C D What is the full CPT code description for 61535? A. Craniotomy with elevation of bone flap; for subdural implantation of an electrode array, for long-term seizure monitoring; for removal of epidural or subdural electrode array, without excision of cerebral tissue (separate procedure) B. Craniotomy with elevation of bone flap; for removal of epidural or subdural electrode array, without excision of cerebral tissue (separate procedure) C. For removal of epidural or subdural electrode array, without excision of cerebral tissue (separate procedure) D. For excision of epileptogenic focus without electrocorticography during surgery; ; for removal of epidural or subdural electrode array, without excision of cerebral tissue (separate procedure) 26. Postoperative Diagnosis: Carpal tunnel syndrome right wrist The patient was brought to the operating room and sedated by anesthesia. After sterile prepping and draping of the right hand, wrist and arm the patient s area of incision was infiltrated with Xylocaine/Marcaine infiltration. After satisfactory anesthesia an Esmarch bandage was used to exsanguinate the right hand and wrist and used about the distal forearm as a tourniquet. A curvilinear incision was made on the palmar aspect of the right wrist. Dissection was carried out through the skin and subcutaneous tissue. Bleeding was controlled. The median nerve and it branches were identified, retracted, and protected at all times. The ligament was incised from proximal to distal. A thorough decompression was carried out. A neurolysis was carried out. The nerve was found to be flattened and ischemic underneath the transverse carpal ligament. The fascia was closed, the tourniquet was released. A dressing was applied and patient was transferred to recovery room. Code this procedure. A RT B RT C RT D RT 27. A 35-year-old man presents to the urgent care center with severe neck pain. The physician examines the patient and makes the diagnosis of cervical nerve impingement and injects an anesthetic agent into the cervical plexus using three injections. Select the procedure and diagnosis codes. A x 3 B C D x 3

8 28. A four-year-old with chronic otitis media and fluid buildup in both ears was admitted by her otolaryngologist for a bilateral tympanostomy. The procedure was performed with placement of ventilating tubes. The procedure required general anesthetic due to the patient s age. Select the procedure code for this procedure. A B C D A patient presents to the emergency department with complaint of painful eye. The patient states that her right eye is constantly tearing and is sensitive to light. The physician performs an exam and identifies a corneal foreign body in the right eye. Utilizing a slit lamp, the foreign body is removed. Code the encounter. A RT B RT C RT D RT 30. The physician performs a right thyroid lobectomy. The patient was prepped and draped. After adequate general anesthesia, the neck was incised on the right side and sharp dissection was then used to cut down onto the strap muscles and sternodcleidomastoid muscles. The strap muscles were separated and transected on the right side. A small thyroid lobe was visualized and dissected free. There was no evidence of a tumor. The wound was closed with 3-0 interrupted Vicryl for the platysma, 4-0 Vicryl for the deep tissues and 6-0 fast absorbing gut for the skin. Code the encounter. A RT B RT C RT D RT 31. PROCEDURE: Bilateral lumbar medial branch block under fluoroscopy for the L3, L4, L5 medial branches for the L4-L5, L5-S/1 facets for diagnostic and therapeutic purposes. PROCEDURE: The patient was placed in the prone position on the fluoroscopy table and automated blood pressure cuff and pulse oximeter applied. The skin entry points for approaching the anatomic target points of the bilateral segmental medial branches or dorsal ramus of L3, L4, L5 were identified with a 22.5 degree from perpendicular lateral oblique fluoroscopy view and marked. Following thorough Chloraprep preparation of the skin and draping and 1% lidocaine infiltration of the skin entry points and subcutaneous tissues, a 22 gauge 6" spinal needle was placed under fluoroscopic guidance down on the target point for each respective segmental medial branch or dorsal ramus. At each point 1 ml consisting of 0.5% bupivacaine and Depo-Medrol was injected. A total of 80 mg of Depo-Medrol was divided between all six spots. Code the procedure(s). A , 64484, B , , C , 64494, x 4, D , A 43-year-old patient who suffers from severe intermittent vertigo has been definitively diagnosed

9 with Meniere s disease. After a year of various treatments, medications, tests, and behavior/lifestyle changes that have failed to lessen the symptoms, she now presents for a transcanal chemical labyrinthotomy to the right ear. Dr. Miller visualizes the tympanic membrane with an operating microscope, cleans the ear canal, and makes a small incision into the tympanic membrane. Gentamicin is delivered into the right ear. The patient is repositioned with the right ear up and monitored by the nurse. The perfusion is repeated to achieve the maximum result. The ear is suctioned, cleaned, and carefully examined for bleeding. The patient tolerated the procedure well and is returned to the recovery area in satisfactory condition. How would Dr. Miller report his professional services? a , x 2, b , x 2, c , 69801, d , 69905, What code(s) would be reported for the following case? Preoperative diagnosis: Bilateral impacted ventilating tube Postoperative diagnosis: Same Anesthesia: General Procedure performed: Removal and replacement of new tubes, bilaterally via tympanostomy Procedure: Sammie, a 16-year-old patient, was admitted and taken to the operative suite and placed under general anesthesia by inhalation. When adequate sedation was achieved, a 3.8-mm speculum was inserted into the left ear, wax removed, and speculum removed. The impacted tube was then removed. A new site was achieved within the same tympanosclerotic plaque and a new tube placed. The same procedure was repeated to the right ear. Sammie was sent to the recovery suite in stable condition. a , b c d , James returned two weeks after surgery, as planned, for a change in his drug delivery system. Today Dr. Harvey opened the previous incision site. The previously placed reservoir was removed and a new programmable subcutaneous pump was connected to the catheter and secured with sutures, tested, and programmed. The subcutaneous incision was closed in layers with a sterile dressing placed. The patient tolerated the procedure well. How should Dr. Harvey report this service? a b , c

10 d , Dr. Adams completed an anterior discectomy with decompression including osteophytectomy to levels C3 C5.During the same session, he stabilized C3 C5 with anterior cervical interbody fusion. For proper visualization, Dr. Adams used an operating microscope during all phases of the procedure.how should Dr. Adams report this procedure? a , , 22551, x 2, b , , x 2, c , 63076, x 2 d , 63076, 22551, With which code set or individual codes can add-on code be correctly reported? a b or c d. None of the above 37. Carl, a 28-year-old patient, has a history of epilepsy with recurrent seizures. His seizures are intolerable even with medication management. He does not experience non-epileptic seizures, which was confirmed by EEG recordings. Today he underwent an open procedure for implantation of cranial nerve neurostimulator electrode array, which was coiled around the vagus nerve. The pulse generator was connected to the neurostimulator array, tested, and repositioned to ensure maximum effectiveness. The pulse generator was placed and sutured into a created subcutaneous pocket. Again, the system is tested to ensure proper functionality. The subcutaneous tissues and skin are closed with deep sutures and skin staples. Carl tolerated the procedure well and was returned to the recovery suite in stable condition. Which code(s) should be reported for today s services? a , b c d , , A 6-month-old patient required a bilateral subdural tap through a suture. How would this initial procedure be reported? a b c

11 d , A patient with Bell s palsy is unable to squint, blink, or close her left eyelid. To protect the eye, Dr. Risser completes a temporary tarsorrhaphy with a Frost suture technique. How would you report this procedure? a LT b LT c LT d LT 40. What code(s) should be reported with the following case? Preoperative diagnosis: Total retinal detachment, right eye Postoperative diagnosis: Same Procedure performed: Complex repair of retinal detachment with photocoagulation, scleral buckle, sclerotomy/vitrectomy Anesthesia: Local Procedure: The patient was placed, prepped, and draped in the usual manner. Adequate local anesthesia was administered. The operating microscope was used to visualize the retina, which has fallen into the posterior cavity. The vitreous was extracted using a VISC to complete the posterior sclerotomy. Minimal scar tissue was removed to release tension from the choroid. The retina was repositioned and attached using photocoagulation laser, a gas bubble, and a suture placement of a scleral buckle around the eye. The positioning of the retina was checked during the procedure to ensure proper alignment. Antibiotic ointment was applied to the eye prior to placement of a pressure patch. The patient tolerated the procedure well and returned to the recovery suite in satisfactory condition. a , RT, , , b , RT, RT c , RT, RT d , RT, , , A patient had a bilateral strabismus surgery involving the medial and lateral rectus muscles. The surgeon explored and repaired a detached extraocular muscle in the right eye and placed bilateral posterior fixation sutures with muscle recession. How should you report this procedure? a , RT, b , RT,

12 c , RT, d , RT, ANSWERS 1. a The note under Prophylaxis indicate that these services are repetitive, performed in multiple sessions, and are intended to include all services in a defined treatment period. The parenthetical note under code states to use modifier -50 for a bilateral procedure. The operating microscope is bundled into this procedure. Refer to code for a list of bundled codes. 2. d One way to answer this question is to look in the index of the CPT Professional Edition under the main heading of Tumor. 3. b The professional services for the CT should have a modifier -26. The professional service is the procedure; therefore, there would be no modifier -26 on code a This question represents a subsequent tap. The code is reported for an initial procedure. Modifier -50 is not necessary because it is inherently included in the code description. 5. b One way to find this answer is in the index of the CPT Professional Edition under Fenestration Procedure, Revision. You would attach modifier -50 to indicate a bilateral procedure.

13 6. c Each surgeon should report the work he or she completed. Because Dr. Martin completed the definitive procedure, use code 61606, which includes the repair and graft. 7. d The code reports two or more vertebral segments, therefore, there is no need to change the units. You could find this answer by looking in the index of the CPT Professional Edition under Laminoplasty. 8. a You can find this answer by looking up Neuroplasty in the index of the CPT Professional Edition and reading the definition under the sub-heading. 9. c Code describes suturing of a major peripheral nerve in the leg without transposition. The add-on code is used for the second major peripheral nerve. The add-on code reports the shortening of the bone. Add-on codes should not have modifier -51 attached (see Appendix A). 10. a The code is reported for hospitalization. The code is for without hospitalization. 11. C This was a removal of an intrathecal catheter and pump, eliminating multiple choice answer D. The pump is not being implanted or replaced eliminating multiple choice answer B. Nor is the intrathecal catheter being implanted, revised or repositioned eliminating multiple choice answer A. Diagnosis Rationale: This was a complication; an infection due to a nervous system implant, eliminating multiple choice answers A and D. Seroma is mentioned in the documentation, but there is an excludes note for code , for infection due to an implanted device ( ), eliminating multiple choice answer B. 12. B This key word to choose the correct shunt being performed is ventriculo-peritoneal, leading you to multiple choice answer B. 13. C The key term to choose the correct answer is median nerve, found in code D There is more than a single chalazion to be removed, eliminating multiple choice answer C. The chalazion was on the upper and lower lid, eliminating multiple choice answer A. The patient was under general anesthesia, eliminating multiple choice answer B. 15. D Laminectomy was performed, eliminating multiple choice answer B. Facetectomy and foraminotomy were performed, eliminating multiple choice answer C. The laminectomy is performed bilaterally on three segments of the cervical. Modifier 50 is not appended to code , since the code descriptive has a parenthetical note indicting that these codes include unilateral or bilateral, eliminating multiple answer A.

14 16 C The surgery is an extracapsular cataract removal, eliminating multiple choice D. The removal of the cataract and the insertion of the lens were performed at the same time, eliminating multiple choice A. The keyword to choose between codes and is iris expansion device which was used to remove the cataract, eliminating multiple choice answer B. 17. A The patient is under general anesthesia eliminating multiple choice answer C. A ventilating tube was placed in the ears eliminating multiple choice answer D. The diagnosis is indexed in the ICD-9-CM manual under Otitis/ media/chronic/ mucoid, mucous guiding you to code , eliminating multiple choice answer B. 18 C The keywords in this craniectomy procedure to guide you to the correct code are cervical (C-1 and C-2) laminectomy, medulla, and Chiari malformation found in the code description of code D The patient is having the injection in the paravertebral facet joints, eliminating multiple choice answers A and C. The code description for code has the fluoroscopic guidance included in the code, meaning that it should not be coded separately. Also there is a parenthetical note under code that states not to report more than once per day, eliminating multiple choice answer B. 20 B The procedure being preformed is an entropian repair on the left lower eyelid, eliminating multiple choice answers A and D. Since there was a tarsal strip performed the procedure is an extensive repair, eliminating multiple choice C. 21. B.This procedure is being performed in the lumbar which eliminates C for the cervical or thoracic is the correct procedure code since the patient is getting the meds injected by a syringe not a continuous infusion by a catheter is coded since fluoroscopic guidance was used to place the needle for the therapeutic injection. Modifier 26 is appended for the professional component, physician not owning the equipment. 22. B. The key word in this scenario is ectropion, which eliminates D for one who has entropion. One of the eyelids had an excision of the tarsal wedge coded with and modifier E4 is appended to indicate the procedure was performed on the right lower lid. The other eyelid had a suture repair coded with and modifier E2 is appended to indicate the repair was done on the left lower lid. A different procedure was performed on each eyelid. Modifier 50 would not be appended to the codes since both lids did not have the same procedure performed. 23. B.The key word in this encounter is injection which eliminates the spinal puncture procedure codes is the correct code for the patient s blood is injected to plug the wound that is causing the CSF leak (blood patch). This is the only code to bill for this visit, since the lumbar puncture was performed three days ago.

15 24. B. Code is the correct procedure code since the patient had a retinal tear (retinal break) and the physician uses a laser light (photocoagulation) to seal the retina back into place. Code is coded to report the evaluation of the complete visual field. The patient is new patient. An evaluation of the eye was performed in addition to performing the procedure. Modifier 25 is appended to the evaluation code. 25. B.The description for code is indented which means the description from up to the semicolon is the beginning of the full description for A. The keywords for narrowing your search to the correct code is carpal tunnel and median nerve, which is found in the code descriptive of RT is appended to indicate the surgery is performed on the right side. 27. C. There was an anesthetic agent injected in the cervical plexus, eliminating codes A and B. Although three injections are performed, only one nerve is involved. It is inappropriate to report multiple units unless the procedure is performed bilaterally, which in this case it is not. 28. D. A tympanostomy was performed eliminating multiple choice answers A and B. The patient was under general anesthesia which leads you to procedure code C. The key terms for this scenario are Corneal foreign body removal with a slit lamp. This procedure is reported with RT is appended to indicate the procedure is performed on the right eye. 30. C. The patient is having a thyroid lobectomy, eliminating multiple choice answers A and D, which is a thyroidectomy (removal of the thyroid) is the correct code since the scenario indicates that a small thyroid lobe (total lobe) is dissected free; it does not indicate that part of the lobe was removed. 31. D. When coding for facet joint or facet joint nerve injections, you report each level that is injected. In this case, the joints for L4-L5 and L5-S1 were injected. The codes for facet joint and facet joint nerve injections are unilateral. The procedure was performed bilaterally at each level, therefore modifier 50 should be reported. In the coding guidelines for facet joint injections, it states that fluoroscopic guidance is included. This service should not be reported separately. 32. c. The patient in this question underwent a labyrinthotomy (incision), not a labyrinthectomy (excision). Refer to the notes in the CPT Professional Edition for correct reporting. The parenthetical notes under code provide instructions for reporting once per day, and notes provided with the add-on code for the operating microscope indicate modifier -51 should not be reported with this code.

16 33. c. Refer to the parenthetical notes with code in the CPT Professional Edition for correct reporting. This code is not reported in conjunction with code Modifier -50 is reported for a bilateral procedure. 34. a. One way to find this answer in the index of the CPT Professional Edition is under Infusion Pump then Spinal Cord. This was a planned procedure during a postoperative period; therefore, modifier -58 would be reported. Notice that code includes the implantation or replacement; therefore, the removal is included with the replacement of the subcutaneous pump. 35. d. Review the parenthetical notes listed with both the discectomy and arthrodesis codes in the CPT Professional Edition; these notes provide code conjunction guidance. According to the inclusion notes with code 69990, the operating microscope code would not be reported. 36. d. Code is new for Review the CPT Professional Edition parenthetical note under this code for proper code selection and reporting. 37. b. This was an initial implantation for the neurostimulator array and pulse generator. Code includes the creation of the skin pocket and testing of the system, according to CPT Changes: An Insider s View a. This procedure code is described as unilateral or bilateral; therefore, modifier 50 is not required. Additionally, the description includes an infant and suture site. 39. a. Tarsorrhaphy is used to help patients who are unable to close their eyelids. In patients with Bell s palsy (or other conditions that impede the ability to blink or close the eyelids), this procedure keeps the eyes protected and lubricated until the patient recovers from a paralysis condition. 40. b. Code includes multiple procedures related to complex repair of a retinal detachment. These inclusive procedures, if performed, would not be reported separately. The use of the operating microscope would be reported without a modifier d. The CPT Professional Edition provides multiple illustrations with strabismus surgery. These illustrations are helpful for review of anatomic locations of muscles. Codes for strabismus surgery are selected by the number and type of muscles used during a procedure. Additionally, add-on codes are provided to help define other conditions or procedures that may be completed at the time of the surgery.

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