Final Coding Cases CPT Student Version
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CPT FINAL CODING CASES 100 Points
All cases are one code unless otherwise noted. (This does not apply to the extra credit cases) Do not use any Anesthesia codes because we are doing the coding for the surgeon, not the anesthesiologist.
1.
Patient is a 26-year-old man who was driving a car with the window down when another car moving in the opposite direction hit his mirror. Glass from the broken mirror flew into his face
and he sustained two small lacerations. There were no other injuries. The uppermost laceration is below the eye and is 2.25 cm in length. The second laceration is 1.25 cm in length
and is directly below the upper laceration. Both are full-skin thickness. Procedure – Local injection with a total of 3 cc 1% lidocaine with epinephrine. Prepped and routine exploration performed. The upper laceration is only about 5 mm deep. No foreign bodies noted. No neurovascular injuries. It was closed with three 6-0 nylon sutures. The lower laceration was approximately 12 to 15 mm deep. I could not palpate any foreign bodies. Closed in a single layer with five 6-0 nylon sutures. Polysporin ointment was applied. CPT Code: 12001
The procedure performed in this case is a repair of two lacerations on the face. CPT code 12001 is appropriate for this procedure as it represents a simple repair of superficial wounds of face, ears, eyelids, nose, and/or lips that are less than 2.5 cm in length.
2.
Procedure: Fiberoptic bronchoscopy Diagnosis: Hemoptysis with easily bruisable mucosa and Bronchiectasis Technique: The patient was brought to the endoscopy suite and placed on a stretcher. Oxygen was given via nasal cannula at 3 L/min. Local anesthetic lidocaine was given to anesthetize the upper airway. Because the nostrils had considerable blockage secondary to trauma the oral route was used for the bronchoscopy. Following placement of a bite block and application of Cetacaine to the posterior pharynx, the fiber optic bronchoscope was placed without difficulty into the upper airway. The epiglottis appeared somewhat prominent but normal. In addition, the vocal cords appeared normal. The bronchoscope was passed easily through the cords into the trachea, which also appeared normal although somewhat easily bruisable. The carina appeared normal. The right side was entered first. The right upper lobe and its subsegments were seen very clearly, and there appeared to be bronchiectasis. The 6-mm bronchoscope would go very easily into the sub segments. No mass lesions were seen. The bronchus intermedius, right middle lobe, lower lobe, and its subsegments also were entered and again bronchiectasis was noted. There appeared to be no abnormal mucosal lesions and no abnormal secretions; however, the bronchial tree was easily bruisable. The bronchoscope then was
withdrawn to the carina and the left side entered. The left main bronchus, upper lobe, lower lobe, and
its subsegments were seen. There appeared to be an extrinsic compression of a subsegment of the left
lower lobe; however, no mucosal lesions were seen, and this area appeared pulsatile which suggested
pg. 1
CPT FINAL CODING CASES extrinsic compression from the descending aorta. Once again easy bruisability of the mucosa was noted. The bronchoscope was withdrawn there were no apparent complications. CPT Code: 31622
The procedure performed in this case is a fiberoptic bronchoscopy. CPT code 31622 is appropriate for this procedure as it represents a diagnostic examination of the bronchi using a fiberoptic bronchoscope.
3.
Procedure: Sigmoidoscopy
Indications for procedure: The patient is 75 years old. She has had an alteration in her bowel pattern and is being evaluated with a sigmoidoscopy.
Description of procedure: She was given Fleet’s enema preparation. She required no sedation. The CF100L video colonoscope was inserted and passed without difficulty to 50 cm. The mucosa were normal. No diverticulosis was observed . Some scybalous stool was present, but this was minimal. The
patient tolerated the procedure well. CPT Code: 45330
The procedure performed in this case is a sigmoidoscopy. CPT code 45330 is appropriate for this procedure as it represents a diagnostic examination of the rectum and sigmoid colon using a flexible sigmoidoscope.
4.
1 code and 1 modifier needed
Preoperative diagnosis: Right thyroid mass
Postoperative diagnosis: Right thyroid mass Procedure Performed: Excision of thyroid mass
Procedure in Detail: The patient was taken to the operating room and general endotracheal anesthesia with orotracheal intubation was performed. The neck was prepped and draped in the usual fashion and locally injected with 4 cc of 0.5% lidocaine plus 1:200,000 of epinephrine. Incision was made, superior and inferior subplatysmal flaps were elevated, the strap muscles were divided in the midline, and dissection was carried down to the thyroid isthmus. The mass on the right was identified, and capsular dissection around the mass was performed using the harmonic scalpel in regions near the nerve. The superior vessels were isolated and ligated with 2-0 silk, and the inferior vessels were ligated in a similar fashion. The recurrent laryngeal nerve was identified and followed superiorly up to its insertion and the ligament was taken down with the nerve under direct visualization. A medium Blake was placed. The platysma, strap muscles and skin were closed with Caprosyn suture. The patient was awaked, extubated and transported to the recovery room in good condition.
-CPT Code: 60240
-Modifier: -51 (Multiple Procedures)
The procedure performed in this case is an excision of a thyroid mass. CPT code 60240 is appropriate for this procedure as it represents a partial thyroid lobectomy or isthmusectomy. The -51 modifier is added to indicate that multiple procedures were performed during the same operative session.
pg. 2
CPT FINAL CODING CASES 5.
3 codes needed
Diagnosis: Post herpetic neuralgia Procedure: Nerve block Procedure: After the consent was obtained, the patient was placed in the right lateral position. A pillow was placed under her trunk on the right side. The area was then cleansed with Betadine solution. Intercostal blocks were performed at the T8, T9 and T10 level using Marcaine 0.5% with Epinephrine 1:200,000. A 5-cc solution was injected at each site after careful aspiration. A 23-gauge, 1.5-inch needle was used. The patient tolerated the procedure very well. There was no suggestion of pneumothorax or lung puncture during the procedure. A chest x-ray was obtained; it confirmed that there was no pneumothorax. She has been given an instruction sheet and will be discharged home in stable condition.
- Diagnosis Code: Post herpetic neuralgia (ICD-10 code: B02.29) - This code represents the diagnosis of post-herpetic neuralgia, which is a complication of herpes zoster (shingles) that involves persistent pain in the area affected by the shingles rash.
- Procedure Code: Intercostal nerve block (CPT code: 64420) - This code represents the performance of an intercostal nerve block, which involves injecting a local anesthetic near the intercostal nerves to provide pain relief.
- Modifier Code: None needed
The patient was presented with post-herpetic neuralgia, which is a complication of shingles. The procedure performed was an intercostal nerve block at the T8, T9, and T10 levels using Marcaine 0.5% with Epinephrine 1:200,000. No modifier is needed in this case. 6.
1 code and 1 modifier needed Chief complaint: Left eye foreign body for two days The patient is a 29-year-old man who presents to the Emergency Department after having a piece of metal fly into his left eye yesterday. Since that time, he continues to have the metal present. He denies any major disturbance in vision although he states that his vision is slightly blurrier and more irritated. He does complain of some pain. Inspection of the left eye shows a foreign body that resembles a piece of metal at the 6:00 o'clock position. At this time Tetracaine was applied. The foreign body was successfully removed (superficial) with the bevel of a 22-gauge needle. Two more drops of Tetracaine were applied followed by Homatropine and Polysporin ophthalmic ointment. The patient understood all instructions and agreed with the plan at which time he was discharged. - Procedure Code: Removal of foreign body from eye (CPT code: 65222) - This code represents the removal of a foreign body from the eye.
- Modifier Code: Modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) - This modifier indicates that a significant, separately identifiable evaluation and management service was provided on the same day as the procedure. pg. 3
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CPT FINAL CODING CASES The patient presented with a left eye foreign body, and the procedure performed was the removal of the foreign body using a needle. The appropriate CPT code is 65222. Additionally, modifier -25 should be appended to indicate that an evaluation and management service was also provided on the same day.
7.
Procedure: Colposcopy
Diagnosis Class II Pap; cervicitis
The patient is a 27-year-old woman who had previously undergone a pap smear showing Class II pap. She is admitted today for a colposcopy. The patient was placed in the lithotomy position. Her vagina and cervix were examined, and a speculum inserted; dyeing was done with acetic acid followed by gram iodine and methylene blue. Cervical biopsies were performed at indicated areas with Monsel’s solution applied for cautery. There were no complications, and the patient tolerated the procedure well. The patient is to call the office within one week for her biopsy report. -
Procedure Code: Colposcopy (CPT code: 57420) - This code represents the performance of a colposcopy, which is a procedure used to examine the cervix, vagina, and vulva for abnormalities. The patient underwent a colposcopy due to a Class II pap smear result and a diagnosis of cervicitis. The appropriate CPT code for this procedure is 57420. 8.
Diagnosis: Acute cholecystitis, cholelithiasis
Procedure: Laparoscopic cholecystectomy
The otherwise healthy patient was brought to the OR and after the induction of general endotracheal anesthesia, the patient’s abdomen was prepped and draped in the usually sterile manner and a small infraumbilical incision was made in the skin and carried down to the linea alba, which was grasped with a clamp and incised in a vertical manner. The peritoneum was entered under direct vision. Stay sutures were placed in the fascia. The Hasson introduced was placed. Pneumoperitoneum was established and following this, three additional trocars were placed in the abdomen. The gallbladder was grasped with cephalad retraction of the gallbladder fundus and lateralward retraction of the gallbladder infundibulum. The dissector was employed to
take down the peritoneum overlying the gallbladder infundibulum and cystic duct junction. When
this was well delineated on both the anterior and posterior surfaces of the cystic duct, the 5-mm endoscopic clip applier was inserted and two clips were placed on the patient’s side, on the gallbladder side of the cystic duct, which was transected. The reminder of the dissection was performed by using the Bovie spatula cautery, and the liver bed was dry. A toothed clamp was passed through the umbilicus to grasp the gallbladder, which was then removed through the umbilicus in a standard manner. The operative field was irrigated with saline and the return was clear. All three upper abdominal ports were seen to exit the abdomen under direct vision, and with the Hasson introduced removed, the fascial incision was closed with a 2-0 Vicryl figure-of-
eight suture. The skin at the umbilicus was closed with a 4-0 Maxon subcuticular suture. Steristrips was applied at all sites. The patient tolerated the procedure well.
pg. 4
CPT FINAL CODING CASES -
Procedure Code: Laparoscopic cholecystectomy (CPT code: 47562) - This code represents the laparoscopic removal of the gallbladder. The patient had a diagnosis of acute cholecystitis and cholelithiasis, and the procedure performed was a laparoscopic cholecystectomy. The appropriate CPT code for this procedure is 47562.
9.
3 codes needed Procedure: Flexible bronchoscopy and Cervical mediastinoscopy with biopsy and partial thyroid lobectomy with isthmusectomy
The otherwise normally health patient was brought to the operative suite and placed in the supine position. After satisfactory induction of general endotracheal anesthesia, a flexible Olympus bronchoscopy was passed through the endotracheal tube visualizing the distal trachea, carina, and right and left main stem bronchi of the primary and secondary divisions. No evidence of any endobronchial tumor was note. The scope was then withdrawn.
The patient was then prepped and draped in the usual sterile fashion. A shoulder roll was placed. A curvilinear incision in the thyroid was made above the suprasternal notch in the line of a skin crease. Dissection was carried down through the subcutaneous tissue down through the platysma muscle. The strap muscles were next identified and laterally retracted. We continued our dissection down to the pretracheal space. A partial thyroid isthmusectomy was done without any problems; this gave me clear access to the pretracheal space. A pretracheal plane was next developed. A mediastinoscope was placed. I saw multiple, firm right paratracheal lymph nodes. After first aspirating these structures to make sure they are not vascular in nature, generous biopsies were taken and sent to pathology for examination. Excellent hemostasis was obtained. The wound was irrigated using warm antibiotic saline solution. The wound was then closed in layers using Vicryl sutures. Dressings were applied. The patient tolerated the procedure and was sent to the recovery room in stable condition.
-Procedure: Flexible bronchoscopy and Cervical mediastinoscopy with biopsy and partial thyroid lobectomy with isthmusectomy.
-CPT code 31622 - Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; diagnostic, with or without cell washing (separate procedure): Code 31622 is used for the flexible bronchoscopy portion of the procedure, which allows visualization of the trachea
and bronchi.
-CPT code 39503 - Mediastinoscopy, cervical; with biopsy: Code 39503 is used for the cervical mediastinoscopy portion of the procedure, which involves accessing the mediastinum and taking
biopsies of lymph nodes.
-CPT code 60220 - Thyroidectomy, partial (lobectomy, isthmusectomy): Code 60220 is used for the partial thyroid lobectomy with isthmusectomy, which involves removing a portion of the thyroid gland.
pg. 5
CPT FINAL CODING CASES 10.
4 codes needed Diagnosis: C5 compression fracture
Procedure: C5 corpectomy and posterior fusion fixation (arthrodesis) with fibular strut bone graft and Atlantis plate (posterior segmental instrumentation)
The patient was taken to the OR and an endotracheal tube was placed. The right neck was prepped and draped in the usual manner. A linear incision was made over the C5 vertebral body. The platysma was divided. Dissection was continued medial to the sternocleidomastoid to the prevertebral fascia. This was cauterized and divided. The longus colli was cauterized and elevated. The fracture was visualized. A spinal needle was used to verify the location using fluoroscopy. The C5 vertebral body was drilled out. The bone was saved. The disks above and below were removed. The posterior longitudinal ligament was removed. The bone was quite collapsed and fragmented. Distraction pines were then packed with bone removed from the C5 vertebral body prior to implantation. A plate was then placed with screws in the C4 and C6 vertebral bodies. The locking screws were tightened. The wound was irrigated. Bleeding was helped with the bipolar. The retractors were removed. The incision was approximated with simple interrupted Vicryl. The subcutaneous tissue was approximated, and skin edges were approximated subcuticularly. Steri-Strips were applied. A dressing
was applied. The patient was placed in an Aspen collar. The patient was extubated and transferred to recovery. -CPT code 22551 - Arthrodesis, anterior interbody, including disc space preparation, discectomy, osteophytectomy and decompression of spinal cord and/or nerve roots; cervical below C2: Code 22551 is used for the C5 corpectomy and anterior fusion portion of the procedure, which involves removing the
C5 vertebral body and fusing the adjacent vertebrae.
-CPT code 22845 - Posterior segmental instrumentation (eg, pedicle fixation, dual rods with multiple hooks and sublaminar wires); cervical below C2: Code 22845 is used for the posterior fusion fixation (arthrodesis) with instrumentation, which involves placing screws and rods to stabilize the spine.
-CPT code 20936 - Autograft for spine surgery only (includes harvesting the graft); local (eg, ribs, spinous process, or vertebral body bone): Code 20936 is used for the autograft bone graft, which is harvested from the patient's own body.
-CPT code 20938 - Allograft for spine surgery only (includes harvesting the graft); morselized (through separate skin or fascial incision): Code 20938 is used for the allograft bone graft, which is obtained from a donor source.
*****Extra credit cases worth 2 points each*****
pg. 6
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CPT FINAL CODING CASES 1.
Percutaneous thrombectomy of forearm AV graft that was inserted for dialysis treatment.
The code needed for this procedure is: CPT code 36906 - Thrombectomy, percutaneous, arteriovenous dialysis access (eg, graft, fistula).
Code 36906 is used for the percutaneous thrombectomy of an arteriovenous (AV) graft used for
dialysis access.
2.
A patient was seen for surgical treatment of an occlusion of the femoral artery, left.
Percutaneously under guidance, the surgeon inserted a catheter to perform an atherectomy
(lower extremity revascularization).
The codes needed for this procedure are:
-CPT code 37225 - Revascularization, endovascular, open, or percutaneous, femoral, popliteal
artery(s), unilateral; with transluminal angioplasty. Code 37225 is used for the revascularization of
the femoral artery, which involves opening or percutaneously accessing the artery and performing
transluminal angioplasty to restore blood flow.
-CPT code 0234T - Endovascular revascularization, open or percutaneous, tibial, peroneal artery(s),
unilateral; with transluminal angioplasty. Code 0234T is used for the endovascular revascularization
of the tibial and peroneal arteries, which involves opening or percutaneously accessing these
arteries and performing transluminal angioplasty.
3.
Open revision of AV fistula with thrombectomy, patient receiving hemodialysis. Open revision
of AV fistula with thrombectomy, patient receiving hemodialysis. The code needed for this procedure is: CPT code 36832 - Revision, open, arteriovenous fistula, direct (separate procedure); including
thrombectomy, open. Code 36832 is used for the open revision of an arteriovenous (AV) fistula, which
involves accessing and revising the fistula and performing an open thrombectomy to remove any blood
clots.
4.
The patient was diagnosed with severe aortic stenosis. Through a percutaneous incision in the
leg (transfemoral), the surgeon performed a TAVR.
The code needed for this procedure is: CPT code 33361- Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve;
transfemoral approach. Code 33361 is used for the transcatheter aortic valve replacement (TAVR),
which involves replacing the aortic valve with a prosthetic valve using a transfemoral approach. 5.
Bilateral sympathectomy, cervical- The code needed for this procedure is:
CPT code 64620 - Sympathectomy, cervical; bilateral. Code 64620 is used for the bilateral
sympathectomy of the cervical region, which involves surgically interrupting sympathetic nerve
pathways to treat conditions such as hyperhidrosis or chronic pain.
pg. 7
CPT FINAL CODING CASES pg. 8