AAPC CARDIO QUESTIONS

Name: ________________________ Class: ___________________ Date: __________ ID: A 2 Cardio Multiple Choice Identify the choice that best completes the statement or answers the question. ____ 1. How many layers of tissue does an artery have? a. One c. Three b. Two d. Four ____ 2. The conduction system contains pacemaker cells, nodes, the ____ and the ____. a. Bundle of His and electrical system b. Purkinje fibers and bundle of His c. Heart valves and purkinje fibers d. Electrical system and bundle of His ____ 3. What part of the cardiovascular system is responsible for the one-way flow of blood through the chambers of the heart? a. Septum c. Bundle of His b. Heart valves d. Atria ____ 4. Which main coronary artery bifurcates into two smaller ones? a. Right c. Inverted b. Left d. Superficial ____ 5. What is the term for the divider between the heart chamber walls? a. SA node c. Septum b. Bundle branch d. Mitral ____ 6. 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. 34841 c. 34701 b. 34842 d. 34703 ____ 7. A physician places a centrally inserted, tunneled central venous access device with a subcutaneous pump in a 7-year-old patient. a. 36561 c. 36560 b. 36563 d. 36558 ____ 8. Patient presents to her physician 10 weeks following a true posterior wall myocardial infarction. The patient is still symptomatic and is diagnosed with ischemic heart disease. What is (are) the correct ICD-10-CM code(s) for this condition? a. Z51.89, I25.9 c. I21.29 b. I22.8 d. I25.2 ____ 9. ____ is a term standing for enlargement of the heart. a. Cardiorenal c. Cardiomegaly b. Angiomegaly d. Valvuloplasty

Name: ________________________ ID: A 2 ____ 10. Repair of coronary vessel is called: a. Endarterectomy c. Aortic b. Angioplasty d. Endovascular ____ 11. A physician performs a four-vessel autogenous (one venous, three arterial) coronary bypass graft on a patient who had a previous CABG two years ago. The saphenous vein, radial artery (harvested in an open procedure), and the left and right internal mammary arteries were utilized. What CPT® coding is reported for this procedure? a. 33535, 33510-51, 33530, 35600 c. 33533, 33519, 33530, 35600 b. 33534, 33530, 33518 d. 33535, 33530, 35600, 33517 ____ 12. A patient in the ED was found to have a ruptured abdominal aortic aneurysm. He was taken to emergency surgery; a physician performed a direct repair. The physician documented that the aneurysm involved the common iliac. Select the proper CPT® code for this procedure. a. 34704 c. 35103 b. 35092 d. 35102 ____ 13. A patient presents to the hospital for a cardiovascular SPECT study. A single study is performed under stress, but without quantification, with a wall motion study, and ejection fraction. Select the CPT® code(s) for this procedure. a. 78451, 78472 c. 78453 b. 78453, 78472 d. 78451 ____ 14. Intracoronary stents are placed percutaneously in the right coronary and left anterior descending arteries for a patient with stenosis. Percutaneous transluminal balloon angioplasty is performed on the left circumflex coronary artery. Choose the correct CPT® codes for this procedure. a. 92928-RC, 92928-LD, 92920-LC c. 92933-RC, 92934-LD, 92934-LC b. 92928-RC, 92929-LD, 92920-LC d. 92928-RC, 92920-LD, 92920-LC ____ 15. Select the ICD-10-CM diagnosis codes used for pseudoaneurysm, cardiac tamponade and left ventricular failure. a. I72.9, I31.4, I50.1 c. I34.8, I31.9, I50.9 b. I25.3, I31.9, I50.9 d. I71.9, I31.9, I50.9 ____ 16. Physician changes the old battery to a new one on a patient’s dual chamber permanent pacemaker. What CPT® code(s) is/are reported? a. 33212 c. 33213, 33233-51 b. 33229 d. 33228 ____ 17. Physician replaces a single chamber permanent pacemaker with a dual chamber permanent pacemaker. What CPT® code(s) is/are reported? a. 33213, 33233-51 c. 33214 b. 33213, 33233-51, 33235-51 d. 33212, 33233-51 ____ 18. Patient is seen in his physician’s office and diagnosed with benign hypertension and stage 3 chronic kidney disease. a. I12.9, N18.30 c. I13.10, N18.6 b. I10, N18.30 d. I10, N18.9

Name: ________________________ ID: A 4 ____ 27. 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. 37221, 37230-51 c. 37236, 37224-51, 37230 b. 37230, 37224-51 d. 37230, 37232-51 ____ 28. An arterial catheterization is performed by cutdown for transfusion. What CPT® code is reported? a. 36600 c. 36625 b. 36620 d. 36640 ____ 29. 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. 36568 c. 36570, 77001-26 b. 36571, 77001-26 d. 36571 ____ 30. 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. 36825 c. 36831 b. 36832 d. 36904

Name: ________________________ ID: A 5 ____ 31. The cardiologist advances a 6 French catheter into the left renal artery via a right common femoral puncture. It is selectively catheterized and angiographic films are taken. The catheter was then removed and a diagnostic guiding type, RDC catheter was used and the left renal artery was selectively engaged. A 0.014 Supracore wire was used and the lesion was crossed. A 6.0 X 18 mm balloon expandable Racer stent was introduced. This was expanded around 8 atmospheres of pressure which is nominal. Angiography revealed excellent results with no residual stenosis. What CPT® codes are reported? a. 36245-LT, 75625-26, 37236 c. 36245-LT, 36251, 37236 b. 36245-LT, 37236 d. 36246-LT, 37236 ____ 32. 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. 33390, 33533-51, 33510 c. 33405, 33533-51, 33510, 35500 b. 33405, 33533-51, 35600, 33517 d. 33411, 33533-51, 35600, 33517 ____ 33. 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. 93453-26, c. 93460 b. 93460-26, 93566 d. 93460, 93565

Name: ________________________ ID: A 7 ____ 38. INDICATIONS FOR CORONARY INTERVENTION: Acute inferior myocardial infarction. Documented mildly occlusive plaque with much clot in the right coronary artery. PROCEDURE: Insertion of temporary pacemaker in the right femoral vein. Primary stenting of the right coronary artery with a 4.5 x 16 mm Express stent. Angio-Seal to the vessels of the right common femoral artery post procedure, and also Angio-Seal of the right common femoral vein. TECHNIQUE: Judkins percutaneous approach from the right groin with Perclose at the arterial puncture site post procedure. CATHETERS: 4 French Angio-Jet catheter device, insertion of a 5 French temporary pacing wire, a 4.5 x 16 mm Express stent. PRESSURES: Aortic Pressure: 107/78 RESULTS: Coronary stenting procedure of the right coronary artery: The right coronary artery was primarily stented with a 4.5 x 16 mm Express stent. It was expanded to 12 atmospheres. There was no residual stenosis. IMPRESSION: Successful Angio-Jet and stenting of the distal right coronary artery with no residual stenosis. Angio-Seal to the right femoral vein post procedure. PROCEDURE: Through the femoral artery sheath, the EBU was advanced to the right coronary. Following this a PT graphic intermediate wire was used to cross the lesion. Following this angioplasty of the lesion was performed, utilizing a 2.5 x 20-millimeter CrossSail balloon at multiple sites to ten atmospheres. Following this there was a fair result; however, there was a significant stenosis and significant calcification at the area, and the decision was made to pursue trying to stent the lesion. Multiple stents were attempted, including a 2.5 x 9-millimeter zipper MX and a 2.5 x 13-millimeter Guidant stent. This was abandoned, and in switching out to a balloon for further ballooning, the patient became hypertensive and with difficulty in terms of her respiratory status. Angiography revealed an occlusion of the mid left anterior descending and thrombus throughout the proximal left anterior descending extending into the left main. Recheck of ACT showed the ACT to be at eight seconds. This likely represented subtherapeutic range for her anticoagulation. A check of her medications revealed that instead of Angiomax, the patient had been given ReoPro without antithrombotic agent. She was therefore given IV heparin up to 12,000 units, and her ReoPro was continued. The lesion was then rewired, and an AngioJet was used to try to suction out this area of thrombus. Unfortunately, the AngioJet was unable to cross the mid left anterior descending lesion and therefore was somewhat limited in its use for a more distal thrombus, although it did suction out the proximal left anterior descending thrombus. At this point, the patient was emergently intubated, and multiple pressors were started, including dopamine, Levophed, vasopressin, and epinephrine. Following this, a laser was attempted to cross the lesion an excimer laser X80 Spectranetics 0.9 Vitesse; however, this laser was unable to cross the lesion. Therefore, a long balloon, a 2.0 x 40-millimeter CrossSail balloon, was used to cross the lesion and inflate multiple segments of the mid left anterior descending up to a maximum inflation pressure of ten atmospheres. This improved flow though by no means restored it back to normal. Therefore, following this, longer balloon inflations were performed utilizing a 2.0 x 20-millimeter CrossSail balloon up to fourteen atmospheres for one and a half minutes. This did not improve significantly the flow distally, and therefore the decision was made to try to stent the mid segment with a 2.5 x 9-millimeter zipper MX stent to a maximum inflation pressure of fourteen atmospheres. This resolved the issue in terms of the mid left anterior descending lesion; however, beyond the stent there continued to be residual stenosis, and multiple balloons were used to balloon this up to a 2.5 x 20-millimeter balloon up to fourteen atmospheres. The final result in the left anterior descending revealed a lesion in the mid-left anterior descending that was approximately 40 percent, there was TIMI III flow throughout the proximal and mid left anterior descending. However, at the level of the apex, there was TIMI 0 flow. Throughout the angioplasty, the patient had episodes of bradycardia, and a temporary pacemaker was placed, and this was removed at the end of the procedure.

Name: ________________________ ID: A 8 IMPRESSION: Successful stent to the mid left anterior descending, complicated by thrombotic event in the left anterior descending system. Final result was a successful stent to the mid left anterior descending with residual TIMI 0 flow in the distal left anterior descending. We returned to the right coronary artery and successfully employed a 4.5 x 16 mm Express sent. At the end of the case, an intra-aortic balloon pump was placed in the left femoral artery sheath, and the patient was sent to the Coronary Care Unit on multiple pressors including epinephrine, vasopressin, Levophed and dopamine. What CPT  coding is reported? a. 92928-RC, 92929-LD b. 92928-RC, 92928-LD, 33967, 92973 c. 92928-RC, 92929-LD, 92973 d. 92928-RC, 92929-LD, 33967, 92973-RC ____ 39. A patient has a complete TTE performed to assess her mitral valve prolapse (congenital). The physician performs the study in his cardiac clinic. What CPT® code is reported? a. 93303 c. 93308 b. 93306 d. 93312 ____ 40. A patient has a Transtelephonic rhythm strip pacemaker evaluation for his dual chamber pacemaker. It has been more than four months from his last evaluation due to him moving. The physician evaluates remotely retrieved information, checking the device’s current programming, battery, lead, capture and sensing function, and heart rhythm. The monitoring period has been 35 days. What CPT® code can the physician report for the service? a. 93288 c. 93296 b. 93295 d. 93293 ____ 41. A patient is brought to the operating suite when she experiences a large output of blood in her chest tubes post CABG. The physician performing the original CABG yesterday is concerned about the post-operative bleeding. He explores the chest and finds a leaking anastomosis site and he resutured. What CPT® code is reported? a. 35211 c. 35820-78 b. 35820 d. 35241 ____ 42. 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 c. 33256 b. 33255 d. 33259 ____ 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 c. 33430, 33405-51 b. 33426, 33405-51 d. 33468, 33426-51 ____ 44. 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 c. 33510-80 b. 33533-80, 35600-80 d. 33517-80, 35600-80

Name: ________________________ ID: A 10 ____ 48. In the cardiac suite, an electrophysiologist performs an EP study. With programmed electrical stimulation, the heart is stimulated to induce arrhythmia. Observed is right atrial and ventricular pacing, recording of the bundle of His, right atrial and ventricular recording and left atrial and ventricular pacing and recording from the left atrium. What CPT® coding is reported? a. 93600, 93602, 93603, 93610, 93612, 93618, 93621, 93622 b. 93619, 93621 c. 93620, 93621, 93622 d. 93620, 93618, 93621 ____ 49. CLINICAL SUMMARY: The patient is a 41-year-old female with known coronary disease and recent recurrent chest pain, cardiac catheterization demonstrated subtotal occlusion of the diagonal artery at its takeoff from the left anterior descending artery. PROCEDURE: With informed consent obtained, the patient was prepped and draped in the usual sterile fashion. With the right groin area infiltrated with 2% Xylocaine, the patient was given 2 mg of Versed and 50 mcg Fentanyl intravenously for conscious sedation and pain control. The right femoral artery was cannulated with a modified Seldinger technique and a 6 French catheter sheath placed. A 6 French JL3.5 catheter with no side holes was utilized as a guiding catheter. After the initial guiding picture had been obtained, the patient was given Angiomax per protocol, and a short Cross-it 100 wire was advanced to the LAD and then into the diagonal vessel. A 2.0. 15-mm-long Maverick balloon was used for dilatation of the diagonal artery ostium with inflation pressure up to 8 atmospheres applied. Final angiographic documentation was carried out after the patient received 200 mcg of intracoronary nitroglycerine. The guiding catheter was then pulled, the sheath secured in place. The patient is now being transferred to telemetry for post coronary intervention observation and care. RESULTS: The initial guiding picture of the left coronary system demonstrates the high-grade ostial stenosis of the diagonal artery taking off within the LAD. Following the coronary intervention with balloon angioplasty there is complete resolution of the stenosis with less than 10 percent residual narrowing observed, no evidence for intimal disruption, no intraluminal filling defect, and good antegrade TIMI III flow preserved. CONCLUSION: Successful coronary intervention with balloon angioplasty to the ostial/proximal segment of the second diagonal vessel. What CPT® code is reported? a. 92924-LD c. 92921-LD b. 92920-LD d. 92937-LD

Name: ________________________ ID: A 11 ____ 50. Preoperative Diagnosis: Coronary artery disease associated with congestive heart failure. In addition, the patient has diabetes and massive obesity. Postoperative Diagnosis: Same Anesthesia: General endotracheal Incision: Median sternotomy Indications: The patient had presented with severe congestive heart failure associated with her severe diabetes. She had significant coronary artery disease, consisting of a chronically occluded right coronary artery but a very important large obtuse marginal artery coming off as the main circumflex system. She also has a left anterior descending artery which has moderate disease and this supplies quite a bit of collateral to her right system. The decision was therefore made to perform a coronary artery bypass grafting procedure particularly because she is so symptomatic. The patient was brought to the operating room. Description of Procedure: The patient was brought to the operating room and placed in supine position. Myself, the operating surgeon was scrubbed throughout the entire operation. 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. The patient weighs almost three hundred pounds and with her obesity there was some concern as to taking down the left internal mammary artery. Because the radial artery appeared to be a good conduit, she should have an arterial graft to the left anterior descending artery territory. She was cannulated after the aorta and atrium were exposed and after full heparinization. Attention was turned to the coronary arteries. The first obtuse marginal artery was a very large target and the 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 left anterior descending artery does not have severe disease but is also a very good target, and the radial artery was anastomosed to this target, and the proximal anastomosis was then carried out to the root of the aorta. Sternal closure was then done using wires. The subcutaneous layers were closed using Vicryl suture. The skin was approximated using staples. What CPT® coding is reported? a. 33533, 33510 c. 33533, 33517 b. 33511 d. 33533, 35600,33517

Name: ________________________ ID: A 13 ____ 54. What information is needed to accurately code hypertension retinopathy in ICD-10-CM? a. The affected eye(s). b. The stage of retinopathy c. Whether the hypertension is malignant or benign. d. Which side of the heart is affected? ____ 55. In ICD-10-CM what is the default code for coronary artery atherosclerosis? a. I25.10 Atherosclerosis heart disease of native coronary artery without angina pectoris b. I25.709 Atherosclerosis of coronary artery bypass graft(s), unspecified, with unspecified angina pectoris c. I25.810 Atherosclerosis of coronary artery bypass graft(s) without angina pectoris d. I25.9 Chronic ischemic heart disease, unspecified ____ 56. What information is required to accurately code PVD with diabetes in ICD-10-CM? a. The side of the body affected. c. The state of gangrene. b. Whether the patient has gangrene. d. The state of PVD.

ID: A 1 Cardio Answer Section MULTIPLE CHOICE 1. ANS: C Rationale: An artery has three layers: an outer layer of tissue, a muscular middle and an inner layer of epithelial cells. PTS: 1 DIF: Easy 2. ANS: B Rationale: The conduction system contains pacemaker cells, nodes, the bundle of His and the Purkinje fibers. PTS: 1 DIF: Easy 3. ANS: B Rationale: Heart valves are made of flaps (cusps/leaflets) opening and closing like one way swinging doors, preventing blood from flowing back. PTS: 1 DIF: Easy 4. ANS: B Rationale: The left main coronary artery branches into two slightly smaller arteries: the left anterior descending coronary artery and the left circumflex coronary artery. PTS: 1 DIF: Easy 5. ANS: C Rationale: The heart is divided into right and left sides by a septum which is a muscular wall. PTS: 1 DIF: Easy 6. ANS: B 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. PTS: 1 DIF: Easy 7. ANS: B 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. PTS: 1 DIF: Easy 8. ANS: A Rationale: Because it is past four weeks since the myocardial infarction and the patient is still symptomatic, ICD-10-CM guideline, I.C.9.e.1, indicates that the appropriate aftercare code is assigned rather than a code from category I21. Look in the ICD-10-CM Alphabetic Index for Aftercare referring you to Z51.89. Verify code selection in the Tabular List. The instructional note under category Z51 indicates to code also condition requiring care. Look in the Alphabetic Index for Disease/heart/ischemic (chronic or with a stated duration of over 4 weeks) directing you to I25.9. Verify in the Tabular List. PTS: 1 DIF: Easy

ID: A 3 14. ANS: A Rationale: Only one base intervention is reported for each major coronary artery. The hierarchy from highest to lowest is as follows: atherectomy, stent placement, followed by angioplasty. The base intervention code 92928 is reported for the stent placement in the right coronary (92928-RC) and the left anterior descending arteries (92928-LD). Each is reported with the corresponding coronary artery modifiers. Look in the CPT® Index for Coronary Artery/Angioplasty/with Stent Placement referring you to 92928-92929. To locate the angioplasty code, look in the CPT® Index for Coronary Artery/Angioplasty referring you to 92920-92921. The base code 92920-LC is reported for the angioplasty of the left circumflex. PTS: 1 DIF: Moderate 15. ANS: A Rationale: In the ICD-10-CM Alphabetic Index look for Pseudoaneurysm referring you to see Aneurysm. Look for Aneurysm and the subterm pseudoaneurysm is not listed; therefore, the unspecified code I72.9 is correct. In the Alphabetic Index look for Tamponade, heart referring you to I31.4. Next, in the Alphabetic Index look for Failure/ventricular/left referring you to I50.1. Verify code selection in the Tabular List. PTS: 1 DIF: Moderate 16. ANS: D Rationale: CPT® guidelines state “When the battery of a pacemaker is changed, it is actually the pulse generator that is changed.” It is reported with one code. In the CPT® Index look for Pacemaker. This will direct you to see Cardiac Assist Devices. Look for Cardiac Assist Devices/Pacemaker System/Replacement/Pulse Generator referring you to codes 33227-33229. Code 33228 is reported for dual chamber (dual lead system). PTS: 1 DIF: Moderate 17. ANS: C 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. PTS: 1 DIF: Moderate 18. ANS: A Rationale: ICD-10-CM Coding Guideline I.C.9.a.2 states a causal relationship is always assumed with hypertension and chronic kidney disease. Look in the ICD-10-CM Alphabetic Index for Hypertension/kidney/with/stage 1 through stage 4 chronic kidney disease which directs you to I12.9. Verify the code in the Tabular List. The note below code I12.9 instructs you to report an additional code for the stage of chronic kidney disease. This is stage 3, unspecified; therefore, N18.30 is also reported. PTS: 1 DIF: Moderate 19. ANS: C 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. PTS: 1 DIF: Moderate

ID: A 4 20. ANS: D Rationale: Look in the CPT® Index for Angiography/Renal Artery referring you to code range 36251-36254. This is a bilateral procedure, with an accessory left renal artery. Code 36252 includes bilateral and accessory renal angiography, and radiologic supervision and imaging. PTS: 1 DIF: Moderate 21. ANS: A 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. PTS: 1 DIF: Moderate 22. ANS: C Rationale: Because leads were placed on the right atrium and right ventricle, it is a dual chamber system. Two codes are necessary to report placement of an epicardial system. The parenthetical note under 33203 directs the coder to report codes 33202 and 33203 with 33212, 33213, 33221, 33230, 33231, and 33240. Look in the CPT® Index for Cardiac Assist Devices/Pacemaker System/Insertion/Pulse Generator. You are referred to 33212, 33213, and 33221. For the placement of the epicardial electrodes look in the CPT® Index for Cardiac Assist Device/Pacemaker System/Insertion/Electrode. Code 33202 is reported. In the ICD-10-CM Alphabetic Index look for Block, blocked/bundle-branch referring you to code I45.4. Look in the Alphabetic Index for Dysfunction/sinoatrial node referring you to code I49.5. Verify codes in the Tabular List. PTS: 1 DIF: Moderate 23. ANS: A 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. PTS: 1 DIF: Moderate

ID: A 6 29. ANS: B 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. PTS: 1 DIF: Moderate 30. ANS: B 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. PTS: 1 DIF: Moderate 31. ANS: B Rationale: The left renal artery is a first order vessel as noted in Appendix L of the CPT® codebook (36245-LT). To locate the selective catheterization, look in the CPT® Index for Artery/Abdomen/Catheterization referring you 36245-36248. 36245 is the correct code for the selective catheterization. Angiography of the left renal vessel was performed; however, there is no mention in the report of the results of the angiography. This is not a diagnostic angiography, rather it is angiography for mapping (checking out known stenosis). The stent was deployed (37236) in the left renal artery; this code also includes the radiologic supervision and interpretation. In the CPT® Index look for Angioplasty/with Intravascular Stent Placement referring you to 37215-37218, 37236-37239 or you can look for Artery/Stent Placement/Carotid. Follow-up renal angiography is bundled with the stent procedure. PTS: 1 DIF: Difficult 32. ANS: B 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. PTS: 1 DIF: Difficult

ID: A 7 33. ANS: B 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. PTS: 1 DIF: Difficult 34. ANS: C 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. PTS: 1 DIF: Difficult 35. ANS: D Rationale: CPT® guidelines for Vascular Injection Procedures indicate the above listed in D as being included. PTS: 1 DIF: Difficult 36. ANS: D Rationale: This is a Category III code. Look in the CPT® Index for Artery/Stent Placement/Extracranial Vertebral referring you to 0075T-0076T, 37236, 37237. Codes 37236 and 37237 exclude the extracranial vertebral artery. There is a parenthetical note under these codes that refer you to 0075T, 0076T for open or percutaneous placement of an extracranial vertebral artery stent. The code description these codes include supervision and interpretation; therefore, modifier 26 reports the professional service. PTS: 1 DIF: Difficult 37. ANS: A 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. PTS: 1 DIF: Difficult