medical coding 1 2 study guide

Study Guide

Medical Coding, Part 2

INSTRUCTIONS TO STUDENTS 1

LESSON ASSIGNMENTS 3

LESSON 5: CARDIOLOGY 5

LESSON 6: OB/GYN 7

EXAMINATION—LESSONS 4, 5, AND 6 11

LESSON 7: RADIOLOGY, PATHOLOGY,LABORATORY, AND INTERNAL MEDICINE 17

LESSON 8: PAYMENT FOR PROFESSIONAL HEALTH CARE SERVICES, AUDITING,AND APPEALS 21

TEXTBOOK EXERCISE ANSWERS 23

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Welcome to Medical Coding, Part 2. In Medical Coding, Part 1,you learned the basics of coding and began to explore theICD-9-CM and CPT manuals. Medical Coding, Part 2 buildson the experience and skills you’ve already gained by guidingyou through the process of coding several important areas ofdiagnosis and treatment.

As you proceed through the lesson assignments, you’llexamine specialty areas such as internal medicine, cardiology,and obstetrics/gynecology. You’ll also study the fascinatingfields of radiology, pathology, and laboratory work. Finally,you’ll take an in-depth look at the mechanics of reimburse-ment, auditing, and appeals.

You’ve already gained a good deal of familiarity with the medical terminology and the highly specialized language ofmedical coding as you worked through Medical Coding, Part 1.As you work through the material covered in this study guide,you’ll find yourself even more proficient at reviewing andreporting a wide range of medical procedures and diagnosticterms. Soon you’ll have the confidence you need to seek achallenging and rewarding career in the health care industry.

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Remember to regularly check “My Courses” on your student home-

page. Your instructor may post additional resources that you can

access to enhance your learning experience.

Instructions to Students2

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Lesson 5: CardiologyFor: Read in the Read in

study guide: the textbook:

Assignment 9 Pages 5–6 Pages 273–329

Lesson 6: OB/GYNFor: Read in the Read in

study guide: the textbook:


Examination 38189800 Material in Lessons 4, 5, and 6

Lesson 7: Radiology, Pathology, Laboratory, and Internal Medicine

For: Read in the Read in study guide: the textbook:



Lesson 8: Payment for Professional Health Care Services, Auditing, and Appeals

For: Read in the Read in study guide: the textbook:


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Lesson Assignments4

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CardiologyCardiology focuses on diagnosing and treating disorders ofthe heart and the circulatory system. As you’ll learn in thislesson, the cardiovascular system is quite complex, and itsvarious functions play a critical role in a patient’s overallhealth. Cardiology therefore includes a broad range of diag-nostic and procedural services, and coders are encouraged to pay careful attention to the subtle distinctions betweenvarious diagnoses and procedures. Because research teamsacross the globe are constantly producing new tools for diagnosing and treating cardiovascular disorders, it’s equallyimportant for coders to stay on top of all changes relating to cardiology coding procedures.

ASSIGNMENT 9Read through the following material in your study guide. Afteryou’ve read the study guide commentary, read pages 273–329of your textbook Understanding Medical Coding.

To understand the various services and procedures associatedwith cardiology, it’s important to know how the cardiovascularsystem functions. The principal element of the cardiovascularsystem is the heart, which pumps blood through every organof the body. Blood transfers oxygen and nutrients to organtissues and carries away waste products left behind by variousorgan processes. Disruption or irregularity in the pumpingaction of the heart can adversely affect the function of thebody’s other organs and may even result in organ failure.

The heart consists of four chambers. The right and leftventricles are muscular chambers designed to push blood out of the heart. The right ventricle propels blood to the lungs,while the left ventricle moves blood to all other organs. Theright and left atria store blood returning through the networkof veins and blood vessels to the heart. When the heart isoperating smoothly, the atria open at exactly the right momentto empty their contents into the right and left ventricles.

To ensure that blood moves in the right direction through thefour chambers of the heart, four heart valves—the tricuspid,pulmonic, mitral, and aortic valves—open and close at preciseintervals.

The heart muscle never stops working and therefore requiresa constant supply of oxygenated blood. This requirement issupplied by three major coronary arteries attached to theaorta: the right coronary artery (RCA) and two left arteries, the left anterior descending artery (LAD) and the circumflexartery. Blockage, or occlusion, in any of these coronary arteriescan seriously damage the heart muscle. Commonly referred to as a heart attack, damage stemming from coronary arteryblockage is medically known as a myocardial infarction.

The various processes of the heart are controlled by an elec-trical signal generated in the upper part of the right atrium.The strength and regularity of this signal can be measured by placing electrodes on the skin of the chest. Known as an electrocardiogram, this method of recording the heart’s electrical activity is a standard cardiology service. Anothercommon procedure, known as echocardiography, uses ultrasound waves to evaluate the heart’s structure and the direction and flow of blood through the heart muscle.

Cardiovascular system procedure codes form a subsection ofthe Surgery section of the CPT manual. The cardiovascular sub-section is divided into two subheadings based on anatomicalsite: Heart/Pericardium and Arteries/Veins. The codes ineach of these subheadings are organized by procedure. In theICD-9-CM manual, diagnostic codes are organized by condition,while most procedures are grouped in the Operations on theCardiovascular System section of the Index of Procedures.

After you’ve finished Lesson 5, take the time to review all thestudy assignments before you proceed to Lesson 6.


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OB/GYNLesson 6 continues your study of specialty practice codingwith a detailed look at Obstetrics/Gynecology—a name oftenabbreviated as OB/GYN. As the name of this specialty sug-gests, OB/GYN is a dual specialty, serving pregnant patientsas well as female patients who aren’t pregnant. Due to theirunique dual role, gynecologists may act as specialists, primarycare physicians, or both. This dual capacity—in addition to thesubtle distinctions among OB/GYN diagnoses and procedures—poses unique challenges to those involved in coding OB/GYNservices.

ASSIGNMENT 10Read through the following material in your study guide. Afteryou’ve read the study guide commentary, read pages 331–383of your textbook Understanding Medical Coding.

Most OB/GYN codes for procedures performed on patientswho aren’t pregnant are located in the General Surgery section of the CPT manual, under the Female Genital Systemsubsection. The codes in this subsection are categorizedaccording to anatomic site. Similar procedures—for example,incision or destruction—are grouped together under commonheadings. The Female Genital System subsection includescodes for minor procedures typically performed in a physi-cian’s office, as well as more intensive treatments performedin a hospital setting.

Coding OB/GYN procedures requires close reading of both thecode descriptions and any accompanying notes. Otherwise,you may insert incorrect or redundant codes, which may resultin rejection of a claim. For example, to report a total abdominalhysterectomy performed with a bilateral oophorectomy—removal of the ovaries—you need only enter the hysterectomycode (CPT 58150), which includes the statement with orwithout removal of ovaries in the description. Entering a sepa-rate code for the oophorectomy is incorrect. The FemaleGenital System subsection also includes a number of lesioncodes not listed in the Integumentary subsection.

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Bear in mind, too, that many of the codes in the FemaleGenital System subsection refer to the vulva, the externalportion of the female genital system. The vulva include several different parts, including the mons pubis, the labiamajora, the labia minora, the vaginal orifice, and variousvestibular glands. Codes for procedures performed on thispart of the female genital system refer to all areas of the vulva.

The Maternity Care and Delivery subsection is organizedaccording to procedure rather than anatomic site. Proceduresand services are broken down into the following subcategories:

■ Antepartum

■ Excision

■ Insertion

■ Repair

■ Vaginal Delivery

■ Cesarean Delivery

■ Delivery After Previous Cesarean Delivery

■ Abortion

■ Other Procedures

When the maternity case is uncomplicated, the service codesnormally include the antepartum (prior to childbirth) care,delivery, and postpartum (after childbirth) care. Antepartumcare covers a wide range of services, including

■ Initial and subsequent history and physical examinations

■ Routine urinalysis

■ Fetal heart tone assessment

■ Monthly visits up to 28 weeks of pregnancy

■ Biweekly visits from the 29 through 36 weeks of pregnancy

■ Weekly visits from 37 weeks until delivery

Lesson 6 9

Services other than those covered under antepartum caremust be reported separately. For example, an E/M servicecode would be required if a pregnant patient visited herphysician’s office for treatment of a cold or flu. Similarly,although postpartum care includes regular hospital or officevisits, services unrelated to postpartum care must also becoded separately.

After you’ve finished Lesson 6, take the time to review all the study assignments. Then, take the examination forLessons 4, 5, and 6.


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Lessons 4, 5, and 6Medical Coding 1

Exam 2

When you feel confident that you have mastered the material in

Lessons 4, 5, and 6, go to http://www.takeexamsonline.com

and submit your answers online. If you don’t have access to the

Internet, you can phone in or mail in your exam. If you’re unable

to take the exam by telephone or online, please call Student

Services and request the special answer sheet and mail in your

exam. Submit your answers for this examination as soon as you

complete it. Do not wait until another examination is ready.

Note: When you receive your examination evaluation after sub-

mitting your answers for grading, “Book 1” will refer to your

Understanding Medical Coding textbook. “Book 2” will refer to

your ICD-9-CM manual. “Book 3” will refer to your CPT manual.

Questions 1–35: Select the one best answer to each question.

1. Which of the following codes would be used to report therepair of one superficial 1-cm laceration, one superficial 3-cmlaceration, and one superficial 2-cm laceration, all to the cheek?

A. 12001 × 3 C. 12002B. 12011 × 3 D. 12014

2. The metacarpal bones are located in the

A. wrist. C. foot.B. palm. D. skull.

3. Degenerative arthritis is classified in ICD-9-CM category

A. 712. C. 714.B. 713. D. 715.

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EXAMINATION NUMBER:

38189800Whichever method you use in submitting your exam

answers to the school, you must use the number above.

For the quickest test results, go to

http://www.takeexamsonline.com



Examination, Lessons 4, 5, and 6 12

4. What is the ICD-9-CM procedural code for spinal nerve decompression by destructionof intervertebral disc via enzyme injection?

A. 77.7 C. 80.52B. 78.02 D. 81.1

5. What is the first consideration for selecting a burn injury code?

A. Degree of burn C. Presence of infectionB. Anatomical site D. Type of burn

6. Which of the following ICD-9-CM categories would be used to code fractures ofthe vertebrae?

A. 809 C. 807B. 808 D. 806

7. Which of the following ICD-9-CM procedural codes is used to report the closed reductionand internal fixation of a fracture dislocation of the surgical neck of the humerus?

A. 81.52 C. 79.27B. 78.03 D. 79.11

8. Which of the following procedures is abbreviated as either ECG or EKG?

A. Echocardiogram C. Electrophysiology B. Echocardiography D. Electrocardiogram

9. Which of the following OB/GYN subspecialties specializes in the use of a hysteroscopy?

A. Reproductive endocrinologyB. Gynecologic endoscopyC. Gynecologic oncologyD. Perinatology

10. The CPT code for percutaneous transluminal pulmonary artery balloon angioplasty for asingle vessel is

A. 92996. C. 92998.B. 92997. D. 92999.

11. ICD-9-CM codes for placental anomalies, such as abruptio placentae or placenta previa,are listed under category

A. 639. C. 641.B. 640. D. 642.


12. Identify the appropriate four-digit ICD-9-CM code for primary pulmonary hypertension.

A. 443.89 C. 416.0B. 440.1 D. 411.81

13. A spontaneous abortion is an abortion that occurs

A. before the twentieth week of gestation without apparent cause.B. for the safeguard of the mother’s mental or physical health.C. because of an infection of the products of conception and in the endometrail lining

of the uterus.D. when parts of the products of conception are retained in the uterus.

14. What is the V-code for postsurgical PTCA status?

A. V45.81 C. V45.83B. V45.82 D. V45.84

15. What is the ICD-9-CM code for tubal ectopic pregnancy without intrauterine pregnancy?

A. 633.10 C. 613.1B. 623.1 D. 603.1

16. Procedures performed within the cardiology subspecialty of internal medicine are typicallyeither _______ or intravascular.

A. percutaneous C. epidermalB. subcutaneous D. surgical

17. Which of the following CPT codes is used to report Doppler echocardiography color-flowvelocity mapping in addition to the code for echocardiography?

A. 93307 C. 93327B. 93305 D. 93325

18. Identify the appropriate four-digit ICD-9-CM code for congestive heart failure, unspecified.

A. 402.8 C. 482.9B. 408.2 D. 428.0

19. In which of the following procedures might a catheter be placed in the heart preoperativelyto monitor hemodynamic status?

A. Right-heart catheterizationB. PericardiocentesisC. Transesophageal echocardiographyD. Swann-Ganz placement

20. Which of the following structures is included in the internal organs of the female reproductive system?

A. Mons pubis C. Labia majoraB. Fallopian tubes D. Labia minora


21. In which section of the CPT manual would you look for the appropriate code to describecardiac magnetic resonance imaging?

A. Radiology C. Evaluation and ManagementB. General Surgery D. Medicine

22. Which of the following CPT codes would be used for intracervical artificial insemination?

A. 58321 C. 58974B. 58970 D. 58726

23. The acronym AICD stands for

A. arterial implantation catheter device.B. automatic implantable cardioverter-defibrillator.C. autogenic intervascular collapse and destruction. D. arthro-invasive cardiac deployment.

24. Identify the appropriate CPT code for combined right-heart catheterization and retrogradeleft-heart catheterization.

A. 93526 C. 93526-51B. 93526-27 D. 92526-RLT

25. Which of the following codes is used to report emergency OB/GYN office services?

A. 99000 C. 99025B. 99024 D. 99058

26. An echocardiography performed with an endoscopic probe introduced either nasally orby swallowing is called a/an

A. ECG. C. ICD.B. TTE. D. TEE.

27. Anemia, gestational diabetes, and _______ are common complications of pregnancy.

A. hydramnios C. toxemiaB. encephalitis D. sepsis

28. During an initial cardiology visit, the patient has no previous cardiac history but has ablood pressure of 200/95. You should code this as

A. hypertension, transient. C. elevated blood pressure.B. hypertension, controlled. D. hypertension, uncontrolled.

29. Which of the following code groups would be used to report a successful vaginal birthafter previous Cesarean delivery?

A. 59610–59614 C. 59400–59410B. 59050–59051 D. 59040–59041


30. Which of the following terms is used to describe a history of three viable offspring?

A. Nullipara C. TriparaB. Primapara D. Primagravida

31. Identify the appropriate code for laparoscopic lysis of adhesions.

A. 49000 C. 78040B. 99078 D. 58660

32. An extensive biopsy of vaginal mucosa that requires sutures would be coded to

A. 57105. C. 88158.B. 88141. D. 57100.

33. Identify the appropriate separate code for the tubal ligation performed at the sametime as a Cesarean section.

A. 59840 C. 58611B. 59841 D. 58610

34. Which of the following procedures is commonly performed to determine the cause ofdysfunctional uterine bleeding?

A. Cervical capping C. Cervical C/SB. Oviduct transection D. Endometrial biopsy

35. Which of the following ICD-9-CM code groups is used to report the infant status afterdelivery of a birth event?

A. V26.0–V26.9 C. V28.0–V28.9B. V27.0–V27.9 D. V29.0–V29.9


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Radiology, Pathology,Laboratory, and InternalMedicineLesson 7 examines several interesting specialty areas relatedto the detection, prevention, and treatment of disease.Radiation, the first of these specialties, chiefly involves theuse of radioactive particles to produce diagnostic images ofbones, organs, and tissues. X-ray and MRI scans are amongthe most well-known procedures in this category. Radiationis also involved in many types of cancer treatment.

Laboratory and pathology services are equally critical todiagnosis and treatment, and are commonly involved in routine evaluation and primary care. Blood, urine, and othersamples are typically collected in the office of a primary carephysician or specialist and sent to a laboratory for rigoroustesting. In more serious cases, tissue samples may be extractedfrom a patient and sent to a laboratory for examination.

In addition to the specialties covered here, we’ll also coverinternal medicine, which includes subspecialties such ascardiology.

ASSIGNMENT 11Read through the material for this assignment in your studyguide. After you’ve read the study guide material, read pages385–407 of Understanding Medical Coding.

The term radiology originally referred to using X-rays as ameans of producing radiographic images of bones, organs,and tissues. In recent decades, however, a number of other—and in many cases, more sophisticated—techniques haveemerged, which enable physicians and surgeons to examinevarious features of a patient’s anatomy without resorting toinvasive procedures. These newer techniques include

■ Fluoroscopy, a method of projecting live images of internalanatomy onto a television screen

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Medical Coding, Part 2 18

■ Computed axial tomography (CAT scan), a procedurethat involves using computers to generate a three-dimensional image as opposed to two-dimensional X-ray images

■ Magnetic resonance imaging (MRI), used primarily to produce cross-sectional images of the brain, spinal cord, soft tissues, and adrenal and renal masses

■ Diagnostic ultrasound, a procedure that uses high-frequency sound waves to produce images of the internal anatomy

■ Nuclear medicine, the internal administration of radio-active elements that emit gamma rays as they dissolve,enabling physicians to view internal abnormalities

■ Radiation oncology, the therapeutic administration of external or internal radiation to treat various types of cancers

The Radiology section of the CPT manual is divided into sevensubsections. The first subsection, Diagnostic Radiology, issubdivided into procedures related to anatomical sites.Different codes may be used according to whether contrastmaterial—chemical substances such as barium and iohexol—are administered to facilitate viewing of soft tissue or organs.

The second subsection, Diagnostic Ultrasound, is similarlyorganized by anatomical site. In addition, CPT specifies fourdifferent categories of ultrasound:

■ A-mode, which produces a one-dimensional image

■ M-mode, which produces a one-dimensional image that also displays movement

■ B-scan, which delivers a two-dimensional image

■ Real-time scan, which produces a two-dimensional image with motion

The next subsection, Radiologic Guidance, provides codes for guidance of surgical tools and radiation therapy fields.Next are codes for mammography, and after that comes theBone and Joint Studies subsection.

Lesson 7 19

The sixth subsection, Radiation Oncology, includes codes for both professional services—which are provided by aphysician, and typically include determination of a course oftreatment—and technical procedures, which involve the actualadministration of treatment by a radiation technician. Whencoding professional services, it’s important to remember thatinitial consultations with a patient are usually describedwith E/M codes.

The final subsection, Nuclear Medicine, is divided into two sub-headings: Diagnostic and Therapeutic. Diagnostic proceduresinvolve the administration of radionuclides to monitor variousbody systems. Accordingly, codes in this subheading are cate-gorized by anatomical site. The Therapeutic proceduressubheading is rather small, and therefore isn’t subdivided atall. Most of the services listed involve radiopharmaceuticaltreatment of thyroid conditions.

Pathology and laboratory services are listed together in adedicated section following the Radiology section. Codes are arranged in subsections according to procedure. Whendetermining codes for procedures in this section, it’s importantto distinguish between services performed by a physician orin a physician’s office, and those performed in a laboratory to which samples have been sent. In many cases, samples arecollected in a physician’s office and sent to an outside lab foranalysis. Some offices and clinics, however, are equippedwith the tools to perform analysis internally.


Although some people believe that family practice or generalpractice physicians are synonymous with internal medicinepractitioners, this isn’t true. Internal medicine physiciansspecialize in treating diseases of adults. From the onset ofadulthood to the end of life, internal medicine physicians aretrained in all diseases that can occur. Because so many dis-eases and medical conditions affect adults, there are more

Medical Coding, Part 2 20

subspecialties in internal medicine than in any other spe-cialty. There’s even a subspecialty of adolescent medicinethat bridges the gap between pediatric and regular internalmedicine care. Here’s the full listing of subspecialties thatfall under the auspices of internal medicine:

■ Adolescent medicine

■ Allergy/immunology

■ Cardiology

■ Endocrinology

■ Gastroenterology

■ Geriatrics

■ Hematology

■ Infectious disease

■ Nephrology

■ Oncology

■ Pulmonology

■ Rheumatology

■ Sports medicine

Because of the general nature of an internal medicine prac-tice, many of the codes are similar to those of a familypractice. You’ll be using many E/M and medicine codes.This type of practice relies heavily on the HCPCSII manual.There will be few surgical procedures, as most of those typesof problems are referred to specialists.

After you’ve finished Lesson 7, review the study assignments,then proceed to Lesson 8.

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Payment for ProfessionalHealth Care Services,Auditing, and AppealsAs you’ve progressed through each lesson in your program,you’ve learned a great deal about diagnostic and proceduralcodes, and you’ve gained valuable insights into anatomy,physiology, and medical terminology. Lesson 8 provides thelink that connects all the various aspects of coding you’velearned so far. In this lesson, you’ll discover why providingaccurate and consistent codes is vitally important in terms ofobtaining reimbursement for services provided in an office,clinic, or hospital setting. You’ll also examine the potentialrisks of inaccurate coding, as well as the steps you can takewhen third-party agencies deny reimbursement of medicalclaims. After completing Lesson 8, you’ll have thorough under-standing of the major issues involved in medical coding.


As you’ve probably grasped during preceding lessons, thehealth care industry in the United States is multifaceted andcontinually evolving. Analytical and procedural technologiesare constantly being updated, modified, or replaced. Today’stools enable modern health care providers to detect and treatconditions with greater skill, speed, and sophistication thanever before.

The benefits of a highly evolved medical system pose a numberof challenges, however—especially in the area of billing,reporting, and reimbursement. Managing these critical areasrequires excellent organizational and record-keeping skills,as well as a firm grasp of current health care regulations,practices, and procedures. A proactive approach to under-standing revisions to the current system is also essential.

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As a general guideline for maintaining accurate and compre-hensive medical records—upon which timely reimbursementdepends—your textbook outlines a principle referred to as the“Five W’s” of claim preparation. To avoid errors, omissions,or oversights, the following “W’s” must be accurately recordedwhen preparing a claim for reimbursement:

■ Where (the location at which a service was performed)

■ When (the date of service provided by the physician)

■ Who (both the provider and the recipient of the service)

■ What (the services, treatments, supplies, and diagnosesprovided to a patient)

■ Why (the medical necessity for the service provided)

Ensuring that these five critical elements are accuratelyreported and consistent with a patient’s medical record andwith current coding regulations will provide immeasurableassistance in processing claims quickly and efficiently.

After you’ve finished Lesson 8, take time to review all thestudy assignments from Lessons 5, 6, 7, and 8. Your examtimetable will depend on the program in which you’re enrolled.

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TEXTBOOK EXERCISE ANSWERS

Chapter 9

Exercise 9-1

1. Systole and diastole

2. Epicardium, endocardium, and myocardium

3. moon

Exercise 9-2

1. V81.2 Other cardiovascular conditions screening

V67.51 Following completed treatment with high-riskmedication, not elsewhere classified

909.5 Late effect of medicine isn’t reported, as this testdoesn’t reflect a condition. Although the patient wasmedicated with a high-risk medication, the disease/illness hasn’t yet presented for her. The treatment plan continues to screen for potential disease.

2. 402.11 Hypertensive heart disease benign with heartfailure (Note: The physician documentation should actually state whether diagnosed as benign or malig-nant, rather than the coder selecting based on the B/Pdocumentation.)

428.0 Congestive heart failure, unspecified

Exercise 9-3

1. transesophageal echocardiogram; transthoracic echocardiogram

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3. ICD-9-CM

4. Two diagnoses are listed in the clinical indications for this study: congestive heart failure and atrial fibrillation.When the body of the report is read, however, you

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should also pick up on (nonrheumatic) mitral and tricuspid regurgitation. These diagnoses are coded as

Congestive heart failure 428.0 Atrial fibrillation 427.31 Mitral regurgitation 424.0 Tricuspid regurgitation 424.2

Modern echocardiography employs three different studiesdone during the same session to evaluate cardiac andvalvular structures: two-dimensional echocardiography,color-flow mapping, and Doppler pulsed-wave imaging.Turn first to the CPT index under “Echocardiography.”You’ll find “Cardiac” listed with a 93320–93350 coderange. One of the subterms found is “Transthoracic,” with a 93303–93317 range noted. You might also choose to look under “Doppler,” where you’ll find listed 93303–93317,93320–93321, and 93662. When you turn to the Cardiologymedicine section of the CPT, pay careful attention to theinstructional notes found in parentheses. Because the diagnostic study report includes color-flow mapping, wemust also add this code to accurately report the studiesperformed. You’ll also note that with the description of thiscode, the coder is instructed to make sure the other correctcodes are also reported.

Some offices may perform this study in specialized suites.In that case, no modifier is required. If performed in anancillary setting, however, the -26 professional componentmodifier should be appended to each of the three codes.

Echocardiography, transthoracic, real-time with imagedocumentation (2D), includes M-mode recording whenperformed, complete, without spectral or color Dopplerechocardiography: 93307

Doppler echocardiography, pulsed-wave and/or continuous-wave with spectral display: 93320

Doppler echocardiography color-flow velocity mapping:93325

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Exercise 9-4

1. Arterial

2. Venous

3. Pulmonary

4. Portal

5. Lymphatic

Exercise 9-5

1. Though not stated in the clinical indications for this procedure, you’ll note the mention of pain several timeswithin the body of the operative report. Therefore, thisdiagnosis should be included on the CMS-1500 claimform. You’ll also note that there are two obstructionsdescribed (in two separate vessels) without mention ofan acute myocardial infarction found. For this reason,you should choose a code for this occasion that reportsocclusion or obstruction of a native coronary artery:

Precordial chest pain: 786.51Obstruction of a native coronary artery: 414.01

In searching for CPT codes, you should remember thatyou’re reporting for two separate lesions, in two separatevessels with two separate interventions, that is, atherec-tomy of the LAD and angioplasty of the diagonal vessel of the left coronary artery.

Look in the CPT index under “Atherectomy.” Next, choose“percutaneous” rather than “open.” Always remember, cardiologists perform invasive procedures percutaneously(through the skin and vessels), while cardiothoracic sur-geons use the “open” method. Because you’re reporting a coronary atherectomy, choose the code range 92995–92996 for reporting and billing purposes. This describesthe major procedure performed in this session.

Next, look under “Angioplasty” in the index. Under thesubterm “Coronary Artery,” you’ll see Percutaneous,Transluminal, and code range 92982–92984. This willallow you to report the second lesion found within thediagonal branch of the LCA treated by the cardiologistduring this invasive session.

Answers26

Because of the unusual circumstances of this operativesession, and to preclude confusion on the part of thethird-party payer, you should add modifier -59 to the balloon angioplasty procedure. This will indicate that the second intervention was unique and distinct from theinitial atherectomy. This modifier will signal the insurerthat special circumstances apply and that the operativereport should be consulted for particular details relevantto the second intervention.

Percutaneous transluminal coronary atherectomy, bymechanical or other method, with or without balloonangioplasty, single vessel: 92995

Percutaneous transluminal coronary balloon angioplasty,single vessel: 92982-59

2. This patient has a multitude of serious cardiovascularproblems. Therefore, you should try to choose the mostserious to clearly define the medical necessity for allensuing interventions this patient will require.

Because there’s no evidence of an acute (or previous)myocardial infarction, but clear evidence of arterial occlusion in the coronaries, a very specific diagnosis can be used for reporting and billing purposes. The previous scenario might be coded with these diagnoses:

Severe pulmonary hypertension 416.0Coronary occlusion without infarction 411.81Bilateral renal artery stenosis 440.1Peripheral vascular disease 443.89

Many procedures were done during the catheterizationsession; therefore, several codes will be required for accurate billing and reporting.

You’ll note within the cath report that both a right- andleft-heart catheterization were performed. If you consultCPT’s index, locate the terms “Catheterization, Cardiac.”Next, find “Combined Left and Right Heart.” This directsyou to the code range 93526–93529. When you go to thetabular section, you’ll see easily that 93526 is the correctcode. Don’t forget to append a -26 modifier according toCPT and ACC guidelines.

Answers 27

Because imaging is a great portion of catheterization procedures, look under this term in the index. You’ll be directed to “Vascular Studies.” Looking at the manyoptions under these subterms, you should focus on“Cardiac Catheterization/Imaging,” in which you’ll find reference to code range 93555–93556.

To locate “Aortography,” consult the index again. Becauseyou’re reporting cardiovascular medicine procedures, choose93544 from the options listed. For the reporting of selectivecoronary angiography, choose 93545. For angiography ofthe heart vessels, find the terms “Angiography” and “HeartVessels.” Next, locate the term “Injection” for code 93545.For the left-heart injection inherent in this procedure,choose “Left Heart” and “Injection” to locate code 93543.

Cardiac catheterizations always use at least three codes,and a fourth if there’s a thrombolytic agent. None ofthese codes need a -51 modifier appended.

The complex catheterization performed should be codedas follows:

Combined right-heart catheterization and retrograde left-heart catheterization: 93526-26

Injection procedure during cardiac catheterization for selective left ventricular or left atrial angiography: 93543

Injection procedure during cardiac catheterization for aortography: 93544

Injection procedure during cardiac catheterization for selective coronary angiography: 93545

Imaging supervision, interpretation, and report for injection procedure(s) during cardiac catheterization; ventricular and/or atrial angiography: 93555

Imaging supervision, interpretation, and report for injection procedure(s) during cardiac catheterization; pulmonary angiography, aortography, and/or selectivecoronary angiography including venous bypass grafts and arterial conduits (whether native or used in bypass): 93556

Answers28

Exercise 9-6

1. Thrombolysis is the destruction of blood clots within a vessel.

2. Embolysis is the destruction of an abnormal particle,such as an air bubble, circulating in the blood.

3. Pericardiocentesis withdraws fluid from the pericardial sac(pericardium) that surrounds the heart’s outer surface.

4. myxomas

5. Directional, rotational, and extraction

6. percutaneous transluminal coronary angioplasty

7. 413.9, 414.01 (if the patient hasn’t suffered an MI,411.81 may be substituted), V45.82. Medicare won’tallow billing an angioplasty or angiography on the sameclaim as a stent. The methods used to deploy the stent,though similar to the above procedures, are inherent inCPT code 92980 and can’t be billed separately.

Exercise 9-7

1. Automatic implantable cardioverter-defibrillator

2. electrophysiology

3. Single- or dual-chamber devices

4. pulse generator

5. Clinical indications for this study include ischemia and ahistory of ventricular fibrillation. These diagnoses shouldbe coded as follows:

Ventricular fibrillation 427.41Ischemia (unspecified) 414.9

Knowing by the title of the procedure that this is an elec-trophysiologic test, you should revert back to the coderange 93600–93660 in the Electrophysiology Procedureportion of the CPT index.

Commonly, EP physicians won’t do only a comprehensiveelectrophysiologic study, but will also perform a pro-grammed stimulation and pacing test after IV druginfusion to evaluate the accuracy of the comprehensive

Answers 29

study findings. In such cases, two CPT codes will berequired for accurate reporting and billing. When choos-ing the correct code, you should pay close attention tothe operative report to determine where the recordings are coming from (that is, right atrium vs. left atrium),whether or not pacing is involved, and whether or not anarrhythmia is induced. Additionally, you should find out whether this is an initial or follow-up study prior toproceeding in the code selections.

Because this procedure is routinely performed in anambulatory facility, the -26 professional componentmodifier would be appended to both codes used. Thecomplete EP study has the highest relative value as itrepresents the greater portion of expertise and effort.Therefore, it should be listed first on the claim form, followed by the programmed stimulation code.

Comprehensive electrophysiologic evaluation with rightatrial pacing and recording, right ventricular pacing andrecording, His bundle recording, including insertion andrepositioning of multiple electrode catheters, with induc-tion or attempted induction of arrhythmia: 93620-26

Programmed stimulation and pacing after intravenousdrug infusion: 93623-26

6. The only diagnosis stated in the clinical indications forthis procedure is syncope.

The diagnosis is located in the ICD-9-CM index as stated in the operative report. The correct code for thisdiagnosis is

Syncope 780.2

In determining how to find a tilt-table evaluation in theCPT book, you should first be advised that the tilt-tableevaluations are most frequently performed by electro-physiologists in large cardiology practices. (In smallerpractices, other cardiologists may also order this test.)Additionally, it’s usually performed in an ambulatory setting, thus requiring that the physician’s professionalcomponent modifier -26 be appended to the code. In CPT’s index, therefore, you’ll find under “ElectrophysiologyProcedure” the code range 93600–93660.

Answers30

If you carefully read the code descriptions within the stated range, you’ll locate the correct definition of theprocedure performed.

Evaluation of cardiovascular function with tilt-table evaluation, with continuous ECG monitoring and inter-mittent blood pressure monitoring, with or withoutpharmacological intervention: 93660-26

7. The clinical indications for this procedure show that thepatient has an LV (left ventricular) aneurysm as well aseasily inducible and sustained ventricular tachycardia.

These diagnoses would be coded as follows:

Sustained ventricular tachycardia 427.1LV aneurysm 414.10

In looking at the procedure(s) performed, you shouldcarefully read through CPT’s options for AICD implanta-tion in the cardiovascular surgical section. You’ll find that some codes deal with implantation of pads, pulsegenerators (batteries), and/or electrodes (leads). Some ofthe available codes deal with removals and/or revisions.The code best describing what the cardiologist in thisreport has performed is for the insertion or repositioningof electrode lead(s) for single or dual chamber pacing cardioverter-defibrillator and insertion of pulse generator.The accurate CPT code is 33249.

8. When a mechanical device, such as a pacemaker orAICD, is implanted in a patient, there’s always thechance that a complication will occur. In recalling theICD-9-CM chapter, you’ll remember that complications may be surgical, medical, or mechanical. In this case, amechanical complication has occurred with an implantedcardiac device that’s still in place. The end result of thiscomplication is, of course, the patient’s unspecifiedarrhythmia. Therefore, this scenario is coded as follows:

Mechanical complication due to cardiac pacemaker electrode 996.01Status-post cardiac pacemaker, in situ V45.01Cardiac dysrhythmia, unspecified 427.9

Answers 31

Two separate procedures were performed in this scenario.If you consult the CPT index under “Pacemaker, Heart,”you’ll locate (under “Insertion, Electrode”) codes33210–33211, 33216–33217, and 33224–33225. Looking further, but within this same area, you’ll see “Revise Pocket, Chest,” code 33222.

In checking various coding tools such as the FederalRegister, you’ll note that 33222, revision of the pocket,carries a higher relative value than that of 33217 forreplacement of electrodes. Even though codes 33216 and 33217 say “insertion,” these codes can be used forinsertion (placement) or replacement of leads. Since thisprocedure is subsequent in the major revision procedure,it should be listed second with a -51 modifier appended tothe code:

Revision or relocation of skin pocket for pacemaker: 33222

Insertion of a transvenous electrode(s); dual chamber (twoelectrodes) permanent pacemaker or dual chamber pacingcardio-defibrillator: 33217-51

Chapter 10

Exercise 10-1

1. 76805 (consideration of modifier -52 due to the poorlydocumented maternal anatomy)V28.4 Screening for fetal growth retardation usingultrasonicsNo other symptoms or abnormal findings

2. Code(s) from 651–659 would be primary, describing the delivery and probably complications. V27.3 is thesecond code.

3. 59425 V22.____ to select whether normal first or otherpregnancy. If symptoms are present or there are riskfactors, select V23.____.

Answers32

Exercise 10-2

1. 643.03

2. 644.13

3. 648.83

4. 642.73

5. 641.90 or 641.93

Exercise 10-3

1. 641.20 or 641.23Not able to select CPT for procedure as it isn’t documented.

2. 7680576810 × 2V28.81

3. 59151633.10 or 633.11V23.9

Exercise 10-4

1. 59015V28.____

2. 652.20

3. 5900076946V28.0

4. 59821632

5. 74.1 (principal)88.78641.13 (principal)646.63V72.69 (optional for urinalysis)

6. 644.03 (principal)913.099.29 (optional for Brethine administration)75.34 (optional for fetal monitoring)

Answers 33

Exercise 10-5

1. 99395V72.31

2. 9924236415626.8

3. No code as patient has called for an appointment andhasn’t yet been seen by the physician.

Exercise 10-6

Diagnostic laparoscopy 49320 code isn’t selected, asprogressed to surgical.

Exam under anesthesia isn’t coded.

58661 RT Ovary removed

44180 (Select -51 or -59 depending on the insuranceplan rules.) Lysis of adhesions is usually bundled withinthe same scope/site.

58662-LT (Select -51 or -59 depending upon the insur-ance plan rules. The LT may be enough of a modifier todescribe separate site.) Left ovarian fulguration of cyst.

It’s very important to review the insurance plan rulesprior to submitting the claim.

Exercise 10-7

ICD-9-CM: Right Bartholin cyst: 616.2Left labial cyst: 624.8

CPT: Marsupialization Bartholin right cyst: 56440-RTI&D left labial cyst: 56405-LT-59

Exercise 10-8

ICD-9-CM: 621.0CPT: 58558, 57720-59

Answers34

Exercise 10-9

1. 58671V25.2

2. 57454622.10

3. 58100627.1

4. 57065078.0

Exercise 10-10

1. 58323V26.21

2. 622.5 (not able to code visit/procedure as no informationis documented)

3. 57265618.6618.04

4. 58340628.2

5. 58150-80 (no ICD-9-CM code as reason or diagnosis not given)

Exercise 10-11

1. 617.3

2. 099.53616.11

3. 610.1

4. 625.2

5. 233.1

6. 5840057240-51618.4

Answers 35

7. 56420616.3646.63

8. 58950183.0

9. 992058100181025364159900096372599.0 (597.80—urethritis covered in UTI code)623.5625.9V72.41 for pregnancy test

10. 99205-5758563 (primary procedure)7685684702621.0 (primary diagnosis)625.0V72.41 for pregnancy test

Chapter 11

Exercise 11-1

1. 70328

2. 71020-26

3. 73580

4. 74270

5. 74740

Exercise 11-2

1. Question deleted—not enough information

2. 76830

Answers36

3. 76930

4. 76965

5. 76975

Exercise 11-3

1. 77305

2. 77409

3. 77605

4. 77763

5. 77790

Exercise 11-4

1. 78000

2. 78215

3. 78428

4. 78802

5. 78707

6. ICD-9-CM: 574.50CPT: Intraoperative cholangiogram: 74300

7. ICD-9-CM: Rt. subcutaneous emphysema: 958.7Recurrent rt. pneumothorax: 512.8CPT: Chest X-ray, PA view: 71010

8. ICD-9-CM: Intertrochanteric fracture of rt. hip: 820.21Nondisplaced fracture rt. femoral neck: 820.8CPT: X-ray of rt. hip (code depends on how many viewsof the hip are taken). Right hip indicates a unilateralprocedure. Code for one view is 73500; complete withminimum of two views is 73510. X-ray of pelvis. Again, code depends on how many viewsare taken. Anteroposterior view is 72170; minimum ofthree views is 72190.

9. ICD-9-CM: Trauma, right foot: 959.7X-ray shows nondisplaced fracture of the shaft of the2nd proximal phalanx: 826.0CPT: X-ray, rt. foot: 73620 (two views)

Answers 37

10. ICD-9-CM: Rheumatoid arthritis: 714.0CPT: X-rays of hands, AP and lateral: 73120-RT, 73120-LT

11. ICD-9-CM: Arthritis/capsulitis lt. shoulder: 726.0X-ray shows erosive arthropathy of the left humeral head with degenerative osteoarthritis: 715.91 and calcific subacromial bursitis: 726.19CPT: X-ray, AP and lateral of lt. shoulder: 73030

Exercise 11-5

1. 85651

2. 81025

3. 80050

4. Question deleted—not enough information

5. 84597

6. 86689

7. 82746

8. 86632

9. 87177

10. 85032 (may be coded multiple times—one for each element coded manually)85027

11. 81002

12. 83088

13. 80047 or 80048 (The only difference between thesecodes is the kind of calcium—ionized or total—whichisn’t specified here.)

14. 85610

15. 86592

Answers38

Chapter 15

Exercise 15-1

1. Before the care or service is provided by the professional

2. Appointment, obtaining patient demographic information,contacting the insurance plan, care begins, encounterform, superbill or charge ticket, collection of payment atthe time of service, charge entry, claim submission, insur-ance plan receives the claim, insurance plan policies andedits are applied, payment of the claim, follow-up, accurate payment, appeal, resubmit the claim

3. Accurate patient demographics, verification of eligibilityand benefits, follow-up, accurate payment review, appealthe claim

Exercise 15-2

1. Participating, nonparticipating, opt-out, or deactivation

2. CMS-R-131 for physician services

3. False. HIPAA rules include ABN for all health insuranceplans for electronic claims.

Exercise 15-3

1. Downcoding, upcoding, unbundling, frequency, pro-fessional courtesies

2. Absolutely not. Accuracy is required per law. The codeselection should be a “mirrored image” to the servicethat’s documented.

3. National Correct Coding Initiative

4. The manual is updated annually, released in October.The edit pairings are updated quarterly.

5. The documentation matches the professional servicesthat were performed.

Answers 39

Exercise 15-4

1. Transaction and data sets, security rules, and privacyrules

2. If the patient signed the initial notice, the practice mayrelease health information for care purposes. Only theminimum necessary information should be shared. State laws should be considered and use extra care formental health data.

3. The Office of Civil Rights

medical coding 1 2 study guide

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