A new patient with cystic fibrosis underwent evaluation of lung function, including percussion, vibration and cupping to the chest wall to facilitate his lung function. What CPT® code(s) is/are reported for this service?
94667Rationale : In the CPT® Index look for Pulmonology/Therapeutic/Manipulation of Chest Wall or Chest Wall/Manipulation. Code 94667 is the correct code because it includes the patient's first time, and it includes the evaluation.
A 15-year-old underwent placement of a cochlear implant 1 year ago. It now needs to be reprogrammed. What CPT® code is reported for the reprogramming?
92604Rationale : Cochlear implants differ from hearing aids; they bypass the damaged part of the ear. The use of a cochlear implant involves relearning how to hear and react to sounds. In the CPT® Index look for Cochlear Device/Programming which directs you to codes 92602, 92604. The code selection is based on the age of the patient and whether it is the initial programming or subsequent reprogramming. Code 92604 describes subsequent reprogramming for a patient age 7 or older.
A patient was brought to the emergency department in cardiac arrest. The physician immediately initiated CPR. What CPT® code is reported for CPR?
92950Rationale : Medical personnel usually begin cardiopulmonary resuscitation (CPR) which provides artificial breathing and chest compressions for a person in cardiac arrest. In the CPT® Index, you can look for either CPR or Cardiopulmonary Resuscitation or Resuscitation/Cardiopulmonary. All indexed items direct you to code 92950.
A patient who has had two recent seizures underwent a 3-hour continuous EEG recording, without video. The physician interpreted the study and documented a report in the patient's medical record. What CPT® code is reported?
95705Rationale : In the CPT® Index look for EEG directing you to See Electroencephalography (EEG). Look for Electroencephalography (EEG)/Recording/Detection. The patient had a 3 hour continuous EEG without the use of video which the physician interpreted, not an EEG technologist. The correct code to report is 95717.
A 5-year-old fell on broken glass and required suturing of a laceration. Due to the age and combative behaviour of the patient, the provider utilized moderate sedation while repairing the laceration. The provider gave the child 50 mg of Ketamine IM. A nurse monitored the patient during the procedure which took 30 minutes. What CPT® code is reported for moderate sedation?
99152, 99153Rationale : Moderate sedation is often used for pediatric patients in situations not normally requiring sedation. In this case, the provider administered sedation with a nurse assisting in monitoring the patient. In the CPT® Index look for Sedation/Moderate/with Independent Observation. Code selection is based on the age of the patient and the length of time. Code 99152 describes an encounter using moderate sedation, and the physician or other qualified health care professional rendering the diagnostic or therapeutic service also manages the sedation. This code is specific for the age of the patient and up to 15 minutes of time. Add-on 99153 is for each additional 15 minutes of intraservice time.
A teenager has been chronically depressed since the separation of her parents 1 year ago and moving to a new city. Her school grades continued to slip and she has not made new friends. She has frequent crying episodes and is no longer interested in her appearance. She has attended the community mental health centre and participates in group sessions. Recently her depression exacerbated to the point inpatient admission was required. The provider diagnosed adjustment disorder with emotional and conduct disturbances. Due to the length of the depression and no real improvement, the provider discussed electroconvulsive therapy with her mother. After discussing the benefits and risks, the mother consented to the procedure. What CPT® and ICD-10-CM codes are reported for electroconvulsive therapy?
90870, F43.25Rationale : In the CPT® Index look for Electroconvulsive Therapy which directs you to 90870. For the diagnosis, in the ICD-10-CM Alphabetic Index look for Disorder/adjustment/with/conduct disturbance/with emotional disturbance and you are directed to F43.25. F43.25 includes disturbances of conduct, so F43.24 is not reported separately. Verification in the Tabular List confirms code selection.
A patient sustained a neck strain as a driver in an automobile accident, losing control, hydroplaning and hitting a tree off the highway which caused the car to overturn. He has continued to have neck pain and stiffness. He sees a chiropractor who assesses the patient and manipulates his neck. The diagnosis is neck strain. What CPT® and ICD-10-CM codes are reported for the chiropractor?
98940, S16.1XXA, V47.0XXARationale : In the CPT® Index look for Manipulation/Chiropractic. The neck is the cervical spine and code selection is based on the number of regions treated. In this case, 1 region is treated making 98940 is the correct code choice.In the ICD-10-CM Alphabetic Index look for Strain/cervical or Strain/neck and you are directed to code S16.1-. The Tabular List shows seven characters are needed to complete the code. X is used as a placeholder for the 5th and 6th characters. A is the 7th character for the initial encounter receiving active treatment. Next, report the external cause. The patient was the driver in a non-collision vehicle accident when he lost control of the car. Look in the ICD-10-CM External Cause of Injuries Index for Accident/car which states to see Accident, transport, car occupant. Look for Accident/transport/car occupant/driver/collision (with)/stationary object/nontraffic. When referring to the Tabular List, subcategory code V47.0 is used and it shows seven characters are needed to complete this code. X is used as the 5th and 6th characters and A, initial encounter, is used for the 7th character.
A patient diagnosed with amyotrophic lateral sclerosis has increasing muscle weakness in the upper extremities. The provider orders needle electromyography (EMG) to record the electrical activity of the muscles. What CPT® and ICD-10-CM codes are reported?
95861, G12.21Rationale : In the CPT® Index look for Electromyography/Needle/Extremities. Code selection is based on the number of extremities studied. In this case, two extremities (upper) are studied making 95861 the correct code selection. Amyotrophic lateral sclerosis (ALS) is also known as Lou Gehrig's disease. In the ICD-10-CM Alphabetic Index, look for Amyotrophia, amyotrophy, amyotrophic/lateral sclerosis or Sclerosis/amyotrophic (lateral) which directs you to code G12.21. Verification in the Tabular List confirms code selection.
What ICD-10-CM code is reported when a flu vaccine is administered?
Z23Rationale : In the ICD-10-CM Alphabetic Index look for Vaccination (prophylactic)/encounter which refers you to Z23. Verification in the Tabular List confirms Z23 is for an encounter for immunization. This code is nonspecific as to the type of vaccination that is given. The type of vaccination given (i.e. influenza, MMR, DPT) will be specified by the CPT® or HCPCS codes.
A patient mangled his left hand in machinery requiring amputation at the wrist. The wound has healed and the patient is fitted with an artificial hand. The device has a moulded socket, flexible elbow hinges and triceps pad. A total of 30 minutes was spent training the patient to use the prosthesis. What codes are reported for the prosthesis, training and diagnosis?
97761 x 2, L6050, Z44.8, Z89.112Rationale : In the CPT® Index look for Training/Prosthetics and you are directed to 97761. The code is reported for every 15 minutes. Since 30 minutes were spent training, 2 units are reported. In the HCPCS Level II codebook look for Wrist/Disarticulation prosthesis, and you are directed to codes L6050, L6055. Based on the description the prosthesis is reported with code L6050. The wound has healed and is ready for fitting of the prosthesis. In the ICD-10-CM Alphabetic Index look for Fitting (and adjustment) (of)/device NOS/prosthetic (external)/specified NEC directing you to code Z44.8. In the Alphabetic Index look for Absence (of) (organ or part) (complete or partial)/hand and wrist (acquired) referring you to code Z89.11-. Tabular List shows the 6th character of 2 to indicate left hand amputation site.
A 70-year-old male presents with localized oedema in his legs. He has hypertension and congestive heart failure and is currently on medication for both conditions. The provider ordered a complete venous duplex scan of his lower extremities. The femoral, superficial femoral, posterior tibial and popliteal veins were assessed. There was no evidence of thrombus. The study was normal. What CPT® and ICD-10-CM codes are reported?
93970, R60.0, I11.0, I50.9Rationale : In the CPT® Index look for Duplex Scan/Venous Studies/Extremity. Code 93970 indicates a complete bilateral study. For the ICD-10-CM codes, since the study was normal, the symptoms indicating the test are reported. In the ICD-10-CM Alphabetic Index look for Edema/legs or Edema/localized which refers you to code R60.0. Hypertension and congestive heart failure have a causal relationship. In the Alphabetic Index, look for Hypertension/heart/with/heart failure (congestive) referring you to I11.0. Instructional note in the Tabular List for I11.0 indicates to also identify the type of heart failure. Look for Failure, failed/heart/congestive which refers you to I50.9. Verification in the Tabular List confirms code selections.
A 30-year-old male cut his right hand on a nail repairing the gutter on his house. Six days later it became infected. He went to the intermediate care centre in his neighbourhood, his first visit there. The wound was very red and warm with the purulent material present. The wound was irrigated extensively with sterile water and covered with a clean sterile dressing. An injection of Bicillin CR, 1,200,000 units were given. The patient was instructed to return in three to four days. The provider diagnosed open wound of the hand with cellulitis. A problem-focused history and examination with a low MDM were performed. What are the codes?
99201, 96372, J0558 x 12, S61.411A, L03.113, W45.0XXA, Y93.H9Rationale : The patient is a new patient to the clinic. Code selection is made from 99201-99205 for the office visit. For a new patient, all three key components must be met. The clinic visit is reported as 99201.In the CPT® Index look for Antibiotic Administration/Injection. Code selection is based on the route of administration. The administration of the antibiotic is reported with 96372. The Bicillin CR is found in the HCPCS Level II codebook in the Table of Drugs and Biologicals. Look for Bicillin C- which directs you to code J0558. The code descriptor for J0558 is 100,000 units. Report 12 units to correctly charge for the 1,200,000 units delivered to the patient, J0558 x 12. In the ICD-10-CM Alphabetic Index look for Wound, open/hand/laceration which states to see Laceration, hand. Look for Laceration/hand/right directing you to S61.411-. Tabular Lists indicates a 7th character is needed to complete the code. Report A for the initial encounter. Next, look in the Alphabetic Index for Cellulitis/hand which states to see Cellulitis, upper limb. Look for Cellulitis/upper limb referring you to L03.11-. Complete code in the Tabular List to indicate right hand, L03.113. Then look in the ICD-10-CM External Cause of Injuries Index for Contact (accidental)/nail referring you to W45.0-. The Tabular List indicates the code is complete with seven characters. The complete code requires placeholders be placed at the 5th and 6th characters and a 7th character A for initial encounter. The second external cause code is used to identify the activity. In the External Cause of Injuries Index look for Activity/maintenance/property referring you to Y93.H9. Verification in the Tabular List confirms code selection.
A baby was born with a ventricular septal defect (VSD). The provider performed a right heart catheterization and transcatheter closure with the implant by percutaneous approach. What codes are reported?
93581, Q21.0Rationale : In the CPT® Index look for Septal Defect/Closure/Ventricular. Reading the descriptions code 93581 describes percutaneous transcatheter closure of a congenital ventricular septal defect using an implant. There is a parenthetical note under code 93581 stating that the right heart catheterization is included in this procedure and not to report code 93530 with code 93581. VSD is a congenital condition (present at birth). In the ICD-10-CM Alphabetic Index look for Defect/ventricular septal which refers you to Q21.0. Verification in the Tabular List confirms code selection.
A 70-year-old patient with chronic obstructive asthma is brought to the urgent care centre with increased wheezing and coughing. The provider-initiated an albuterol inhalation treatment, one dose, delivered by nebulizer. After treatment, the patient's exacerbation was somewhat improved but the provider determined a second treatment was necessary. What codes are reported?
94640, 94640-76, J7609 x 2, J44.1Rationale : In the CPT® Index look for Inhalation Treatment/for Airway Obstruction/Pressured or Non pressured which directs you to 94640. Inhalation treatment was given therapeutically in treating the acute airway obstruction. Two treatments were given so code 94640 is reported twice. Under code 94640 there is a parenthetical instruction stating to use modifier 76 if more than one inhalation treatment is performed on the same date. Because treatment is in the office (urgent care is considered office treatment), the provider will also bill for the medication used. In this case, it is albuterol. In the HCPCS Level II codebook go to the Table of Drugs and Biologicals and look for Albuterol, unit dose form which directs you to J7609, J7613. J7609 is reported for albuterol per dose. Two doses were given reporting J7609 x 2. For the diagnosis in the ICD-10-CM Alphabetic Index look for Asthma/chronic obstructive/with exacerbation (acute) directing you to J44.1. There is no mention of status asthmaticus, but exacerbation is mentioned. The diagnosis code is J44.1. Verification in the Tabular List confirms code selection.
A patient with severe atrial fibrillation presents for an EPS study. The cardiologist performs the professional component of a comprehensive EPS study, including right atrial and ventricular pacing/recording, the bundle of His recording and induction of atrial fibrillation, and insertion and repositioning of multiple electrode catheters. What CPT® code(s) is/are reported?
93620 -26Rationale : An EPS study is an electrophysiology study evaluating the electrical system of the heart. In the CPT® Index look for Electrophysiology Procedure. It is important to read code descriptions carefully to avoid coding each element separately when there is a code combining all elements performed. 93620 includes all the elements described. Modifier 26 is appropriate to indicate the professional component was performed by the provider.
A female patient reports repeated falls. She has no known head trauma or other injuries. She noticed some slight stiffness in her joints and weakness in her lower extremity muscles, with slight stiffness in her arm joints. The provider decided to test for possible multiple sclerosis (MS). She was sent to a clinic providing somatosensory studies. The testing included upper and lower limbs. What CPT® and ICD-10-CM codes are reported?
95938, M62.81, M25.60, R29.6Rationale: In the CPT® Index look for Somatosensory Testing. Studies are reported based on location. The list of codes ranges for upper limbs are 95925, 95938, 95939 and lower limbs are 95926, 95938, 95939. In this case, the upper limbs and lower limbs were both performed guiding you to code 95938. MS has not been confirmed. Symptoms of weakness in her muscles and stiffness of the joints are reported. She also reports repeated falls. In the ICD-10-CM Alphabetic Index look for Weak, weakening, weakness/muscle leading to M62.81. Also, look for Stiffness, joint NEC leading to M25.60. Specific joints affected are not identified. Next, in the Alphabetic Index look for Falling, falls (repeated) R29.6. Verification in the Tabular List confirms code selection.
A pregnant female is Rh-negative and at 28 weeks gestation. The child's father is Rh-positive. The mother is given an injection of a high-titer Rho (D) immune globulin, 300 mcg, IM. What CPT® and ICD-10-CM codes are reported?
90384, 96372, O36.0130, Z3A.28Rationale : When a mother is Rh-negative and the father is Rh-positive, the fetus is generally Rh-positive, and fetal hemolytic anaemia may develop in the fetus. In the CPT® Index look for Immune Globulins/Rho (D) and you are directed to code range 90384-90386. A full dose is 300 mcg. Code 90384 is reported. According to the guidelines for Immune Globulins, an administration code is also reported. In the CPT® Index look for Immune Globulin Administration/Injection directing you to 96372. The administration code for intramuscular injection is 96372. In the ICD-10-CM Alphabetic Index look for Rh (factor)/incompatibility, immunization or sensitization/affecting management of pregnancy NEC/anti-D antibody which directs you to O36.01-. Tabular List shows seven characters are needed to complete the code. The 6th character 3 is used to indicate the patient is in her 3 rd trimester. The 7th character 0 is used to indicate this is a single gestation. Next look for Pregnancy/weeks of gestation/28 directing you to Z3A.28.
A 32-year-old ETOH dependent female is in a partial hospitalization program and has been seeing an addictive disease specialist (psychotherapist) in a chemical dependency program. Her employer is aware of her problem. She was referred to the group through their Employee Assistance Program. As long as she is in compliance they will support her efforts. Recently, she has arrived late at the meetings. The provider met with the patient and discussed the importance of her treatment, compliance with the program and avoidance of situations in which she may use alcohol. She denies contact with her previous associates and assures the provider she has had no alcohol intake since beginning the substance abuse treatment program. They will continue to reinforce her progress and successful sobriety. Time of the session was 45 minutes. What CPT® and ICD-10-CM codes are reported?
90834, F10.20Rationale : In the CPT® Index look for Psychotherapy/Individual Patient. Code selection is based on time. The duration of the counselling session was 45 minutes making 90834 the correct code. Evaluation and Management services were not performed. The diagnosis is ETOH dependence. ETOH is alcohol. The patient is alcohol dependent, although there is no indication of the frequency of her intoxication. Look in the ICD-10-CM Alphabetic Index for Dependence/alcohol directing you to F10.20. Report code F10.20 for the condition as there is no mention of intoxication or complications. Verification in the Tabular List confirms code selection.
A patient with carcinoma of the descending colon presents for chemotherapy administration at the infusion centre. The infusion was started with 1000 cc of normal saline. Heparin, 1000 units were added and then Fluorouracil, 800 mg was added and infused over 2 hours. Dexamethasone, 20 mg was administered IV push. At the end of the 2 hours, the IV was disconnected and the patient was discharged. What codes are reported?
96413, 96415, 96375, J9190 x 2, J1100 x 20, J1644, Z51.11, C18.6Rationale : In the CPT® Index look for Chemotherapy/Intravenous/Infusion. Chemotherapy infusion administration ran for two hours and is reported with 96413 for the 1st hour and 96415 for each additional hour. Dexamethasone was administered as a push technique. Dexamethasone is not a chemotherapy agent. In the CPT® Index, look for Injection/Intravenous Push referring you to 96374-96376. This is a sequential infusion following the initial service of chemotherapy and is reported with add-on code 96375. The chemotherapy drugs are Fluorouracil and Heparin. The Fluorouracil is reported with J9190 (HCPCS Level II). It is listed as 500 mg therefore 2 units are charged for 800 mg administered. Heparin (J1644) is listed as 1,000 units, therefore one unit is reported for the 1000 units given. Dexamethasone is packaged in 1 mg; charge 20 units for the 20 mg administered (J1100). Per ICD-10-CM guideline I.C.2.e.2, a visit for the purpose of chemotherapy is reported with Z51.11 with the primary and the malignancy sequenced second. In the ICD-10-CM Alphabetic Index, look for Chemotherapy(session) (for)/cancer which directs you to Z51.11. Report also the reason for the chemotherapy. In this case, it is carcinoma of the descending colon. Look in the Alphabetic Index for Carcinoma which states see also Neoplasm, by site, malignant. Go to the ICD-10-CM Table of Neoplasms and look for Neoplasm, neoplastic/intestine, intestinal/large/descending and select from the Malignant Primary column which refers you to C18.6. Verification in the Tabular List confirms code selection.
A 42-year-old patient presented to the urgent care centre with complaints of slight dizziness. He had received services at the clinic about 2 years ago. The patient-related this episode happened once previously and his 51-year-old brother has a pacemaker. A chest X-ray with 2 views and an EKG with rhythm strip was ordered (equipment owned by the urgent care centre). The provider detected no obvious abnormalities, but the patient was advised to see a cardiologist within the next two-three days. The provider interpreted and provided a report for the rhythm strip and chest X-ray. What CPT® and ICD-10-CM codes are reported for the provider employed by the urgent care centre who performed a level 3 office visit in addition to the ancillary services?
99213-25, 71046, 93040, R42Rationale : The patient is an established patient to an urgent care clinic. A code from 99211-99215 is reported. Level three is reported with 99213. Because an EKG was also performed, a modifier 25 is appended to the office visit. The X-ray & EKG equipment are owned by the clinic. In the CPT® Index look for X-ray/Chest referring you to 71045-71048. The chest X-ray, 2 views, is reported with 71046. The EKG and rhythm strip are read, interpreted and a report is written by the provider. Modifiers 26 and TC are not appended to the radiology codes because the urgent care centre owns the equipment and the radiologist is an employee of the urgent care centre. In the CPT® Index look for Electrocardiography/Rhythm/Tracing and Evaluation and you are referred to CPT® code 93040. With no confirmed diagnosis, refer to the initial signs and symptoms. The symptom is dizziness. In the ICD-10-CM Alphabetic Index look for Dizziness which refers you to R42. Verification in the Tabular List confirms code selection.
A 55-year-old patient had several episodes of faecal incontinence. A colonoscopy had been performed one year ago with normal results. Anorectal manometry was performed to determine the pressure on the sphincter muscles. The test indicated a mild relaxation of the sphincter. Biofeedback training was prescribed. What CPT® and ICD-10-CM codes are reported?
91122, K62.89, R15.9Rationale : In the CPT® Index look for Manometry/Anorectal and you are directed to 91122. Biofeedback training is not reported since it was prescribed but not performed. The diagnosis of relaxation of the anal sphincter is reported with K62.89. In the ICD-10-CM Alphabetic Index look for Relaxation/anus (sphincter). Verification in the Tabular List shows an instructional note to code also any faecal incontinence. In the Alphabetic Index look for Incontinence/faeces directing you to R15.9. Verify code selection in the Tabular List.
Mrs Salas had angina decubitus that lasted for 30 minutes and was admitted to the Coronary Care Unit with a diagnosis of r/o MI. The cardiologist (private practice based) takes her to the cardiac catheterization suite at the local hospital for a left heart catheterization. Injection procedures for selective coronary angiography and left ventriculography were performed and imaging supervision and interpretation for the selective coronary angiography and left ventriculography was provided. What CPT® code(s) is/are reported for the services?
93458-26Rationale : Left heart catheterization in the CPT® Index refers you to Cardiac Catheterization/Left Heart/with Ventriculography. Code 93452 is for the left heart catheterization for left ventriculography alone. Code 93458 includes coronary artery angiography, left heart catheterization and injection procedures for coronary angiography and left ventriculography with imaging supervision and interpretation. Modifier 26 is reported for the professional component of radiologic services.
A 5-year-old is brought in to see an allergist for generalized urticaria. The family just recently visited a family member that had a cat and dog. The mother wants to know if her son is allergic to cats and dogs. The child's skin was scratched with two different allergens. The provider waited 15 minutes to check the results. There was a flare-up reaction to the cat allergen, but there was no flare-up to the dog allergen. The provider included the test interpretation and report in the record.What CPT code(s) is/are reported for the services?
95004 x 2Rationale : In the CPT® Index look for Allergy Tests/Skin Tests/Allergen Extract. Code selection is based on the method of testing performed. Code 95004 describes the scratch test with allergenic extracts. The test is reported twice for the number of substances that were tested.
A 49-year-old patient had several episodes of oesophagal reflux and underwent a gastroesophageal reflux test to measure the pH balance (a measure of the degree of acidity or alkalinity). The test was performed with a mucosal attached capsule. The provider provided an interpretation and report. The provider stated the diagnosis as gastroesophageal reflux. What CPT® and ICD-10-CM codes are reported?
91035, K21.9Rationale : In the CPT® Index look for Acid Reflux Test/Esophagus. The provider measured the pH balance and used a mucous capsule, which attaches the electrode to the mucous in the oesophagus which is reported with code 91035. Catheter placement of the electrode is becoming rare with the development of the mucous attaching capsule. In the ICD-10-CM Alphabetic Index look for Reflux/gastroesophageal. The diagnosis code for gastroesophageal reflux without esophagitis is K21.9. Reflux is the regurgitation of gastric contents into the mouth, caused by incompetence of the lower oesophagal sphincter. Verification in the Tabular List confirms code selection.
A 54-year-old female with uncontrolled type 1 insulin-dependent diabetes and related peripheral vascular disease presents with deep diabetic ulceration on the bottom of her right foot. The wound reaches into the fascia and appears to be draining. She acknowledges going barefoot frequently and is not certain how or when the wound occurred. After the provider discusses the seriousness of her condition he debrides the wound, using a water jet and surgical scissors. Size of the wound is 70 sq. cm. He applied topical ointment and a sterile dressing. He counselled the patient about the need to wear shoes at all times and inspect her feet daily. He advised the patient to wear a water protective covering on her lower leg when taking a shower and to change the dressing daily, using ointment provided. A surgical shoe was provided. The patient is to return weekly until the wound heals and continue her insulin regime. If satisfactory progress does not occur, a graft may be considered. What codes are reported?
97597, 97598 x 3, L3260, E10.621, E10.51, L97.513Rationale : In the CPT® Index look for Wound/Care/Debridement/Selective which refers you to 97597, 97598. Code selection is based on the size of the area debrided. 70 sq. cm were debrided. Code 97597 is reported for the first 20 sq. cm and 97598 is reported 3 times to show the remaining area debrided (20 sq. cm, 20 sq. cm, 10 sq. cm). In the HCPCS Level II codebook look for Boot/Surgical, ambulatory referring you to L3260. The patient has type 1 diabetes and peripheral vascular disease with a diabetic foot ulcer. According to ICD-10-CM guidelines, there is a casual cause and effect relationship between diabetes and peripheral vascular disease. The ulcer is also a diabetic complication. In the ICD-10-CM Alphabetic Index look for Diabetes, diabetic (Mellitus) (sugar)/type 1/with/foot ulcer and you are directed to E10.621. In the Tabular List, there is an instructional note to code from L97.4- or L97.5- for the location and type of ulceration. The ulcer is on the bottom of the right foot. Look in the Alphabetic index for Ulcer, ulcerated, ulcerating, ulceration, ulcerative/lower limb/foot/right/with/muscle necrosis which directs you to L97.513. In the Alphabetic Index look for Diabetes, diabetic (Mellitus) (sugar)/type 1/with/peripheral angiopathy and you are directed to E10.51. ICD-10-CM guideline 1.C.4.a. states to assign as many diabetic codes as necessary to describe all complications. Verification in the Tabular List confirms code selection. Long term insulin usage (Z79.4) is not coded with type I diabetes.
A child with suspected sleep apnea was given an apnea monitoring device to use over the next month. The device was capable of recording and storing data relative to the heart and respiratory rate and pattern. The pediatric pulmonologist reviewed the data and reported to the child's primary paediatrician. What CPT® code(s) is/are reported for the monitor attachment, download of data, provider review, interpretation and report?
94774Rationale : In the CPT® Index look for Monitoring/Pediatric Apnea. Code selection is based on the components of the test performed. In this case, code 94774 describes the data storage capability, including the provider or other qualified health care professional interpretation and report. The code is to be reported each 30-day period.
A patient with cardiac arrhythmia has a pacemaker system with electrodes in the atrium and ventricle. The patient visits his cardiologist for evaluation of the battery, leads, capture and sensing function, heart rhythm and programmed parameters of the system which included connection, recording, and disconnection of the pacemaker. Analysis, review, and a report were performed by the physician and placed in the record. What CPT® code is reported?
93288Rationale : In the CPT® Index look for Pacemaker directing you to see Cardiac Assist Devices. In the CPT® Index look for Cardiac Assist Devices/Pacemaker System/Device and Evaluation. Code 93288 describes evaluation, analysis and report for single or dual-chamber or multiple lead pacemakers or leadless pacemaker systems. This patient has a dual chamber system with leads in both the atrium and ventricle. The procedure was performed in the office, not remotely.
A 49-year-old female was brought to the emergency department. She was lethargic but awake. She is four years of post-liver transplant. Neurology was consulted who determined the patient was encephalopathic with altered mental status. There was some question about whether she had a seizure. An EEG and WADA test were performed. What CPT® and ICD-10-CM codes are reported?
95958, G93.40, R41.82, Z94.4Rationale : In the CPT® Index look for WADA Activation Test which refers you to code 95958. You can also look for Electroencephalography (EEG)/Monitoring/with WADA Activation. The WADA activation test is coded as 95958 and includes EEG monitoring. For the diagnoses, look in the ICD-10-CM Alphabetic Index for Encephalopathy which refers you to G93.40. Next, look for Alteration (of), Altered/mental status directing you to R41.82. The patient is also status post liver transplant, which is found in the Alphabetic Index by looking for Transplant(ed) (status)/liver that refers you to Z94.4. Verification of the codes in the Tabular List confirms code selections.
A 5-week-old infant shows signs of fatigue after eating and has poor weight gain. He is suspected to have a congenital heart defect. The neonatologist ordered a transthoracic echocardiogram (TTE). TTE is showing a shunt between the right and left ventricles. The neonatologist read and interpreted the study and indicated the patient has a ventricular septal defect (VSD). What are the CPT® and ICD-10-CM codes for the TTE read?
93303-26, Q21.0Rationale : In the CPT® Index look for Echocardiography/Transthoracic/Congenital Cardiac Anomalies which directs you to 93303, 93304. Code selection is based on whether it is a complete study, follow up or limited study. This is a complete study therefore code 93303 the correct code choice. Since we are only reporting reading and interpretation of the report, a modifier 26 is appended. In ICD-10-CM Alphabetic Index look for Defect, defective/ventricular septal which directs you to Q21.0. Verification in the Tabular List confirms code selection.
A post-MI (myocardial infarction) patient has been receiving cardiac rehabilitation. At this session, the provider evaluates the patient, determines he shows satisfactory progress and may increase his normal daily activities. Continuous EKG is not used at this session. What CPT® code is reported?
93797Rationale : In the CPT® Index look for Rehabilitation/Cardiac. Code 93797 describes the provider services for cardiac rehabilitation when continuous EKG monitoring is not utilized at the encounter.
A patient who has psoriasis Vulgaris on his back has not responded to topical applications. He is treated with laser therapy on a total area of 260 sq cm.What CPT® and ICD-10-CM codes are reported?
96921, L40.0Rationale : In the CPT® Index look for Psoriasis/Treatment. Codes 96910-96913 are for photochemotherapy. Codes 96920-96922 are for laser treatment and code selection is based on the size of the area treated. 260 sq cm is reported with 96921. In the ICD-10-CM Alphabetic Index, look for Psoriasis/Vulgaris referring you to L40.0. Verification in the Tabular List confirms code selection.
A patient with hypertensive cardiovascular disease is admitted by his primary care provider. What is/are the correct ICD-10-CM code(s) for this encounter?
I11.9Rationale : In the ICD-10-CM Alphabetic Index look for Hypertension, hypertensive/cardiovascular/disease (arteriosclerotic) (sclerotic) directs you to see Hypertension, heart. Look for Hypertension/heart (disease) (conditions in I51.4-I51.9 due to hypertension) referring you to I11.9. ICD-10-CM guideline, I.C.9.a.1., states code I11- is used when a causal relationship is stated or implied. Tabular List confirms code I11.9 is correct as heart failure is not documented.
A patient has an open wound on his left lower leg caused by a cat bite. The animal tested negative for rabies, but the wound has failed to heal and became infected by Clostridium perfringens. The patient underwent hyperbaric oxygen therapy attended and supervised by the provider. What CPT® and ICD-10-CM codes are reported?
99183, S81.852A, B96.7, W55.01XARationale : In the CPT® Index look for Hyperbaric Oxygen Pressurization and you are directed to code 99183. The wound is complicated due to the infection. In the ICD-10-CM Alphabetic Index look for Bite(s) (animal) (human)/leg (lower) and you are directed to S81.85-. Tabular List shows seven characters are needed to complete the code. The 6th character 2 indicates the left leg. 7th character A indicates an initial encounter for receiving active treatment. The infectious agent is identified as Clostridium perfringens. Look for Infection/Clostridium/perfringens/as a cause of disease classified elsewhere directing you to code B96.7. The external cause is the cat bite. Look in the ICD-10-CM External Cause of Injuries Index for Bite, bitten by/cat which directs you to code W55.01-. Tabular List shows seven characters are needed to complete the code. A placeholder X is assigned to the 6th character and A is assigned for an initial encounter for the 7th character.
A therapist in a residential care facility works with a nonverbal autistic child, age 4. In this session, the therapist uses drawing paper and washable markers. The therapist sat with the child and began to draw on a sheet of paper. She gave paper and markers to the child and encouraged the child to draw. The psychotherapy session lasted 30 minutes.What CPT® and ICD-10-CM codes are reported?
90832, 90785, F84.0Rationale: Psychotherapy session with was performed lasting 30 minutes. In the CPT® Index look for Psychotherapy/Individual Patient. Review the codes, code 90832 is the correct code to report. Art therapy is frequently used when working with children who are unable to verbalize well or not at all. It may give insight into thought processes through the expressions captured in the artwork. Art therapy is considered an individual psychotherapy. In the CPT® Index lookup Psychotherapy/Interactive Complexity you are directed to code range 90785. Code selection is based on time and whether a medical evaluation and management were performed. Code 90785 is an add-on code and for this case is reported with 90832 per instructions at the beginning of this section. Time is not a factor with 90785. The child is currently autistic and does not communicate verbally. In the ICD-10-CM Alphabetic Index look for Autism, autistic (childhood) (infantile) which directs you to F84.0. Since an autism spectrum is not defined, the correct diagnosis code is F84.0. Verification in the Tabular List confirms code selection.
A patient with bilateral sensory hearing loss is fitted with a digital, binaural, behind the ear hearing aid. What HCPCS Level II and ICD-10-CM codes are reported?
V5261, Z46.1, H90.3Rationale : In the HCPCS Level II Index look for Hearing aid/Binaural/Digital/BTE referring you to V5261. The purpose of the visit is the fitting of the hearing aid. Look in the ICD-10-CM Alphabetic Index for Fitting (and adjustment) (of)/hearing aid directing you to Z46.1. The condition necessitating the hearing aid is bilateral sensory hearing loss. In the Alphabetic Index, look for Deafness/sensorineural/bilateral which directs you to H90.3. Verification in the Tabular List confirms code selection.
A patient with congestive heart failure and chronic respiratory failure with hypoxia is placed on home oxygen. The prescribed treatment is 2L nasal cannula oxygen at all times. A home care nurse visited the patient to assist with his oxygen management. What CPT® and ICD-10-CM codes are reported?
99503, I50.9, J96.11Rationale : In the CPT® Index look for Home Services/Respiratory Therapy which directs you to code 99503. In the ICD-10-CM Alphabetic Index look for Failure/heart/congestive and you are directed to I50.9. Then look for Failure, failed/respiration, respiratory/chronic/with/hypoxia which directs you to J96.11. Verification in the Tabular List confirms code selection.
A 50-year-old male is coming in for an eye examination for iritis. His last visit to the office was two years ago. The ophthalmologist performs a review of history, external ocular and adnexal examination, routine ophthalmoscopy and a biomicroscopy. Iritis is not found. The eye examination is completely normal. What CPT® and ICD-10-CM codes are reported?
92012, Z01.00Rationale : Codes 92002-92014 are for Ophthalmological Services and are reported by new vs. established patient and if the service is intermediate vs. comprehensive. The description of intermediate supports the services performed and 92012 is correct. This is an established patient, above code 92002 there is a parenthetical that tells you to refer to the E/M guidelines to distinguish between a new and established patient. The ophthalmoscopy code is included in codes 92002-92014. Above code 92201 there is information that tells you that routine ophthalmoscopy is included in the ophthalmologic services and not reported separately.In ICD-10-CM Alphabetic Index look for Examination/Eye directing you to Z01.00.
A young child received a mumps, measles, rubella and varicella (MMRV) injection at a neighbourhood clinic with provider counselling. What CPT® code(s) are reported?
90710, 90460, 90461 x 3Rationale : In the CPT® Index look for Vaccine and Toxoids/Measles, Mumps, Rubella and Varicella (MMRV) referring you to 90710. According to the CPT® guidelines for Vaccines and Toxoids, an administration code from 90460-90474 is also reported. In the CPT® Index look for Immunization Administration/Toxoid/with Counseling. Because counselling was included, a code from 90460-90461 is used for the administration. According to the guidelines, 90460 and 90461 are reported per component of the vaccine. Although it is one vaccination, there are four separate components, 90460 is reported for mumps and 90461 x 3 (measles, rubella, and varicella).