Additional Study Questions. 1. A patient was treated for third degree burns on the left ankle.

Transcription

1 Additional Study Questions 1. A patient was treated for third degree burns on the left ankle , [948.00] An E code E988.9 could also be reported but would not add much. 2. A patient presented for treatment of Type II diabetes with associated nephrosis , The note under directs the coder to the code for diabetic nephrosis. 3. A patient was treated for a skull fracture. The injury was caused when the snowmobile he was driving off-road hit a tree. There was no evidence of intracranial injury , E820.0 This must be coded as an other skull fracture because the specific location of the fracture on the skull was not specified. The fracture must be coded as closed if there is no indication that it was open (see the notes preceding code 800). E820.0 is used to report the cause of the injury. Some students have questioned whether E820.8 might be a better code because the vehicle was an off road motor vehicle and there is an argument that E820.0 is only intended to be used with a motor vehicle. However, E820.0 is still probably preferable to E820.8 because, in this case, the person injured was clearly the driver. It would not be appropriate to report E849.9 as an additional code because the place of occurrence is not specified. See Official Guidelines, Section I(C)(19)(b). Do not use E849.9 if the place of occurrence is not stated. 4. A patient presented for treatment of schizophrenia. The physician documented that the patient had schizophrenia, however, the physician did not specify the nature of the schizophrenia is used for the 4 th digit because the specific type of schizophrenia is not documented. 5. Dr. Tom, an internist, saw Jane in the office for headaches. Neither Dr. Tom nor any other physician in his practice had ever seen Jane before. Dr. Tom

2 documented a comprehensive history and a comprehensive examination. Medical decision making was of low complexity. The total face-to-face encounter time was 40 minutes, of which the exam took 30 minutes Level 3 New Patient Office Visit 6. Dr. Bob, a cardiologist, saw Joe in the office for chest pains. Joe was a new patient for Dr. Bob, although, another cardiologist in the practice treated Joe 3 months ago. Dr. Bob documented a comprehensive history and a comprehensive examination. Medical decision making was of low complexity. The total face-toface encounter time was 40 minutes, of which the exam took 30 minutes Level 5 Established Patient Office Visit 7. Dr. Lee saw Mary, a new patient, in the office for treatment of a sexually transmitted disease. Dr. Lee documented a detailed history and a detailed examination. Medical decision making was of low complexity. The total face-toface encounter time was 45 minutes, of which Dr. Lee spent 25 minutes counseling Mary on avoiding sexually transmitted diseases Level 4 New Patient Office Visit. In this case, reporting based on time allows a higher level to be reported than could otherwise be reported based on the key components. 8. Mrs. Jones became ill on Saturday morning. She called Dr. Smith (her primary care physician). Dr. Smith suggested that she report to the hospital Emergency Department and see one of the ED physicians. The ED physician took Mrs. Jones history, performed an examination and wrote her a prescription. Is this an outpatient visit ( ) or an ED visit ( )? ED visit ( ) When an ED physician sees a patient in an ED, the encounter is coded as an ED visit rather than a generic outpatient visit. 9. Mrs. Clark became ill on Saturday morning. She called Dr. Russell (her cardiologist). Dr. Russell suggested that she report to the hospital Emergency Department and see one of the ED physicians. The ED physician took Mrs. Clark s history and performed an examination. One hour later Dr. Russell traveled to the hospital to make rounds. He decided to check on Mrs. Clark who was still in the ED waiting for some test results. Dr. Russell took Mrs. Clark s history, performed an examination, reviewed the test results and admitted her as inpatient. Should Dr. Russell s services in the ED be coded as an outpatient visit ( ), an ED visit ( ) or as initial hospital care ( )?

3 Initial Hospital Care ( ) The rationale for this answer is the same as the rationale for the preceding answer. 10. Dr. Smith saw Mr. Mead in the office. Dr. Smith had last seen Mr. Mead 28 months ago. Dr. Smith took Mr. Mead s history, performed an examination and wrote a prescription. Should this encounter be coded as a new patient office visit ( ) or an established patient office visit ( )? Established Patient Office Visit ( ) This is a simple application of the three-year rule set forth in the E&M section guidelines. 11. Mrs. Jones saw Dr. Potter, an urologist, in his office for the first time. Mrs. Jones had seen Dr. Smith, another urologist with the same practice 28 months ago. Dr. Potter took Mrs. Jones history, performed an examination and wrote her a prescription. Should this encounter be coded as a new patient office visit ( ) or an established patient office visit ( )? Established Patient Office Visit ( ) As discussed in the E&M section guidelines, a patient is considered an established patient if the patient had an encounter with any other physician of the same specialty in the same practice within the preceding three-year period. 12. Dr. Ernst admitted Mr. Boyd at 10 a.m. to observation. At that time he examined Mr. Boyd and wrote orders for his care. Two hours later, Mr. Boyd s condition began to deteriorate and Dr. Ernst admitted him as an inpatient. Should the services provided by Dr. Ernst prior to Mr. Boyd s inpatient admission be coded as initial observation care ( ) or as a part of Mr. Boyd s initial hospital care ( )? Initial Hospital Care ( ) As discussed in the initial hospital care guidelines, when a patient is admitting to the hospital in the course of receiving observation care, the observation services are not separately reported. Rather, they are considered part of the admission and should be considered when selecting the level for the initial hospital care code. 13. Mrs. Smithers became ill and made an appointment to see Dr. Isley at the office. Dr. Isley took a history and performed an examination. Based on the

4 examination, he decided to admit Mrs. Smithers to observation status that same day. Should Dr. Isley s services in the office be coded as an office visit ( ) or as initial observation care ( )? Initial Observation Care ( ) As discussed in the initial observation care guidelines, when a patient is admitting to observation in the course of an outpatient encounter in a physician s office, the outpatient encounter is not separately reported. Rather, the services provided in the office setting are considered part of the observation care and should be considered when selecting the level for the initial observation care code. 14. Dr. Mable, an orthopedic surgeon, admitted Mr. Franks, who is 86 years old, into the hospital for a shattered hip. On the day of the admission, Dr. Mable performed a detailed history, and a detailed exam which lead Dr. Mable to conclude that surgery would be required. The management options and complexity of data to be reviewed are limited. The risk of complications was low. The doctor scheduled Mr. Franks for a total hip arthroplasty the following day. How should Dr. Mable report for his E & M services? The -57 modifier is necessary to inform the payer that the decision to perform surgery was made during this visit. Many payers will pay separately for an E & M encounter during the global period (which sometimes begins the day before the surgery) if the encounter resulted in the decision for surgery. 15. Dr. Bradley performed a cholecystectomy on Mr. Brown three weeks ago. Now Mr. Brown presents with a venous stasis ulcer on his right leg (still within the global period but unrelated to the prior surgical procedure). In the office, Dr. Bradley performed a problem focused history and a problem focused exam. His medical decision making was of low complexity. How should Dr. Bradley s services be reported? Even though the follow-up service was provided within the global period, most payers would pay separately for the follow-up visit because it was unrelated to the surgical procedure. The modifier is necessary to inform the payer that the service was unrelated to the surgical procedure. 16. A 24 year-old female, a new patient, was seen in a physician office for acute chest pain and atrial fibrillation. Although the patient s condition was not life threatening, the patient was immediately transported to the hospital for admission

5 to the CCU by the same physician. The patient s condition did not warrant critical care, but the physician conducted a comprehensive history, a comprehensive exam and medical decision making of high complexity. The total time spent by the physician on the date of admission was 70 minutes. How should the physician s services be reported? a , b , c d c All related E&M services provided on the same date as the admission are bundled into the inpatient admission code. 17. Bob was admitted to the hospital as an inpatient at 8:00 a.m. on Monday morning by Dr. Carter, an endocrinologist to control his uncontrolled diabetes mellitus. Upon admission to the hospital, Dr. Carter performs a comprehensive history, comprehensive exam, and medical decision making was of moderate complexity. Bob underwent treatment to manage his diabetes while in the hospital. Bob responded remarkably well to Dr. Carter s treatment and was discharged at 7:00 a.m. on Tuesday morning. Dr. Carter s discharge services lasted 30 minutes. How should Dr. Carter report these E & M services? a b c , d , d Bob was not admitted and discharged on the same date of service therefore the Observation or Inpatient Care Services (Including Admission and Discharge) would not be correct. Bob was admitted as an inpatient not into observation status so answer c would be incorrect. 18. An anesthesiologist administers anesthesia for a patient with mild diabetes prior to surgery involving an inner ear biopsy. How should the anesthesia services be reported? P2 19. A surgeon performs a vaginal hysterectomy on an otherwise healthy 71 year-old female patient. An anesthesiologist administers general anesthesia complicated

6 by utilization of controlled hypotension. How should the anesthesia services be reported? P1, 99100, During the above procedure, the anesthesiologist must administer blood. What code is used to report the blood administration? None bundled 21. A patient presents to a physician s office with a large hematoma on the right leg. The physician performs a puncture aspiration in order to drain blood from the hematoma. How should this service be reported? 10160, This was a puncture aspiration not an incision, therefore would not be appropriate. 22. A single callus was pared (cut) from a patient s hand. How should these services be reported? A patient has a 2.0 cm dermal lesion shaved from his neck. How should these services be reported? Code is only reported when the lesion is over 2.0 cm. 24. A physician excised a 2 cm excised diameter benign leg lesion and a 4 cm excised diameter benign back lesion (both excisions required simple closure). How should these services be reported? 11404, A burn victim presented to the emergency department (ED) for the treatment of several third degree burns. A surgeon was called in to consult on the case. The surgeon determined that the patient would have to undergo two stages of skin

7 grafting. The surgeon performed the initial skin graft (which has a global period of 90 days) in the ED that same day. The patient returned 30 days later and the same surgeon performed the second skin graft. What is the most appropriate modifier to use for reporting the physician s services in connection with the second skin graft? a. -77 b.-78 c. -57 d.-58 d Modifier -58 is used to report a staged or related surgical procedure by the same physician within the postoperative (i.e., global) period. 26. A surgeon performs an excision of a breast lesion utilizing a radiological marker that was placed preoperatively by a radiologist. How should the surgeon s services be reported? A physician performs a bilateral arthrotomy of the temporomandibular joints. How would these services be reported? Two co-surgeons perform a radical resection of a scapular tumor. How would the surgeons services be reported? Each surgeon would report A surgeon performs a McBride type of bunionectomy on the patient s right foot. How would these services be reported? [-RT] A T5 modifier would not be appropriate since the procedure is not solely performed on the phalange but rather a combination of the metatarsal (medial eminence) and the proximal phalange.

8 30. A physician performs an open reduction with internal fixation of a greater trochanteric fracture. The same physician also applied a uniplanar external fixation device to stabilize the fracture site. How should these services be reported? a b , c d , d Look up femur, fracture, trochanter in the CPT index. The open reduction includes the internal fixation however the external fixation device should be reported separately. To reference the external fixation code, look up external fixation, application in the CPT index. 31. A surgeon performs a diagnostic hip arthroscopy followed by a surgical hip arthroscopy with the removal of a foreign body. How would these services be reported? A diagnostic arthroscopy is included in a surgical arthroscopy. 32. Insertion of a nontunneled centrally inserted central VAD into a 35 year-old patient Repair of a peripherally inserted central VAD (with a port). The surgeon administered moderate sedation in a hospital setting. The intraservice time was 30 minutes. The patient was 55 years old Moderate sedation is inherently included in this procedure therefore assigning CPT code as an additional code would be incorrect. 34. Removal and reinsertion of a tunneled centrally inserted VAD with a port (through the same venous access).

9 A physician inserts a single temporary transvenous pacing catheter into the atrium and connects the catheter to an external pulse generator. How should these services be reported? Mr. Spencer, a 50 year-old male, had a centrally inserted non-tunneled central venous catheter (without a subcutaneous port or pump) placed six weeks ago. Mr. Spencer had the VAD placed for continued antibiotic administration for treatment of recurrent pneumonia (the pneumonia was not evaluated during this encounter). He now presents for a complete replacement of the old device (through the same access site). How should the physician s services be reported? a. V58.81, b. V58.81, 36589, c. 486, d. 486, 36589, a The reason for the encounter was for replacement of the VAD not the pneumonia, therefore the V58.81 should be first listed. Look up, Admission for, adjustment, vascular catheter. An additional code for the pneumonia could be reported if the pneumonia had been evaluated or required treatment during the encounter. The removal of a non-tunneled central venous access device is not separately reported. See not under CPT code CPT code includes the work for removing the old device and inserting the new device. 37. A physician upgrades a single chamber transvenous permanent pacemaker system to a new dual chamber model. How should these services be reported? 33214

10 38. An 80 year-old patient requires long term central venous access for hemodialysis. A tunneled centrally inserted central venous catheter with a subcutaneous pump was inserted. How should the procedure be reported? The patient s central venous access device had a subcutaneous pump not port therefore, CPT code would not be appropriate. 39. A physician performed a shaving of a patient s lip with mucosal advancement. How should these services be reported? Look up in the index- Lip, excision. 40. The physician performed balloon dilation of the esophagus for achalasia. The balloon is 40 mm in diameter. How should these services be reported? Achalasia means failure of a muscle to relax. 41. A patient presented with a thrombosed hemorrhoid. The physician incised an external thrombosed hemorrhoid. How should these services be reported? Code would not be appropriate because the physician incised (rather than excised) the hemorrhoid. 42. How would a laparoscopic recurrent inguinal hernia repair be coded? A physician performs a cystourethroscopy with fulguration and resection of a 6 cm bladder tumor. How should this service be reported? 52240

11 44. During the same operative session as the above procedure, the same physician performs a steroid injection into a urethral stricture. How should the entire operative session be reported? 52240, According to the AMA s Principles of CPT Coding, when multiple endoscopic procedures are performed at the same session by the same provider, it is appropriate to separately report [each] procedure (except when the scope procedures involve a biopsy of a lesion followed by excision of the same lesion). The -51 modifier is used because these are multiple procedures performed in the same anatomic area. 45. A physician performs a partial transurethral resection of the prostate as the first stage of a two-stage resection. How should this service be reported? should be used to report the first stage partial resection of prostate. Per 2009 instructional note, CPT code(s) has been deleted. 46. Two days later the physician completes the above resection. How should this service be reported? should be used to report the second stage partial resection of prostate. Per 2009 instructional note, CPT code has been deleted. 47. A physician performs a complete transurethral resection of the prostate including a complete vasectomy for BPH. The procedure was performed using an electrocautery knife. How should this service be reported?

12 a , b , 52601, , c , d , 52450, a BPH is an acronym for benign prostatic hypertrophy. The vasectomy is bundled with the TURP. Answer c would be incorrect as regrowth or residual prostate tissue and d would be incorrect because it was a complete resection rather than an incision of the prostate. 48. A physician performs an extensive destruction of twelve vaginal lesions. How should this service be reported? A physician performs routine antepartum care, delivers the baby vaginally and provides postpartum care. The patient had a previous cesarean delivery but expected a vaginal delivery with this baby. How should these services be reported? A physician uses a surgical drill to create a trephine hole in the skull and then biopsies a brain tumor through the hole. How should these services be reported? A physician performs surgery on a simple brain aneurysm with carotid circulation using an intracranial approach. How should these services be reported? 61700

13 52. Same as above except the physician uses an operating microscope for the procedure. How should this surgery (including the use of the operating microscope) be reported? 61700, Same as above except the same physician performs a craniotomy in preparation for the surgery. How should the craniotomy be reported? Bundled 54. A physician removes the contents of the eyeball leaving the shell intact. Four months later (outside the postoperative period), the same physician inserts an implant inside the muscle cone. What is the correct code for the insertion of the implant? A physician repairs a.2 cm laceration of the iris. How should these services be reported? The code would not be appropriate because there is no indication that the physician retrieved suture through a small incision. 56. A physician destroys a lesion on the conjunctiva. How should these services be reported? A physician performs a biopsy of the external auditory canal. How should these services be reported? 69105

14 58. A radiologist interpreted a complete four view x-ray of the mandible taken at the hospital. How should the radiologist s professional services be reported? A patient presented to an orthopaedic surgeon s office for evaluation and possible treatment of lower back pain. The patient previously had spine x-rays taken at the hospital. The patient brought the x-rays and the radiologist s report with him to the orthopaedic surgeon s office. The surgeon reviewed the films and concluded that spine surgery was indicated. How should the surgeon report her review of the x-rays? The review of the x-rays would not be separately reported. However, the review of the x-rays, including the radiologist s report, would be relevant to the amount or complexity of data reviewed which could potentially affect the complexity of medical decision making and the assignment of the E&M code for the office encounter. 60. A radiologist interpreted an MRI of the thoracic spine taken by the hospital. The study included both images taken without contrast and images taken with contrast (administered intravenously). How should the radiologist s professional services be reported? During the course of an established patient office visit involving a problem focused history and problem-focused examination for a 25 year-old male, the physician administers Hepatitis A vaccine and Lyme disease vaccine by intramuscular injection (there were two separate injections). How should these services be reported? 90471, 90472, 90632, 90665,

15 62. A physician sees a new patient in the office. The patient presents complaining of depression. The physician takes a problem focused history, performs a problem focused examination, performs medical decision making of low complexity and provide 25 minutes of face-to-face individual, interactive psychotherapy. How should these services be reported? A physician sees a patient in a psychiatric partial hospitalization setting. The physician provides 120 minutes of face-to-face individual, insight-oriented psychotherapy. How should these services be reported? According to AMA s Principles of CPT Coding, specific times are included in psychotherapy codes descriptors which indicate approximate face-to-face time spent with a patient. If the time spent, face-to-face, is less than or greater than the specific time indicated then the modifier -52 or -22 may be reported with a specific code from this series. 64. A physician provides intermediate level general ophthalmological services for an established patient. The services include gross visual field testing (e.g., confrontation testing) and tonography with water provocation. How should these services be reported? 92012, The gross visual field testing is bundled per the note following code The tonography is a special ophthalmological service and is therefore reported separately per the ophthalmology subsection guidelines. 65. A physician performs a transcatheter placement of three stents in the left main coronary artery. How should these services be reported? A single codes applies to multiple stents in the same vessel. 66. A physician performs a percutaneous transluminal coronary angioplasty and places one stent in the left main coronary artery. During the same session, the physician performs a PTCA without stent placement of the left circumflex artery. How should these services be reported? 92980, 92984

16 67. A physician places a probe for real-time transesophageal echocardiography. The physician then acquires an image with Doppler color flow velocity mapping and dictates an interpretation (including report) of the image. All services were provided in the hospital. How should the professional services be reported? , The echocardiography guidelines state when interpretation is performed separately use modifier A physician prepares two five-dose vials of allergy extract containing multiple antigens. The physician then gives the patient a single injection. The patient leaves the office with the vials so that the remaining injections may be administered by student health services at her college. How should these services be reported? 95165x10, A physical therapist places hot packs on both of a patient s knees and leaves the patient alone for 20 minutes. How should these services be reported? The code should only be reported once because the description states, one or more areas. 70. The physical therapist spent 10 minutes setting up equipment prior to the patient arriving. Once the patient arrived, the physical therapist administered electrical stimulation to both of a patient s knees for 20 minutes. The therapist remained in constant attendance the entire time. How should these services be reported? 97032, Per the AMA s CPT Assistant November 2001, these codes ( ) are reported once for each 15 minutes of service. If less than 15 minutes of service is provided, then the reduced services modifier -52 should be appended to the code to identify the reduction of service. 71. Ms. Johnson returned to her primary care physician, Dr. Mindy, for follow up (two weeks after the first visit) regarding an upper respiratory infection. Dr. Mindy performed an expanded problem focused history and an expanded problem focused exam. Her medical decision making was of straightforward complexity.

17 99213 Because this was an established patient encounter, only 2 of the 3 key components are required. 72. A physician interpreted x-rays of both hips including two views of each hip and an AP view of the pelvis. The films were taken by the physician s staff in his office using x-ray equipment owned by the practice. How should these radiology services be reported? a b c d d The -26 modifier should not be reported because, in this case, the physician provided both the technical and professional components.