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Study Guide

Medical Coding, Part 2


Contents
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

iii
Welcome to Medical Coding, Part 2. In Medical Coding, Part 1,
you learned the basics of coding and began to explore the
ICD-9-CM and CPT manuals. Medical Coding, Part 2 builds

I ns tructions
on the experience and skills you’ve already gained by guiding
you through the process of coding several important areas of
diagnosis and treatment.
As you proceed through the lesson assignments, you’ll
examine specialty areas such as internal medicine, cardiology,
and obstetrics/gynecology. You’ll also study the fascinating
fields of radiology, pathology, and laboratory work. Finally,
you’ll take an in-depth look at the mechanics of reimburse-
ment, auditing, and appeals.

truction s
You’ve already gained a good deal of familiarity with the
medical terminology and the highly specialized language of
medical 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 and
reporting a wide range of medical procedures and diagnostic
terms. Soon you’ll have the confidence you need to seek a
challenging and rewarding career in the health care industry.

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.

1
NOTES

2 Instructions to Students
Lesson 5: Cardiology
For: Read in the Read in

A s s ignments
study guide: the textbook:

Assignment 9 Pages 5–6 Pages 273–329

Lesson 6: OB/GYN
For: Read in the Read in
study guide: the textbook:

Assignment 10 Pages 7–9 Pages 331–383

Examination 38189800 Material in Lessons 4, 5, and 6

Lesson 7: Radiology, Pathology, Laboratory, and

ignment s
Internal Medicine
For: Read in the Read in
study guide: the textbook:

Assignment 11 Pages 17–19 Pages 385–407

Assignment 12 Pages 19–20 Pages 409–424

Lesson 8: Payment for Professional Health Care


Services, Auditing, and Appeals
For: Read in the Read in
study guide: the textbook:

Assignment 13 Pages 21–22 Pages 529–568

3
NOTES

4 Lesson Assignments
Cardiology
Cardiology focuses on diagnosing and treating disorders of

Lesson 5
the heart and the circulatory system. As you’ll learn in this
lesson, the cardiovascular system is quite complex, and its
various functions play a critical role in a patient’s overall
health. Cardiology therefore includes a broad range of diag-
nostic and procedural services, and coders are encouraged
to pay careful attention to the subtle distinctions between
various diagnoses and procedures. Because research teams
across the globe are constantly producing new tools for
diagnosing and treating cardiovascular disorders, it’s equally
important for coders to stay on top of all changes relating
to cardiology coding procedures.

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

To understand the various services and procedures associated


with cardiology, it’s important to know how the cardiovascular
system functions. The principal element of the cardiovascular
system is the heart, which pumps blood through every organ
of the body. Blood transfers oxygen and nutrients to organ
tissues and carries away waste products left behind by various
organ processes. Disruption or irregularity in the pumping
action of the heart can adversely affect the function of the
body’s other organs and may even result in organ failure.
The heart consists of four chambers. The right and left
ventricles 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. The
right and left atria store blood returning through the network
of veins and blood vessels to the heart. When the heart is
operating smoothly, the atria open at exactly the right moment
to empty their contents into the right and left ventricles.

5
To ensure that blood moves in the right direction through the
four chambers of the heart, four heart valves—the tricuspid,
pulmonic, mitral, and aortic valves—open and close at precise
intervals.
The heart muscle never stops working and therefore requires
a constant supply of oxygenated blood. This requirement is
supplied by three major coronary arteries attached to the
aorta: the right coronary artery (RCA) and two left arteries,
the left anterior descending artery (LAD) and the circumflex
artery. Blockage, or occlusion, in any of these coronary arteries
can seriously damage the heart muscle. Commonly referred
to as a heart attack, damage stemming from coronary artery
blockage 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. Another
common 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 of
the Surgery section of the CPT manual. The cardiovascular sub-
section is divided into two subheadings based on anatomical
site: Heart/Pericardium and Arteries/Veins. The codes in
each of these subheadings are organized by procedure. In the
ICD-9-CM manual, diagnostic codes are organized by condition,
while most procedures are grouped in the Operations on the
Cardiovascular System section of the Index of Procedures.

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

6 Medical Coding, Part 2


OB/GYN
Lesson 6 continues your study of specialty practice coding
with a detailed look at Obstetrics/Gynecology—a name often

Lesson 6
abbreviated as OB/GYN. As the name of this specialty sug-
gests, OB/GYN is a dual specialty, serving pregnant patients
as well as female patients who aren’t pregnant. Due to their
unique dual role, gynecologists may act as specialists, primary
care physicians, or both. This dual capacity—in addition to the
subtle distinctions among OB/GYN diagnoses and procedures—
poses unique challenges to those involved in coding OB/GYN
services.

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

Most OB/GYN codes for procedures performed on patients


who aren’t pregnant are located in the General Surgery
section of the CPT manual, under the Female Genital System
subsection. The codes in this subsection are categorized
according to anatomic site. Similar procedures—for example,
incision or destruction—are grouped together under common
headings. The Female Genital System subsection includes
codes for minor procedures typically performed in a physi-
cian’s office, as well as more intensive treatments performed
in a hospital setting.
Coding OB/GYN procedures requires close reading of both the
code descriptions and any accompanying notes. Otherwise,
you may insert incorrect or redundant codes, which may result
in rejection of a claim. For example, to report a total abdominal
hysterectomy performed with a bilateral oophorectomy—
removal of the ovaries—you need only enter the hysterectomy
code (CPT 58150), which includes the statement with or
without removal of ovaries in the description. Entering a sepa-
rate code for the oophorectomy is incorrect. The Female
Genital System subsection also includes a number of lesion
codes not listed in the Integumentary subsection.

7
Bear in mind, too, that many of the codes in the Female
Genital System subsection refer to the vulva, the external
portion of the female genital system. The vulva include
several different parts, including the mons pubis, the labia
majora, the labia minora, the vaginal orifice, and various
vestibular glands. Codes for procedures performed on this
part of the female genital system refer to all areas of the vulva.
The Maternity Care and Delivery subsection is organized
according to procedure rather than anatomic site. Procedures
and 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 codes


normally include the antepartum (prior to childbirth) care,
delivery, and postpartum (after childbirth) care. Antepartum
care 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

8 Medical Coding, Part 2


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

After you’ve finished Lesson 6, take the time to review all


the study assignments. Then, take the examination for
Lessons 4, 5, and 6.

Lesson 6 9
NOTES

10 Medical Coding, Part 2


Lessons 4, 5, and 6
Medical Coding 1

Examinat io n
Exam 2

EXAMINATION NUMBER:

38189800
Whichever 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

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 the


repair of one superficial 1-cm laceration, one superficial 3-cm
laceration, and one superficial 2-cm laceration, all to the cheek?
A. 12001 × 3 C. 12002
B. 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.

11
4. What is the ICD-9-CM procedural code for spinal nerve decompression by destruction
of intervertebral disc via enzyme injection?
A. 77.7 C. 80.52
B. 78.02 D. 81.1

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


A. Degree of burn C. Presence of infection
B. Anatomical site D. Type of burn

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


the vertebrae?
A. 809 C. 807
B. 808 D. 806

7. Which of the following ICD-9-CM procedural codes is used to report the closed reduction
and internal fixation of a fracture dislocation of the surgical neck of the humerus?
A. 81.52 C. 79.27
B. 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 endocrinology
B. Gynecologic endoscopy
C. Gynecologic oncology
D. Perinatology

10. The CPT code for percutaneous transluminal pulmonary artery balloon angioplasty for a
single 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 Examination, Lessons 4, 5, and 6


12. Identify the appropriate four-digit ICD-9-CM code for primary pulmonary hypertension.
A. 443.89 C. 416.0
B. 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. V45.83
B. V45.82 D. V45.84

15. What is the ICD-9-CM code for tubal ectopic pregnancy without intrauterine pregnancy?
A. 633.10 C. 613.1
B. 623.1 D. 603.1

16. Procedures performed within the cardiology subspecialty of internal medicine are typically
either _______ or intravascular.
A. percutaneous C. epidermal
B. subcutaneous D. surgical

17. Which of the following CPT codes is used to report Doppler echocardiography color-flow
velocity mapping in addition to the code for echocardiography?
A. 93307 C. 93327
B. 93305 D. 93325

18. Identify the appropriate four-digit ICD-9-CM code for congestive heart failure, unspecified.
A. 402.8 C. 482.9
B. 408.2 D. 428.0

19. In which of the following procedures might a catheter be placed in the heart preoperatively
to monitor hemodynamic status?
A. Right-heart catheterization
B. Pericardiocentesis
C. Transesophageal echocardiography
D. 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 majora
B. Fallopian tubes D. Labia minora

Examination, Lessons 4, 5, and 6 13


21. In which section of the CPT manual would you look for the appropriate code to describe
cardiac magnetic resonance imaging?
A. Radiology C. Evaluation and Management
B. General Surgery D. Medicine

22. Which of the following CPT codes would be used for intracervical artificial insemination?
A. 58321 C. 58974
B. 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 retrograde
left-heart catheterization.
A. 93526 C. 93526-51
B. 93526-27 D. 92526-RLT

25. Which of the following codes is used to report emergency OB/GYN office services?
A. 99000 C. 99025
B. 99024 D. 99058

26. An echocardiography performed with an endoscopic probe introduced either nasally or


by 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. toxemia
B. encephalitis D. sepsis

28. During an initial cardiology visit, the patient has no previous cardiac history but has a
blood 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 birth
after previous Cesarean delivery?
A. 59610–59614 C. 59400–59410
B. 59050–59051 D. 59040–59041

14 Examination, Lessons 4, 5, and 6


30. Which of the following terms is used to describe a history of three viable offspring?
A. Nullipara C. Tripara
B. Primapara D. Primagravida

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


A. 49000 C. 78040
B. 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 same
time as a Cesarean section.
A. 59840 C. 58611
B. 59841 D. 58610

34. Which of the following procedures is commonly performed to determine the cause of
dysfunctional uterine bleeding?
A. Cervical capping C. Cervical C/S
B. Oviduct transection D. Endometrial biopsy

35. Which of the following ICD-9-CM code groups is used to report the infant status after
delivery of a birth event?
A. V26.0–V26.9 C. V28.0–V28.9
B. V27.0–V27.9 D. V29.0–V29.9

Examination, Lessons 4, 5, and 6 15


NOTES

16 Examination, Lessons 4, 5, and 6


Radiology, Pathology,
Laboratory, and Internal
Medicine

Lesson 7
Lesson 7 examines several interesting specialty areas related
to the detection, prevention, and treatment of disease.
Radiation, the first of these specialties, chiefly involves the
use of radioactive particles to produce diagnostic images of
bones, organs, and tissues. X-ray and MRI scans are among
the most well-known procedures in this category. Radiation
is also involved in many types of cancer treatment.
Laboratory and pathology services are equally critical to
diagnosis and treatment, and are commonly involved in
routine evaluation and primary care. Blood, urine, and other
samples are typically collected in the office of a primary care
physician or specialist and sent to a laboratory for rigorous
testing. In more serious cases, tissue samples may be extracted
from a patient and sent to a laboratory for examination.
In addition to the specialties covered here, we’ll also cover
internal medicine, which includes subspecialties such as
cardiology.

ASSIGNMENT 11
Read through the material for this assignment in your study
guide. After you’ve read the study guide material, read pages
385–407 of Understanding Medical Coding.

The term radiology originally referred to using X-rays as a


means of producing radiographic images of bones, organs,
and tissues. In recent decades, however, a number of other—
and in many cases, more sophisticated—techniques have
emerged, which enable physicians and surgeons to examine
various features of a patient’s anatomy without resorting to
invasive procedures. These newer techniques include
■ Fluoroscopy, a method of projecting live images of internal
anatomy onto a television screen

17
■ Computed axial tomography (CAT scan), a procedure
that 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 seven


subsections. The first subsection, Diagnostic Radiology, is
subdivided into procedures related to anatomical sites.
Different codes may be used according to whether contrast
material—chemical substances such as barium and iohexol—
are administered to facilitate viewing of soft tissue or organs.
The second subsection, Diagnostic Ultrasound, is similarly
organized by anatomical site. In addition, CPT specifies four
different 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 the
Bone and Joint Studies subsection.

18 Medical Coding, Part 2


The sixth subsection, Radiation Oncology, includes codes
for both professional services—which are provided by a
physician, and typically include determination of a course of
treatment—and technical procedures, which involve the actual
administration of treatment by a radiation technician. When
coding professional services, it’s important to remember that
initial consultations with a patient are usually described
with E/M codes.
The final subsection, Nuclear Medicine, is divided into two sub-
headings: Diagnostic and Therapeutic. Diagnostic procedures
involve the administration of radionuclides to monitor various
body systems. Accordingly, codes in this subheading are cate-
gorized by anatomical site. The Therapeutic procedures
subheading is rather small, and therefore isn’t subdivided at
all. Most of the services listed involve radiopharmaceutical
treatment of thyroid conditions.
Pathology and laboratory services are listed together in a
dedicated section following the Radiology section. Codes
are arranged in subsections according to procedure. When
determining codes for procedures in this section, it’s important
to distinguish between services performed by a physician or
in a physician’s office, and those performed in a laboratory
to which samples have been sent. In many cases, samples are
collected in a physician’s office and sent to an outside lab for
analysis. Some offices and clinics, however, are equipped
with the tools to perform analysis internally.

ASSIGNMENT 12
Read through the material for this assignment in your study
guide. After you’ve read the study guide material, read pages
409–424 of Understanding Medical Coding.

Although some people believe that family practice or general


practice physicians are synonymous with internal medicine
practitioners, this isn’t true. Internal medicine physicians
specialize in treating diseases of adults. From the onset of
adulthood to the end of life, internal medicine physicians are
trained in all diseases that can occur. Because so many dis-
eases and medical conditions affect adults, there are more

Lesson 7 19
subspecialties in internal medicine than in any other spe-
cialty. There’s even a subspecialty of adolescent medicine
that bridges the gap between pediatric and regular internal
medicine care. Here’s the full listing of subspecialties that
fall 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 family
practice. 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 types
of problems are referred to specialists.
After you’ve finished Lesson 7, review the study assignments,
then proceed to Lesson 8.

20 Medical Coding, Part 2


Payment for Professional
Health Care Services,
Auditing, and Appeals

Lesson 8
As you’ve progressed through each lesson in your program,
you’ve learned a great deal about diagnostic and procedural
codes, and you’ve gained valuable insights into anatomy,
physiology, and medical terminology. Lesson 8 provides the
link that connects all the various aspects of coding you’ve
learned so far. In this lesson, you’ll discover why providing
accurate and consistent codes is vitally important in terms of
obtaining reimbursement for services provided in an office,
clinic, or hospital setting. You’ll also examine the potential
risks of inaccurate coding, as well as the steps you can take
when third-party agencies deny reimbursement of medical
claims. After completing Lesson 8, you’ll have thorough under-
standing of the major issues involved in medical coding.

ASSIGNMENT 13
Read through the material for this assignment in your study
guide. After you’ve read the study guide material, read pages
529–568 of Understanding Medical Coding.

As you’ve probably grasped during preceding lessons, the


health care industry in the United States is multifaceted and
continually evolving. Analytical and procedural technologies
are constantly being updated, modified, or replaced. Today’s
tools enable modern health care providers to detect and treat
conditions with greater skill, speed, and sophistication than
ever before.
The benefits of a highly evolved medical system pose a number
of challenges, however—especially in the area of billing,
reporting, and reimbursement. Managing these critical areas
requires 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.

21
As a general guideline for maintaining accurate and compre-
hensive medical records—upon which timely reimbursement
depends—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 recorded
when 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 diagnoses


provided to a patient)

■ Why (the medical necessity for the service provided)

Ensuring that these five critical elements are accurately


reported and consistent with a patient’s medical record and
with current coding regulations will provide immeasurable
assistance in processing claims quickly and efficiently.
After you’ve finished Lesson 8, take time to review all the
study assignments from Lessons 5, 6, 7, and 8. Your exam
timetable will depend on the program in which you’re enrolled.

22 Medical Coding, Part 2


TEXTBOOK EXERCISE ANSWERS

Chapter 9

An s we r s
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-risk
medication, not elsewhere classified
909.5 Late effect of medicine isn’t reported, as this test
doesn’t reflect a condition. Although the patient was
medicated 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 heart
failure (Note: The physician documentation should
actually state whether diagnosed as benign or malig-
nant, rather than the coder selecting based on the B/P
documentation.)
428.0 Congestive heart failure, unspecified

Exercise 9-3
1. transesophageal echocardiogram; transthoracic
echocardiogram
2. 24
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

23
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 studies
done during the same session to evaluate cardiac and
valvular 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 code
range. 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 Cardiology
medicine section of the CPT, pay careful attention to the
instructional notes found in parentheses. Because the
diagnostic study report includes color-flow mapping, we
must also add this code to accurately report the studies
performed. You’ll also note that with the description of this
code, the coder is instructed to make sure the other correct
codes are also reported.
Some offices may perform this study in specialized suites.
In that case, no modifier is required. If performed in an
ancillary setting, however, the -26 professional component
modifier should be appended to each of the three codes.
Echocardiography, transthoracic, real-time with image
documentation (2D), includes M-mode recording when
performed, complete, without spectral or color Doppler
echocardiography: 93307
Doppler echocardiography, pulsed-wave and/or
continuous-wave with spectral display: 93320
Doppler echocardiography color-flow velocity mapping:
93325

24 Answers
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 times
within the body of the operative report. Therefore, this
diagnosis should be included on the CMS-1500 claim
form. You’ll also note that there are two obstructions
described (in two separate vessels) without mention of
an acute myocardial infarction found. For this reason,
you should choose a code for this occasion that reports
occlusion or obstruction of a native coronary artery:
Precordial chest pain: 786.51
Obstruction of a native coronary artery: 414.01
In searching for CPT codes, you should remember that
you’re reporting for two separate lesions, in two separate
vessels 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 describes
the major procedure performed in this session.
Next, look under “Angioplasty” in the index. Under the
subterm “Coronary Artery,” you’ll see Percutaneous,
Transluminal, and code range 92982–92984. This will
allow you to report the second lesion found within the
diagonal branch of the LCA treated by the cardiologist
during this invasive session.

Answers 25
Because of the unusual circumstances of this operative
session, and to preclude confusion on the part of the
third-party payer, you should add modifier -59 to the
balloon angioplasty procedure. This will indicate that
the second intervention was unique and distinct from the
initial atherectomy. This modifier will signal the insurer
that special circumstances apply and that the operative
report should be consulted for particular details relevant
to the second intervention.
Percutaneous transluminal coronary atherectomy, by
mechanical or other method, with or without balloon
angioplasty, single vessel: 92995
Percutaneous transluminal coronary balloon angioplasty,
single vessel: 92982-59
2. This patient has a multitude of serious cardiovascular
problems. Therefore, you should try to choose the most
serious to clearly define the medical necessity for all
ensuing 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 416.0
Coronary occlusion without infarction 411.81
Bilateral renal artery stenosis 440.1
Peripheral vascular disease 443.89
Many procedures were done during the catheterization
session; therefore, several codes will be required for
accurate billing and reporting.
You’ll note within the cath report that both a right- and
left-heart catheterization were performed. If you consult
CPT’s index, locate the terms “Catheterization, Cardiac.”
Next, find “Combined Left and Right Heart.” This directs
you to the code range 93526–93529. When you go to the
tabular section, you’ll see easily that 93526 is the correct
code. Don’t forget to append a -26 modifier according to
CPT and ACC guidelines.

26 Answers
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 many
options 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. Because
you’re reporting cardiovascular medicine procedures, choose
93544 from the options listed. For the reporting of selective
coronary angiography, choose 93545. For angiography of
the heart vessels, find the terms “Angiography” and “Heart
Vessels.” 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 of
these codes need a -51 modifier appended.
The complex catheterization performed should be coded
as 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 selective
coronary angiography including venous bypass grafts
and arterial conduits (whether native or used in
bypass): 93556

Answers 27
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’t
allow billing an angioplasty or angiography on the same
claim as a stent. The methods used to deploy the stent,
though similar to the above procedures, are inherent in
CPT 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 a
history of ventricular fibrillation. These diagnoses should
be coded as follows:
Ventricular fibrillation 427.41
Ischemia (unspecified) 414.9
Knowing by the title of the procedure that this is an elec-
trophysiologic test, you should revert back to the code
range 93600–93660 in the Electrophysiology Procedure
portion of the CPT index.
Commonly, EP physicians won’t do only a comprehensive
electrophysiologic study, but will also perform a pro-
grammed stimulation and pacing test after IV drug
infusion to evaluate the accuracy of the comprehensive

28 Answers
study findings. In such cases, two CPT codes will be
required for accurate reporting and billing. When choos-
ing the correct code, you should pay close attention to
the 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 an
arrhythmia is induced. Additionally, you should find
out whether this is an initial or follow-up study prior to
proceeding in the code selections.
Because this procedure is routinely performed in an
ambulatory facility, the -26 professional component
modifier would be appended to both codes used. The
complete EP study has the highest relative value as it
represents 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 right
atrial pacing and recording, right ventricular pacing and
recording, His bundle recording, including insertion and
repositioning of multiple electrode catheters, with induc-
tion or attempted induction of arrhythmia: 93620-26
Programmed stimulation and pacing after intravenous
drug infusion: 93623-26
6. The only diagnosis stated in the clinical indications for
this procedure is syncope.
The diagnosis is located in the ICD-9-CM index as
stated in the operative report. The correct code for this
diagnosis is
Syncope 780.2
In determining how to find a tilt-table evaluation in the
CPT book, you should first be advised that the tilt-table
evaluations are most frequently performed by electro-
physiologists in large cardiology practices. (In smaller
practices, other cardiologists may also order this test.)
Additionally, it’s usually performed in an ambulatory
setting, thus requiring that the physician’s professional
component modifier -26 be appended to the code. In
CPT’s index, therefore, you’ll find under “Electrophysiology
Procedure” the code range 93600–93660.

Answers 29
If you carefully read the code descriptions within the
stated range, you’ll locate the correct definition of the
procedure performed.
Evaluation of cardiovascular function with tilt-table
evaluation, with continuous ECG monitoring and inter-
mittent blood pressure monitoring, with or without
pharmacological intervention: 93660-26
7. The clinical indications for this procedure show that the
patient has an LV (left ventricular) aneurysm as well as
easily inducible and sustained ventricular tachycardia.
These diagnoses would be coded as follows:
Sustained ventricular tachycardia 427.1
LV aneurysm 414.10
In looking at the procedure(s) performed, you should
carefully 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, pulse
generators (batteries), and/or electrodes (leads). Some of
the available codes deal with removals and/or revisions.
The code best describing what the cardiologist in this
report has performed is for the insertion or repositioning
of 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 or
AICD, is implanted in a patient, there’s always the
chance that a complication will occur. In recalling the
ICD-9-CM chapter, you’ll remember that complications
may be surgical, medical, or mechanical. In this case, a
mechanical complication has occurred with an implanted
cardiac device that’s still in place. The end result of this
complication is, of course, the patient’s unspecified
arrhythmia. Therefore, this scenario is coded as follows:
Mechanical complication due to cardiac pacemaker
electrode 996.01
Status-post cardiac pacemaker, in situ V45.01
Cardiac dysrhythmia, unspecified 427.9

30 Answers
Two separate procedures were performed in this scenario.
If you consult the CPT index under “Pacemaker, Heart,”
you’ll locate (under “Insertion, Electrode”) codes
33210–33211, 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 Federal
Register, you’ll note that 33222, revision of the pocket,
carries a higher relative value than that of 33217 for
replacement of electrodes. Even though codes 33216
and 33217 say “insertion,” these codes can be used for
insertion (placement) or replacement of leads. Since this
procedure is subsequent in the major revision procedure,
it should be listed second with a -51 modifier appended to
the code:
Revision or relocation of skin pocket for pacemaker: 33222
Insertion of a transvenous electrode(s); dual chamber (two
electrodes) permanent pacemaker or dual chamber pacing
cardio-defibrillator: 33217-51

Chapter 10

Exercise 10-1
1. 76805 (consideration of modifier -52 due to the poorly
documented maternal anatomy)
V28.4 Screening for fetal growth retardation using
ultrasonics
No other symptoms or abnormal findings
2. Code(s) from 651–659 would be primary, describing
the delivery and probably complications. V27.3 is the
second code.
3. 59425 V22.____ to select whether normal first or other
pregnancy. If symptoms are present or there are risk
factors, select V23.____.

Answers 31
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 641.23
Not able to select CPT for procedure as it
isn’t documented.
2. 76805
76810 × 2
V28.81
3. 59151
633.10 or 633.11
V23.9

Exercise 10-4
1. 59015
V28.____
2. 652.20
3. 59000
76946
V28.0
4. 59821
632
5. 74.1 (principal)
88.78
641.13 (principal)
646.63
V72.69 (optional for urinalysis)
6. 644.03 (principal)
913.0
99.29 (optional for Brethine administration)
75.34 (optional for fetal monitoring)

32 Answers
Exercise 10-5
1. 99395
V72.31
2. 99242
36415
626.8
3. No code as patient has called for an appointment and
hasn’t yet been seen by the physician.

Exercise 10-6
Diagnostic laparoscopy 49320 code isn’t selected, as
progressed to surgical.
Exam under anesthesia isn’t coded.
58661 RT Ovary removed
44180 (Select -51 or -59 depending on the insurance
plan rules.) Lysis of adhesions is usually bundled within
the same scope/site.
58662-LT (Select -51 or -59 depending upon the insur-
ance plan rules. The LT may be enough of a modifier to
describe separate site.) Left ovarian fulguration of cyst.
It’s very important to review the insurance plan rules
prior to submitting the claim.

Exercise 10-7
ICD-9-CM: Right Bartholin cyst: 616.2
Left labial cyst: 624.8
CPT: Marsupialization Bartholin right cyst: 56440-RT
I&D left labial cyst: 56405-LT-59

Exercise 10-8
ICD-9-CM: 621.0
CPT: 58558, 57720-59

Answers 33
Exercise 10-9
1. 58671
V25.2
2. 57454
622.10
3. 58100
627.1
4. 57065
078.0

Exercise 10-10
1. 58323
V26.21
2. 622.5 (not able to code visit/procedure as no information
is documented)
3. 57265
618.6
618.04
4. 58340
628.2
5. 58150-80 (no ICD-9-CM code as reason or diagnosis
not given)

Exercise 10-11
1. 617.3
2. 099.53
616.11
3. 610.1
4. 625.2
5. 233.1
6. 58400
57240-51
618.4

34 Answers
7. 56420
616.3
646.63
8. 58950
183.0
9. 99205
81001
81025
36415
99000
96372
599.0 (597.80—urethritis covered in UTI code)
623.5
625.9
V72.41 for pregnancy test
10. 99205-57
58563 (primary procedure)
76856
84702
621.0 (primary diagnosis)
625.0
V72.41 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

Answers 35
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: 574.50
CPT: Intraoperative cholangiogram: 74300
7. ICD-9-CM: Rt. subcutaneous emphysema: 958.7
Recurrent rt. pneumothorax: 512.8
CPT: Chest X-ray, PA view: 71010
8. ICD-9-CM: Intertrochanteric fracture of rt. hip: 820.21
Nondisplaced fracture rt. femoral neck: 820.8
CPT: X-ray of rt. hip (code depends on how many views
of the hip are taken). Right hip indicates a unilateral
procedure. Code for one view is 73500; complete with
minimum of two views is 73510.
X-ray of pelvis. Again, code depends on how many views
are taken. Anteroposterior view is 72170; minimum of
three views is 72190.
9. ICD-9-CM: Trauma, right foot: 959.7
X-ray shows nondisplaced fracture of the shaft of the
2nd proximal phalanx: 826.0
CPT: X-ray, rt. foot: 73620 (two views)

36 Answers
10. ICD-9-CM: Rheumatoid arthritis: 714.0
CPT: X-rays of hands, AP and lateral: 73120-RT,
73120-LT
11. ICD-9-CM: Arthritis/capsulitis lt. shoulder: 726.0
X-ray shows erosive arthropathy of the left humeral
head with degenerative osteoarthritis: 715.91 and
calcific subacromial bursitis: 726.19
CPT: 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 these
codes is the kind of calcium—ionized or total—which
isn’t specified here.)
14. 85610
15. 86592

Answers 37
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, encounter
form, superbill or charge ticket, collection of payment at
the time of service, charge entry, claim submission, insur-
ance plan receives the claim, insurance plan policies and
edits are applied, payment of the claim, follow-up,
accurate payment, appeal, resubmit the claim
3. Accurate patient demographics, verification of eligibility
and benefits, follow-up, accurate payment review, appeal
the 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 insurance
plans for electronic claims.

Exercise 15-3
1. Downcoding, upcoding, unbundling, frequency, pro-
fessional courtesies
2. Absolutely not. Accuracy is required per law. The code
selection should be a “mirrored image” to the service
that’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 services
that were performed.

38 Answers
Exercise 15-4
1. Transaction and data sets, security rules, and privacy
rules
2. If the patient signed the initial notice, the practice may
release health information for care purposes. Only the
minimum necessary information should be shared.
State laws should be considered and use extra care for
mental health data.
3. The Office of Civil Rights

Answers 39