ANSWERS SET2

1. C There is no documentation that supports the patient had a previous cesarean, eliminating multiple
choice answer A. There is no documentation that supports patient having antepartum care or will be
having postpartum care with the obstetrician delivering the baby, eliminating multiple choice answers B
and D.

2. C Patient is having a repair for a rectocele, not a cystocele, eliminating multiple choice answers B and
D. The repair of rectocele was performed by a “posterior” colporrhaphy approach, eliminating multiple
choice answer A.
3. B. According to CPT® guidelines, when twins are delivered, the global code (prenatal, delivery and
post partum) is only reported once. When one twin is delivered via c-section select 59510 for the global
procedure and the vaginal delivery only (54909) for the second twin. Modifier 51 is appended to indicate
multiple procedures are performed. To code for the twin delivery in the ICD-9-CM manual, look up
Delivery/twins, you are referred to 651.0X, the fifth digit being 1 indicating a delivery. The second
diagnosis is coded due to the second twin being in a transverse lie, the reason for the cesarean. This is
indexed under Delivery/ complicated / transverse/presentation or lie, referring to 652.3X, the fifth digit
being a 1.

4.B. The removal of cyst from the ovary is coded 58925. The RT modifier is appended to indicate to the
payer the ovarian cystectomy was performed on the right side. The removal of the salpingo-
oophorectomy is coded 58720. Modifiers 51 and LT are appended to this procedure code since the
removal of the ovary and fallopian tube was done on the left side and it was an additional procedure
performed during the surgery.

5. A. Since this a 35-year-old patient getting a circumcision, that eliminates code 54160, which is for a
neonate (28 days of age or less). The patient is having the circumcision performed using a clamp with
regional block. Modifier 52 is not appended to 54150 since there is no indication in the encounter of the
physician reducing the services provided. The procedure is performed as it is described by the CPT®
code.

6. C. 55700 is the correct code since only needle biopsies were performed, without mapping the
prostate under a template guide through a transperineal route. There are parenthetical notes under
code 55700, which one states: (If imaging guidance is performed, use 76942). Since ultrasonic guidance
(imaging guidance) was used, you would need to code 76942. Appending modifier 26 indicates the
professional component; the procedure was done in an outpatient surgical center where the physician
does not own equipment.
7. B. One way to get to the correct answer is to code for the diagnosis first. The procedure is being
performed due to the patient having vaginal lesions. In the ICD-9-CM index, look up Lesion(s)/vagina.
You eliminate multiple choice answers C and D. 57065 is the correct code since the scenario states that
the laser surgery was used to destroy “extensive” number of vaginal lesions.

8. B. The physician performs a cervical cerclage. We know the patient is pregnant so 57700 is an
incorrect code. We know the approach for this procedure is vaginally because the scenario states that a
speculum is used to access the vagina to view the cervix. From the index look up cerclage/vaginal. You
are referred to 59320. The patient is diagnosed with an incompetent cervix. In the ICD-9-CM index, look
up incompetent/cervix/in pregnancy. The patient is pregnant so the fifth digit is “3”.
9. C. 52000 is a separate procedure, which indicates that only a cystourethroscopy is performed for
diagnostic (examination) purposes only with no other procedure being performed at this time. For this
scenario a surgical procedure was performed with the cystourethroscopy, eliminating multiple choice
answers A and B. 52204 is not coded because biopsies were not taken from the bladder, leaving multiple
choice answer C as the correct choice since a 7 cm bladder tumor was removed with fulguration.
10. D. The hint to narrow down your choices is a D&C (dilation and curettage) for a blighted ovum. This
eliminates multiple choice answers A (there is no indication this was a hydatidiform molar pregnancy)
and B (there is no indication that this is a missed abortion). 58120 is not the correct D&C, since this is an
obstetrical (pregnancy) reason for the procedure. Blight ovum is indexed in the ICD-9-CM under
Mole/pregnancy.

11. A. This patient is having a stent removed, eliminating multiple choice answers B and D, which should
be used for insertion of a stent. You would not code 52000 since this is a separate procedure, which
means that this code is only billed for diagnostic or examination purposes only, with no other
procedures being performed at that time. A surgical procedure (removal of the stent) was done at the
same time of the cystoscopy. Code 74420 is coded for the use of a retrograde ureterogram (urography).
Modifier 26 is appended to report the professional component was performed.

12. D. You can narrow down your choices by first coding the diagnosis. The patient had testicular cancer;
in the ICD-9-CM index go to the Neoplasm Table testis,testes/malignant/primary column where you are
referred to code 186.9. This eliminates codes A, B, and C. 54690 is the correct procedure code since a
laparoscopy was performed to remove the left testicle (orchiectomy).
13. c. One way to find this answer in the index of the CPT® Professional Edition is under the main term
“Prostate,” then “Biopsy.” Notice that code 55700 indicates single or multiple, which means the code
should be reported only one time per session.
14. b. Code 54000 describes a newborn; therefore, modifier -63 would not be reported with this code.
The CPT® Professional Edition provides this information in the parenthetical note following this code.
15. d. Code 54065 includes extensive destruction of lesion(s) of the penis. This code is reported one time
regardless of the number of lesions destroyed during a session.
16. a. Review of the subcategory notes in the CPT® Professional Edition with urodynamics indicates that
modifier -51 should be used when more than one of these codes is listed in the same investiture session.
17. b. Code 52282 indicates stent (singular); therefore, when more than one stent is placed, the units
should be reported.
18. d. The parenthetical notes provided in the CPT® Professional Edition with procedure code for
resection ofresidual prostate tissue indicate modifier -78 would be appended if the procedure is
performed by the same physician during a postoperative period.
19. c. The routine obstetric care, including the ante- and postpartum care with vaginal delivery, is
reported with code 59400. The diagnosis codes for this case are assigned for the pregnancy complicated
by cardiovascular disease. The mitral valve prolapse is then reported as the specific condition. According
to the ICD-9 Guidelines for Chapter 11, these codes have sequencing priority.
20. a. One way to find this answer in the index of the CPT® Professional Edition is under the main
heading “Miscarriage,” then “Incomplete Abortion.”
21. b. The CPT® Professional Edition provides a parenthetical note below code 57415 that references use
ofevaluation and management codes for impacted vaginal foreign body removal without anesthesia.
This is an example of reading carefully to select the correct answer. The question does not ask for the
evaluation andmanagement code, only the procedure; therefore, answer A is not correct.
22. d. According to CPT® Changes: An Insider’s View 2011, this new code includes x-ray confirmation
forlocation of the apparatus.
23. a. Code 58120 is described as non-obstetrical, whereas 59160 is used for postpartum hemorrhage.