Medical Auditing Training: CPMA®: Practical Application Workbook

2019
Medical Auditing Training: CPMA®

Practical Application Workbook

Disclaimer
This course was current when it was published. Every reasonable effort has been made to assure the accuracy of the information
within these pages. The ultimate responsibility lies with readers to ensure they are using the codes, and following applicable
guidelines, correctly. AAPC employees, agents, and staff make no representation, warranty, or guarantee that this compilation of
information is error-free, and will bear no responsibility or liability for the results or consequences of the use of this course. This
guide is a general summary that explains guidelines and principles in profitable, efficient healthcare organizations.
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This product includes CPT®, which is commercial technical data and/or computer data bases and/or commercial computer
software and/or commercial computer software documentation, as applicable, which was developed exclusively at private expense
by the American Medical Association, 330 N. Wabash, Chicago, Illinois, 60611. U.S. government rights to use, modify, reproduce,
release, perform, display, or disclose these technical data and/or computer data bases and/or computer software and/or computer
software documentation are subject to the limited rights restrictions of DFARS 252.227-7015(b)(2) (November 1995), as applicable,
for U.S. Department of Defense procurements and the limited rights restrictions of FAR 52.227-14 (June 1987) and/or subject
to the restricted rights provision of FAR 52.227-14 (June 1987) and FAR 52.227-19 (June 1987), as applicable, and any applicable
agency FAR Supplements, for non-Department of Defense Federal procurements.
AMA Disclaimer
CPT® copyright 2018 American Medical Association. All rights reserved.
Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of
CPT®, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense
medical services. The AMA assumes no liability for data contained or not contained herein.
CPT® is a registered trademark of the American Medical Association.
Clinical Examples Used in this Book

AAPC believes it is important in training and testing to reflect as accurate a coding setting as possible to students and examinees.
All examples and case studies used in our study guides, exams, and workbooks are actual, redacted office visit and procedure
notes donated by AAPC members.
To preserve the real world quality of these notes for educational purposes, we have not re-written or edited the notes to the
stringent grammatical or stylistic standards found in the text of our products. Some minor changes have been made for clarity or
to correct spelling errors originally in the notes, but essentially they are as one would find them in a coding setting.
© 2018 AAPC
2233 South Presidents Dr. Suites F-C, Salt Lake City, UT 84120
800-626-2633, Fax 801-236-2258, www.aapc.com
Updated 10312018. All rights reserved.
ISBN 978-1-626886-841
CPC®, CIC™, COC™, CPC-P®, CPMA®, CPCO™, and CPPM® are trademarks of AAPC.
ii 2019 Medical Auditing Training: CPMA® CPT® copyright 2018 American Medical Association. All rights reserved.
Chapter
4
Case 1
Patient: Mark Williams
Date of Procedure: 07/23/20XX
Surgeon: David Smith, MD
PREOPERATIVE DIAGNOSIS: Right inguinal hernia.
POSTOPERATIVE DIAGNOSIS: Same.
PROCEDURE: Right inguinal hernia repair with mesh.
ASSISTANT: None.
INTRAOPERATIVE FLUIDS: 2400 mL of crystalloid
DRAINS: None.
SPECIMEN: None.
BLOOD LOSS: Minimal.
COMPLICATIONS: None.
INDICATIONS FOR PROCEDURE: The 25-year-old patient presents with a right groin bulge and findings consistent with a right
inguinal hernia. He is brought to the operating room for repair.
DESCRIPTION OF PROCEDURE: After the risks, benefits, alternatives, potential complications were explained in detail to the
patient, consent was given. The patient was identified, brought to the operative suite and placed supine in the bed.
After adequate anesthesia was obtained, the patient’s abdomen and right groin were prepped with chlorhexidine and draped in
normal fashion. A right inguinal incision was made with a scalpel. The subcutaneous tissue was dissected down to the external
oblique aponeurosis which was incised sharply. A muscle splitting incision was carried down to the preperitoneal space. Epigas-
tric vessels were retracted anterolaterally, cord structures were identified and retracted anteromedially where the epigastric cord
structures were identified and retracted laterally, using careful dissection. A hernia sac was identified and dissected free from the
cord structures. This was an inguinal hernia reduced . The inguinal floor was completely cleared. A small oval Kugel mesh was
then placed in the preperitoneal space to cover the hernia defect and potential hernia defects. This was secured to the transversalis
fascia with interrupted 2-0 Vicryl suture. The muscle was allowed to reapproximate and external oblique aponeurosis closed with
a running 2-0 Vicryl suture. The skin was closed with subcuticular 4-0 Monocryl.
Dressing, Steri-Strips, and gauze were applied. The patient tolerated the procedure well. There were no complications. All counts
reported as correct. Transferred to the recovery area in stable condition.
Electronically signed by: David Smith, M.D.
CPT® copyright 2018 American Medical Association. All rights reserved. www.aapc.com 83
Chapter 4
Surgical Coding Fee Ticket
Patient Name Mark Williams

Medical Record Number/Account Number 400-1
Provider David Smith, MD
Insurance Company Aetna
Comments
Date of Facility Place of CPT® Diagnosis Modifier Quantity Fee

Service Service Code(s) Code(s)
7/23/20XX AAPC 22 49505 K40.90 RT 1 $2,400.00
Hospital
7/23/20XX AAPC 22 49568 K40.90 RT 1 $600.00

Hospital
Total $3,000.00
1. When meeting with the surgeon post audit, which issue(s) need(s) to be addressed?
a. Place of service.
b. Diagnosis and CPT® codes are reported incorrectly.
c. One of the CPT® codes is reported incorrectly.
d. Diagnosis and CPT® codes reported correctly.
2. What documentation in the operative note appears to be missing?
a. Blood loss
b. Complications
c. Fluids
d. Type of anesthesia
84 2019 Medical Auditing Training: CPMA® CPT® copyright 2018 American Medical Association. All rights reserved.
Chapter 4
Case 2
Patient Name: Tom Smith
Date of Service: 07/23/20XX
SURGEON: Ann Davis, MD
PREOPERATIVE DIAGNOSIS: Left lateral malleolus ankle fracture.
POSTOPERATIVE DIAGNOSIS: Left lateral malleolus ankle fracture.
PROCEDURE: Left open reduction and internal fixation of an ankle fracture of lateral malleolus.
ANESTHESIA: General.
INDICATION FOR OPERATION: This 19-year-old male sustained a left ankle fracture when in accident driving an ATV. He was
seen in the emergency room approximately a week and half previously. Because the ankle was significantly swollen, it was elected
not to proceed with open reduction and internal fixation at that time. The patient was referred to my clinic at a week and a half
postop because there was concern about the ankle healing in an abnormal position and the mortise was incongruous. I elected to
proceed with surgery the same day in order to avoid healing in an incongruous position and also making it more difficult to fix it
later. Therefore, we proceeded with open reduction and internal fixation.
DESCRIPTION OF OPERATION: The patient was identified, brought to the operating room, given a general anesthesia, placed
with a pump under his right side. We proceeded with a lateral incision carried down just posterior to the fibula, carried down to
the subcutaneous tissue. The fracture was identified. The two ends were distracted. Hematoma clot and periosteum were removed
from inside of the fracture. The fracture was reduced anatomically under fluoroscopy. I placed a 7-hole plate posterolaterally,
sequentially put screws in with an open reduction and internal fixation using standard AO technique with drilling followed by
screw placement and ultimately, we did a check to make sure that mortise was congruent and was stable to probing with bone
hook and fluoroscopy. We irrigated with antibiotic irrigation and closed in layers using a combination of 0 and 2-0 Vicryl and 3-0
nylon for suture of the skin. The patient did well, again X-ray of ankle showed good reduction. The patient went to the recovery
room in good condition after we placed an AO splint on the patient. He will come back in approximately a week and a half for
wound check, suture removal, and re-X-ray.
Electronically Signed by: Ann Davis, MD
Patient Name Tom Smith

Provider Ann Davis, MD
Insurance Company BCBS
Comments

7/23/20XX AAPC 22 27726 S82.62XK LT 1 $1,400.00
Hospital
7/23/20XX AAPC 22 29515 51, LT 1 $100.00

Hospital
Total $1,500.00
Chapter 4
1. The documentation supports what CPT® code(s)?
a. 27726-LT, 29515-51-LT
b. 27726-LT, 29515-51-LT, 76000-26
c. 27810-LT
d. 27792-LT
2. Based on the review of the medical record what coding issues need to be addressed with the surgeon?
a. Diagnosis and CPT® codes are reported correctly.
b. The wrong CPT® and ICD-10-CM codes are reported.
c. X-ray of the ankle should be reported.
d. The place of service is incorrect.
Case 3
Patient Name: Dan Williams
Date: 03/14/20XX
Anesthesia: General by LMA
Surgeon: D. Smith, MD
Preoperative Diagnosis: Two benign skin lesions of right and left upper back.
Postoperative Diagnosis: Two benign skin lesions of right and left upper back.
Operation Performed: Excision of two benign lesions on the right and left upper back.
Indication: The patient is a 45-year-old white female with two suspicious dark lesions on her back, which were biopsied and
pathology reported them benign. She has had these lesions for many years and wants them removed.
Description of Procedure: The patient was placed in the prone position on the table. No sedation was given. Both areas of the right
and left upper back were prepped and draped in sterile fashion with Betadine paint. The first area was located on the right upper
back . This had a maximum diameter of 1 cm and a 3 mm margin on each side was planned . This was infiltrated with 1 percent
Lidocaine with epinephrine. It was excised . The wound was then irrigated. Hemostasis was achieved.
It was then closed with one layer using 5-0 Prolene . This area was covered with Steri-gauze and tape. The next lesion was located
on the left upper back. This had a maximum diameter of 1.5 cm. This had a 4 mm margin designed. The area was infiltrated with
1% Lidocaine, followed by excision. It was also closed with one layer using 5-0 Prolene, gauzed, and taped . The patient tolerated
this entire procedure with no complications and was sent home in stable condition.
Electronically Signed by: D. Smith, MD
Chapter 4
Patient Name Dan Williams

Provider D. Smith, MD
Comments

3/14/20XX AAPC 22 11401 D23.5 1 $300.00
Hospital
3/14/20XX AAPC 22 11402 D23.5 51 1 $250.00

Hospital
Total $550.00
a. 11401 x 2, 12002-51
b. 11403, 11402-51, 12002-51
c. 11403, 11402-51
d. 11402 x 2
2. Report the ICD-10-CM code:
a. L98.9
b. L08.0
c. D23.5
d. D48.5
Chapter 4
Case 4
Patient Name: Sally Clark
Surgeon: Kaitlyn Smith, MD
Preoperative Diagnosis: Basal cell carcinoma.
Postoperative Diagnosis: Same.
Operation: Mohs Surgery .
Indications: The patient has a biopsy-proven basal cell carcinoma on the nasal tip measuring 8 x 7 mm . Due to its location,
Mohs surgery is indicated. Mohs surgical procedure was explained including other therapeutic options, and the inherent risks
of bleeding, scar formation, reaction to local anesthesia, cosmetic deformity, recurrence, infection, and nerve damage. Informed
consent was obtained and the patient underwent fresh tissue Mohs surgery as follows.
STAGE I: The site of the skin cancer was identified concurrently by both the patient and Dr. and marked with a surgical pen; the
margins of the excision were delineated with the marking pen. The patient was placed supine on the operating table. The wound
was defined and infiltrated with 1% Lidocaine with epinephrine 1:100,000. All gross tumor was completely excised in a
debulking stage using aggressive curettage and/or cold steel. With all visible gross tumor completely excised, an excision was
made around the debulking defect. Hemostasis was obtained by spot electrodessication. A pressure dressing was placed. Tissue
was divided into two tissue blocks which were mapped, color coded at their margins, and examined. Tumor was not found in the
tissue blocks. Following surgery, the defect measured as follows: 10 x 13 mm to the subcutaneous tissue. Closure will be done by
Dr. Wallace from Plastics with a Burrow’s graft .
Condition at Termination of Therapy: Carcinoma removed. Pathology report on file.
Electronically Signed by: Kaitlyn Smith, MD
Patient Name Sally Clark

Provider Kaitlyn Smith, MD
Insurance Company United HealthCare
Comments
Date of Service Facility Place of CPT® Diagnosis Modifier Quantity Fee

Service Code(s) Code(s)
12/05/20XX AAPC 22 14060 C44.311 1 $800.00
Hospital
12/05/20XX AAPC 22 17311 C44.311 59 1 $700.00

Hospital
12/05/20XX AAPC 22 17315 C44.311 2 $300.00
Hospital
Total $1,800.00
Chapter 4
a. 17311, 17315 x 2
b. 14060, 17311-51, 17315 x 2
c. 17311 x 2
d. 17311
2. When meeting with the surgeon post audit, what issues need to be addressed?
a. The modifier, diagnosis, and CPT® codes are correct.
b. Diagnosis is incorrect.
c. The modifier is incorrect
d. A CPT® code and modifier are reported incorrectly.
Case 5
Patient Name: Kelly Adams
Surgeon: Landen Smith, MD
PREOPERATIVE DIAGNOSIS: Coronary artery disease.
POSTOPERATIVE DIAGNOSIS: Coronary artery disease .
PROCEDURES PERFORMED:
1. Coronary artery bypass grafting X 6 utilizing left internal mammary to left anterior descending artery, reverse saphe-
nous vein graft from aorta to the intermediate ramus artery, reverse saphenous vein graft from the aorta to the 1st obtuse
marginal artery and onto the 3rd obtuse marginal artery in sequential fashion, and reverse saphenous vein graft from the
aorta to the proximal posterior descending artery and onto the distal posterior descending artery in sequential fashion.
2. Endoscopic vein harvest.
3. MediStim flow probe graft interrogation x 4.
WIRES: Atrial and ventricular.
TUBES: A 9 mm thoracostomy drainage tubes x 2 and 24 French x 1.
INDICATIONS: This patient is a gentleman with 3-vessel coronary artery disease .
We saw him in consultation, discussed risks, benefits, goals, and alternatives. He verbalized understanding of the above and
granted his full informed consent to proceed. This is all detailed in our office notes.
FINDINGS: Normal ventricular function, significant left ventricular hypertrophy; however, quality of conduit obtained was
excellent. Flow from the mammary artery was outstanding It is a large caliber vessel.
Chapter 4
DESCRIPTION OF PROCEDURE: The patient was brought to the operating room and placed in supine position, after induction
of general endotracheal anesthesia. The skin of the anterior chest, abdomen, and lower extremities were prepared and draped
in the usual sterile fashion with chlorhexidine solution. A primary median sternotomy incision was created. The sternum was
divided in midline with the sternal saw and simultaneous harvesting of the left internal mammary artery. The saphenous vein was
harvested endoscopically from the left leg with the quality of conduit as noted.
The first system addressed is the posterior descending artery. This is opened in 2 places as noted. The patient was systemically
heparinized, cardiopulmonary bypass had been initiated. The proximal anastomosis completed in side-to-side fashion with
segment of reverse saphenous vein utilizing 7-0 Prolene suture in simple running fashion. The distal end of the same vein graft
was appropriate and anastomosed to the more distal arteriotomy utilizing 7-0 Prolene suture in simple running fashion. Lateral
layer of the heart was exposed.
The 3rd obtuse marginal is stabilized, opened, and controlled essentially the posterolateral branch from the left dominant system.
Vein graft anastomosis carried out in end-to-side fashion with 7-0 Prolene suture in simple running technique.
Approximately, same segment of vein was utilized in side-to-side fashion utilizing the first obtuse marginal artery utilizing 7-0
Prolene suture in running fashion.
The intermediate ramus artery was stabilized, opened, and controlled, and separate segment of vein was utilized to get an end-to-
side fashion utilizing 7-0 Prolene suture in simple running technique.
The left anterior descending artery was opened and controlled, anastomosis was made with the mammary artery after it was
tailored appropriately utilizing 7-0 Prolene suture in simple running fashion as well. The pedicle was tacked to epicardium with
two 6-0 Prolene stay sutures upon completion.
There were extrinsic calcifications in the aortic wall. Heartstring device was deployed and each of the 3 proximal anastomoses
completed with a 5-0 Prolene suture in a simple running fashion. Upon completion, the heartstring device was removed, the graft
was de-aired and flow was established Proximal and distal anastomoses were hemostatic.
Atrial and ventricular pacing wires were placed and brought out through separate stab wounds and affixed to the skin.
We were content with surgical hemostasis. We weaned from cardiopulmonary bypass without issue. Flow probe data is obtained
and is satisfactory and protamine was administered. The heart was decannulated without issue. Chest tubes were then placed in
each chest and pericardial wall and brought out through separate stab wounds and affixed to skin. The sternum was reapproxi-
mated with figure-of-eight stainless steel wires. Subcutaneous tissues were closed in layers with 0 Vicryl sutures. The skin was
closed with 4-0 Vicryl subcuticular closure. Dermabond adhesives were used on the skin. Sterile dressings applied. The tubes were
placed to water seal suction. The patient transported to the CVC unit in stable condition, tolerated the procedure as noted.
Electronically Signed by: Landen Smith, MD
Patient Name Kelly Adams

Provider Landen Smith, MD
Comments
Chapter 4

03/05/20XX AAPC 22 33533 I25.10 1 $2000.00
Hospital
03/05/20XX AAPC 22 33522 I25.10 1 $ 800.00

Hospital
03/05/20XX AAPC 22 33508 I25.10 1 $ 100.00
Hospital
Total $2,900.00
1. The documentation supports what CPT® codes?
a. 33533, 33522-51, 33508-51
b. 33536, 33514, 33508
c. 33533, 33517, 33508
d. 33533, 33522, 33508
2. When meeting with the surgeon post audit, what issues need to be addressed?
a. Incorrect CPT® code
b. Incorrect ICD-10-CM code
c. Incorrect modifiers
d. Diagnosis codes and CPT® codes are reported correctly
Case 6
Patient Name: Chris Davis
Surgeon: Roger Smith, MD
PREOPERATIVE DIAGNOSIS: Right middle cerebral artery infarction with hemorrhage. POSTOPERATIVE DIAGNOSIS: Right
middle cerebral artery infarction with hemorrhage . OPERATION PERFORMED: Right-sided hemicraniectomy with duraplasty.
COMPLICATIONS: None.
ANESTHESIA: General endotracheal.
ESTIMATED BLOOD LOSS: Approximately 400 mL.
INDICATIONS: A 56-year-old male with significant past medical history came in this evening with an ischemic infarct to his
right MCA territory, which converted to hemorrhagic transformation. The significant shift was following commands on the right
side and hemiplegic on the left side. After a thorough discussion with the family, we explained to them that this would be a life-
Chapter 4
saving procedure and we could not ensure that there would be any further neurological improvement from the state that he was
in. They understood these risks and wanted to proceed ahead.
OPERATION PERFORMED: After informed consent was obtained, the patient was taken to the operating room and general
endotracheal anesthesia was given without incident. TEE monitor was placed due to the patient’s significant cardiac history. A
roll was placed underneath the right shoulder and the head was placed in a horseshoe. The head was shaved and sterilely prepped
and draped in usual fashion. A #10 blade was used to make a reverse question mark incision. Raney clips were applied to the skin
edges. The temporalis fascia and muscle was then resected with the cutaneous flap anteriorly. The musculocutaneous flap was
then retracted with towel hooks, rubber bands and Allis clamps.
The perforator was then used to make several burr holes, approximately 6, and a
footplate was then put on to perform the hemicraniectomy. We ensured that we were off midline to ensure that we did not get into
the sagittal sinus or any draining veins associated with this. Once the bone was removed, hemostasis was obtained, and the dura
was opened in a C-shaped fashion and a large piece of Durepair was placed underneath this. Another large piece of Durepair was
then used to create a duraplasty. This was stitched in several points with 4.0 nylon. Hemovac was then tunneled through as well.
At this point, the galea and the temporalis fascia was then reapproximated with 0-Vicryl interrupted fashion, overlying galea was
reapproximated 0-Vicryl interrupted fashion. The overlying skin was closed with staples and the Hemovac drain was anchored
with 2-0 nylon. At the end of the case, all counts of the needles and sponges were correct.
Electronically Signed by: Robert Smith, MD
Patient Name Chris Davis

Surgeon Roger Smith, MD
Insurance Company AAPC Insurance Company
Comments

03/05/20XX AAPC 22 61322 I61.9 22 1 $5000.00
Hospital
I63.511
Total $5,000.00
Surgery Audit Tool
Physician ___________________________________ Date of Audit ___________________________________
Patient Name ______________________________________________________________________________
Date of Visit_____________________ Insurance Carrier: _____________________ MR# __________________
Surgical Service(s) reported ____________________________________________________________________
Diagnosis Code(s) reported ____________________________________________________________________
Comments ________________________________________________________________________________
Chapter 4
Documented Y N N/A Comments

Preoperative information
Patient demographics
Surgery date
Preoperative anesthesia
Indication for Procedure
Intra-operative information
Preoperative diagnosis
Postoperative diagnosis
Surgeon/asst/co-surgeons
Procedure title
Findings
Procedure details
Tissue/organ removed
Materials removed/inserted
Closure information
Blood loss/replacement
Wound status
Drainage
Complications noted
Post-operative condition of patient
IV infusion record (If Applicable)
Signatures
Supports procedure (CPT/HCPCS)
Supports medical necessity (ICD-10-CM)
1. The documentation supports what procedure code(s)?
a. 61315, 61618
b. 61315
c. 61322
d. 61322-22
2. What diagnosis codes are reported?
a. I63.231, I61.4
b. I61.9, I63.231
c. I61.9, I63.511
d. I63.511, I61.2
Chapter 4
Case 7
Patient Name: Keegan Davis
Surgeon: John Smith, MD
Preoperative Diagnoses:
1. Chronic ethmoid sinusitis.
2. Chronic maxillary sinusitis.
3. Deviated nasal septum, acquired.
Postoperative Diagnoses:
1. Chronic ethmoid sinusitis.
2. Chronic maxillary sinusitis.
3. Deviated nasal septum, acquired.
Procedure(s) Performed:
1. Bilateral sinus endoscopy with ethmoidectomy.
2. Bilateral sinus endoscopy with maxillary antrostomy.
3. Septoplasty without cartilage graft.
Surgeon: John Smith, MD
Anesthesia: General.
Brief History: The patient is a 53-year-old female with a four- to five-month history of chronic sinusitis. This was maximally
treated with steroid sprays, oral steroids and antibiotics without relief. CT scan revealed bilateral maxillary and ethmoid sinusitis
with left nasal septal deviation. The decision was made to take the patient to the operating room for bilateral maxillary antros-
tomy, total ethmoidectomies, possible frontal sinus exploration and septoplasty. The risks and benefits of the procedures were
explained to the patient, and she agreed to proceed.
Details of Procedure: The patient was taken to the operating room and placed in a supine position on the operating room table.
General face mask anesthesia was given until a deep plane of anesthesia was obtained. At that point, an endotracheal tube was
placed by the anesthesiology service without difficulty. The table was then turned. Approximately 8 mL of 1 percent lidocaine
with 1:100,000 epinephrine was injected into the uncinate, middle turbinate and septum bilaterally. Afrin-soaked pledgets were
then placed in the nasal cavities bilaterally. At that point, the patient was prepped and draped in routine fashion.
I began with the septoplasty. A hemitransfixion incision was performed in the left nasal cavity with a Cottle elevator. A suction Freer
was then used to elevate a submucosal plane posteriorly to the anterior face the sphenoid sinus on the left side. This was carried over
the prominent region of the patient’s deviated septum causing compression of the middle turbinate and middle meatus on the left
side. A Cottle elevator was then used to transect the cartilage just anterior to the deviated segment, and a submucosal plane was
elevated on the right side, through this cartilage transected region. The mucosal layer was elevated on the right side posteriorly again
to the anterior face of the sphenoid sinus. Endoscopic scissors were used to perform a superior and inferior cut of the cartilage back to
the bony septum. This portion was removed with Takahashi rongeurs. The bony septum was then removed with Jansen-Middleton.
The mucosal layers were reapproximated, showing excellent room on both the left and right nasal cavities.
Attention was then turned towards the sinus surgery. Using a 0-degree nasal endoscope, the right nasal cavity was visualized.
The middle turbinate was medialized with a Cottle elevator in its inferior third. A sinus seeker was then used to infracture the
uncinate. Back-biting forceps were then used to create a Parsons window in the uncinate. The uncinate was then taken down in
full extent superiorly to the middle turbinate and posteriorly and inferiorly with a 4 mm Straightshot microdebrider. This allowed
identification of the natural ostium on the right, which showed polypoid change.
A large maxillary antrostomy was then performed with a Straightshot microdebrider. This allowed excellent visualization into
the right maxillary sinus, and there was no further evidence of disease. The right ethmoid bulla was then entered with a Cottle
elevator in its midline. This allowed identification of the inside of the ethmoid bulla and face, microdebriding of the ethmoid
Chapter 4
bulla in its inferior medial, superior anterior, posterior extent. The ethmoid bulla was removed up to the lamina papyracea. A
large window was made in the basal lamella at that point, first with a Cottle elevator and then with a Straightshot microdebrider.
This allowed removal of tissue into the right posterior ethmoid cells. The superior turbinate was identified and left intact. Removal
of tissue was carried back to the anterior wall of the sphenoid sinus. The wound was then thoroughly irrigated with normal saline.
An Afrin pledget was placed into the middle meatus on the right. Attention was then turned towards the left nasal cavity. Again,
the middle turbinate was identified and medialized in its inferior third. There was extensive polypoid change within the left
medial meatus, including severe inflammation and purulent discharge from the left maxillary sinus. This was collected and sent
for culture. The uncinate again was infractured with a sinus seeker. A back-biting forceps was used to create a Parsons window.
Again, the uncinate was taken down with the 0 degree Straightshot microdebrider in its entire extent, inferiorly to superiorly,
to its attachment to the middle turbinate. The natural ostium could not be identified secondary to severe inflammation. A sinus
seeker was used to identify the natural ostium and the ostium was then back-bite in the posterior and inferior direction. This
allowed visualization of the left maxillary sinus, which was severely inflamed with purulent debris, which was suctioned with an
olive tipped suction.
A large maxillary antrostomy was then performed with 0 degree Straightshot microdebrider. This included the natural ostium
secondary to palpation and back-biting forceps of the anterior extent of the maxillary antrostomy to the nasal lacrimal canal. At
that point, the ethmoid bulla was entered the midline with a Cottle elevator. The ethmoid bulla was then removed in its entire
extent to the lamina papyracea with the Straightshot microdebrider. Again using a Cottle, the medial and inferior window was
entered into the basal lamella, preserving an inferior strut, as was done on the right side. Straightshot microdebrider was then
used to remove sinus tissue within the left posterior ethmoids, up to the skull base and posteriorly to the anterior wall of the sphe-
noid sinus. The superior turbinate was identified and preserved. The wound was then thoroughly irrigated with normal saline.
The Afrin-soaked pledgets were then removed. Absorbable NasoPore was placed into the middle meatus bilaterally to allow the
preservation of the middle turbinate without lateralization and scarring. Doyle splints were then placed bilaterally between the
middle turbinates and septum. This was sewn to the midline with a 4-0 Prolene stitch.
The nasopharynx was then suctioned free of blood products. No further evidence of bleeding. At that point, the procedure
was completed. The patient was awoken from general anesthesia, extubated, and sent to the post anesthesia care unit in stable
condition.
I attest that I was present for and performed the key points of this procedure.
Electronically Signed by: Vivian Tyler, MD
Surgery Fee Ticket
Patient Name Keegan Davis

Surgeon Vivian Tyler, MD
Comments

10/02/20XX AAPC 22 30520 J34.2 50 1 $700.00
Hospital
10/02/20XX AAPC 22 31255 J32.8 50, 51 1 $250.00
Hospital
10/02/20XX AAPC 22 31256 J32.8 50, 51 1 $200.00
Hospital
Total $950.00
Chapter 4
1. The documentation supports what CPT® codes?
a. 30520, 31255-51, 31256-51
b. 30520, 31255-50-51, 31256-50-51
c. 30520-50, 31255-50-51, 31256-50-51
d. 30520-50, 31254-50-51, 31276-50-51
2. The auditor reviews the documentation and determines:
a. CPT® codes are incorrect and operative report not signed.
b. Diagnosis codes are incorrect and operative report not signed.
c. A modifier is incorrect and discrepancy with signature.
d. Diagnosis and CPT® codes are reported correctly.
Case 8
Patient Name: Mary Smith
Surgeon: Michael Davis, MD
Preoperative Diagnosis: Fuchs’ dystrophy, left eye
Postoperative Diagnosis: Fuchs’ dystrophy, left eye
Anesthetic: Local MAC
Procedure: Descemet stripping automated endothelial keratoplasty, left eye and cut tissue.
Complication: None.
Note: Following administration of local anesthetic, the patient was prepped and draped. A lid speculum was inserted, left eye. The
cornea was measured. A 7.75 mm trephine was selected. A moistened Weck-Cel sponge was placed on the cornea.
Donor tissue was removed from the tissue culture medium and placed in Moria anterior chamber maintainer. Once tissue was
secured, the pressure was increased until the eye was firm. Then, using a 350 micron setting, the anterior flap was cut. The tissue
was then removed from the anterior chamber maintainer and placed on a Teflon block. A 7.75 mm Barron trephine was used to
trephine the donor tissue. The tissue was then inspected under the microscope.
An irrigation cannula was inserted in the host tissue at 12 o’clock with the bottle height at 60. A 4-mm partial thickness groove
was made at 9 o’clock. The anterior chamber was entered with a 2.2-mm keratome at 3 o’clock. A reverse Sinskey hook was used
to score the endothelium and the Descemet membrane was removed with a Sinskey hook. Two stab incisions were made with the
Grieshaber blade inside the 7.75 mm mark. The anterior chamber was then entered with a keratome at 9 o’clock and the wound
was enlarged to 4 mm. The tissue was then transferred to the Busin injector. It was irrigated gently with balanced salt solution.
Then, the Busin forceps were used to feed the tissue into the insertion portal. The Busin forceps were then used to traverse the
anterior chamber entering at 3 o’clock, exiting at 9 o’clock. The tissue was grasped with the inserter at the 9 o’clock opening and
Chapter 4
the tissue was pulled into the anterior chamber where it folded with the proper orientation promptly. The wounds were then
closed with interrupted 10-0 nylon sutures with the knots buried. The paracentesis site was also closed. Wound was checked and
noted to be watertight. A small air bubble was placed under the graft. Then, a bent 30-gauge sharp needle was used to pull the
transplant into the central position and additional air was injected until the eye was firm, but not hard. After 10 minutes, the air
was replaced with balanced salt solution until the air bubble was approximately 60%. Then, the wound was rechecked and still
watertight. The subconjunctival xylocaine 2% with epinephrine was injected inferiorly followed by dexamethasone 2 mg in 0.5
mL, Gentamicin 10 mg in 0.25 mL, and Vancomycin 7.5 mg in 0.25 mL, and Dexamethasone 1 mg in 0.25 mL. Topical Maxitrol
ophthalmic ointment was placed on the eye. The eye was patched, shield placed over, and the patient was taken to recovery in
good condition.
Electronically Signed by: Michael Davis, MD
Surgery Fee Ticket
Patient Name Mary Smith

Surgeon Michael Davis, MD
Comments

11/01/20XX AAPC 22 65756 H18.51 LT 1 $1,400.00
Hospital
1 $250.00
Total $1,650.00
a. 65710-LT
b. 65730-LT, 65757
c. 65756-LT
d. 65756-LT, 65757
2. When meeting with the surgeon post audit, what issue(s) need to be addressed?
a. Diagnosis and CPT® codes are reported correctly.
b. A CPT® code is missing.
c. The diagnosis is incorrect.
d. Both B and C.
Chapter 4
Case 9
Patient Name: John Smith
Anesthesiologist: Michael Davis, MD
CRNA: Jerry Williams, CRNA
CRNA provided anesthesia care with medical direction by Dr. A who only was directing this case.
CRNA inserted a Swan-Ganz catheter into the pulmonary artery via the right internal jugular and he placed a separate central
line in the left internal jugular vein.
Dr. A inserted an A-line in the right radial artery.
PS 4
Anesthesia Start Time: 19:43
Anesthesia End Time: 01:26
PREOPERATIVE DIAGNOSIS: Multi-vessel coronary artery disease.
POSTOPERATIVE DIAGNOSIS: Multi-vessel coronary artery disease.
NAME OF PROCEDURE: Coronary artery bypass graft x 3, left internal mammary artery to the LAD, saphenous vein graft to the
obtuse marginal, saphenous vein graft to the diagonal.
ANESTHESIA: General
BRIEF HISTORY: This 77-year-old patient who was found to have a huge abdominal aortic aneurysm. Preoperative cardiac
clearance revealed a markedly positive stress test and cardiac catheterization showed critical left-sided disease. Coronary revas-
cularization was recommended. The patient has multiple medical illnesses including chronic obstructive pulmonary disease with
emphysema and chronic renal insufficiency. I discussed with the patient and the family, the risks of operation including the risk
of bleeding, infection, stroke, blood transfusion, renal failure, and death. At operation, we harvested a vein from the left leg using
endoscopic technique; it was a very good conduit. Her obtuse marginal vessel was a 1.5-mm diffusely diseased vessel that was
bypassed distally as it ran in the left ventricular muscle. The diagonal was a surprisingly good vessel at 1.5-mm in size. The LAD
was bypassed in the mid aspect of the LAD and there was distal disease though a 1.5-mm probe passed quite easily. Good flow
was measured in the graft. The patient came off bypass very nicely. Note should be made that her ascending aorta was calcified
and we used a single clamp technique.
DESCRIPTION OF OPERATIVE PROCEDURE: Following delivery of the patient to the operating room, the patient was placed
under general anesthetic, was prepped and draped in the usual sterile manner. A median sternotomy was made and the left
internal mammary artery was harvested from the left chest wall, the saphenous vein was harvested from the left leg. The patient
was heparinized and cannulated and placed on cardiopulmonary bypass with an aortic cannula on the undersurface of the aortic
arch and a venous cannula through the right atrial sidewall. Note should be made that the upper aorta was very heavily calcified,
but the area that we cannulated was felt to be disease free. The aorta was cross clamped and the heart was stopped with antegrade
and retrograde cardioplegic solution. The heart was retracted out of the pericardial sac and then displaced into the right chest
which afforded good access to the lone marginal vessel which was bypassed with a reversed saphenous vein graft using a running
7-0 Prolene suture. Cold cardioplegic solution was then instilled down this graft. Note should be made that during the mammary
artery harvest, the left lung was completely adherent to the left chest wall, most likely from old episodes of pneumonia. Next, a
second saphenous vein segment was placed to the diagonal vessel and then the left internal mammary artery was placed to the
mid LAD. As noted, there was diffuse calcification distally in this artery just beyond the anastomosis, but the 1.5-mm probe
passed very nicely and we felt that it was not necessary to double jump this LAD. With the cross clamp in place, two proximal
aortotomies were made and the two proximal anastomoses were formed using 6-0 Prolene in a running fashion. Just prior to
Chapter 4
completion of the second anastomosis, appropriate de-airing maneuvers were performed and then the suture lines were tied as
the cross clamp was removed. The patient was allowed to rewarm completely and was weaned from bypass. The cannulas were
removed and the cannulation sites were secured with purse string sutures. Once hemostasis was secured, chest tubes were placed
and the wound was closed. Final needle, instrument, and sponge counts were reported as correct. The patient tolerated the proce-
dure well and returned to the recovery room in stable condition.
Electronically Signed by:
Michael Davis, MD
Jerry Williams, CRNA
Surgery Fee Ticket
Patient Name John Smith

Anesthesiologist Michael Davis, MD/Jerry Williams CRNA
Comments
Date of Service Facility Place of CPT/Anes Diagnosis Modifier Quantity Fee

Service Code (s) Code(s)
11/01/20XX XYZ Anes- 21 00563 I25.10 QK, P4 343 minutes $ 1500.00
thesia Group I71.4
J44.9
N18.9
11/01/20XX XYZ Anes- 21 36620 I25.10 QK, P4 1 $ 60.00
thesia Group
11/01/20XX XYZ Anes- 21 99100 I25.00 1 $ 100.00
thesia Group
11/01/20XX XYZ Anes- 21 00563 I25.10 QX, P4 343 minutes 1500.00
thesia Group
11/01/20XX XYZ Anes- 21 99305 I25.10 QX, P4 1 $150.00
thesia Group
11/01/20XX XYZ Anes- 21 36556 I25.10 59 1 $150.00
thesia Group
Total $3,460.00
1. What codes and modifiers are reported by the anesthesiologist and the CRNA?
a. MD: 00562-QY-P4, 99100, 36620; CRNA: 00562-QX-P4, 93503, 36556-59
b. MD: 00563-QK-P4, 99100, 36620; CRNA: 00563-QX-P4, 93503, 36556-59
c. MD: 00567-QY-P4, 99100, 36620; CRNA: 00567-QX-P4, 93503, 36556-59
d. MD: 00566-QY-P4, 99100, 36620; CRNA: 00566-QX-P4
Chapter 4
2. When meeting with the anesthesia group post audit, what issues need to be addressed?
a. The anesthesia CPT® code is incorrect and the number of minutes incorrect.
b. No surgical procedure codes should be reported.
c. The diagnosis codes and CPT® codes are reported correctly.
d. The anesthesia CPT® code and anesthesia modifiers are incorrect.
Case 10
Patient Name: Sally Williams
Anesthesiologist: Michael Davis, MD, medically directing 4 CRNAs during this procedure.
ANES Start: 7:39
ANES End: 14:44
ASA Physical Status: 3
Anesthesiologist: Dr. Davis
An arterial line was placed in the left radial artery by Dr. Davis.
Operative report
Preoperative diagnosis:
1. Cervical spondylosis with myelopathy.
2. Cervical instability C3 through C5.
Postoperative diagnosis:
1. Cervical spondylosis with myelopathy.
2. Cervical instability C3 through C5.
Procedure: Posterior cervical decompression with partial laminectomy C2 to T1 and fusion from C3 to C5 with rib allograft for
tubular allograft, bone morphogenic protein and Mountaineer Instrumentation system, screws and rods.
Anesthesia: General endotracheal
Complications: None
Chapter 4
Justification for Procedure: The patient is a 72 year-old female with a history of progressive myelopathy, debilitating, involving her
hands and her gait. She showed evidence of cervical spondylitic disease with cord stenosis, especially in the upper cervical region
along with instability, so she was brought to the operating room electively for decompression.
Description of the Procedure: The patient was intubated in supine position and then was placed prone with the Mayfield pin head
holder in place on the Relton frame. The suboccipital area was shaved and the suboccipital cervical and upper thoracic areas were
sterilely prepped and draped in the usual fashion. An incision was approximated using bony landmarks from C2 to T1 and this
was carried out with a #10 blade and carried down through the skin and subcutaneous tissues with the additional use of the bovie
coagulator. The paraspinous muscles were reflected laterally off the laminas from C2 to T1 and x-ray was used to confirm our
location and this was appropriate. At this point, we began our laminectomies from C2 to T1 using a combination of the Midas
REX drill, Kerrisons, and curets. We performed partial laminectomies from C2 to T1. During our decompression a synovial cyst
was noted on the right side at the C3-4 joint. We then brought in the fluoroscopic C arm in order to use fluoroscopic guidance
for placement of the screws. Using the aid of fluoroscopic imaging, we used the trauma drill and drilled into the lateral masses
of C3, C4, and C5 bilaterally using a trajectory aim 20 degrees up and 20 degrees lateral beginning approximately 1 millimeter
inferior and 1 millimeter medial to the midpoint of the lateral mass. We drilled the holes, tapped them, and placed screws in the
lateral masses of C3, C4, and C5 bilaterally using the guidance of fluoroscopic imaging. All the screws went in nicely and good
placement was confirmed once again with fluoroscopic imaging. At this point the rod coupling system was brought in and rods
were placed bilaterally from C3 to C5 connecting the screws and these were tightened and final tightening using the Mountaineer
system. At this point, we used the combination of vertebral autograft, rib allograft and bone morphogenic protein to fuse the
levels of interest, specifically C3 through C5 after pulse lavaging with 4 liters of antibiotic solution. At this point, hemostasis was
confirmed and achieved using the Bovie coagulator. Then the muscle was approximated using 0 interrupted Vicryl sutures after
placing a hemovac drain in the wound. The fascia was also approximated using 0 interrupted Vicryl suture and the subcutaneous
tissues were approximated using 2-0 interrupted Vicryl and skin approximated using a combination of subcuticular closure with
3-0 Monocryl and Dermabond. A sterile dressing was applied and a Miami J collar was placed and the patient was turned supine,
extubated and found to be in stable condition with no changes in her monitoring signals throughout the case.
Surgery Fee Ticket
Patient Name John Smith

Anesthesiologist
Comments
Date of Service Facility Place of CPT® Code(s) Diagnosis Code(s) Modifier Quantity Fee
Service
11/01/20XX XYZ Anes- 21 00600 M47.12 QK, P3 425 minutes $2,116.00
thesia Group M53.2X2
11/01/20XX XYZ Anes- 21 36620 1 $60.00
thesia Group
11/01/20XX XYZ Anes- 21 99100 $100.00
thesia Group
11/01/20XX XYZ Anes- 21 00600 QX, P3 425 minutes $2,116.00
thesia Group
Total $4,392.00
Chapter 4
1. What codes and modifiers are reported by the anesthesiologist and the CRNA?
a. MD: 00600-QK-P3, 99100, 36620; CRNA: 00600 QX-P3
b. MD: 00600-QY-P3, 99100, 36620; CRNA: 00600-QX-P3, 99100
c. MD: 00670-QK-P3, 99100, 36620; CRNA: 00670-QX-P3
d. MD: 00670-QK-P3, 99100, 36620; CRNA: 00670-QZ-P3
2. When meeting with the anesthesia group post audit, what issue needs to be addressed?
a. CPT® codes 36620 and 99100 should not be reported.
b. Anesthesia modifiers are incorrect.
c. The diagnosis codes and CPT® codes are reported correctly.
d. The anesthesia CPT® is incorrect.

Medical Auditing Training: CPMA®: Practical Application Workbook

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Medical Auditing Training: CPMA®

CPT® is a registered trademark of the American Medical Association.

Clinical Examples Used in this Book

PREOPERATIVE DIAGNOSIS: Right inguinal hernia.

POSTOPERATIVE DIAGNOSIS: Same.

PROCEDURE: Right inguinal hernia repair with mesh.

INTRAOPERATIVE FLUIDS: 2400 mL of crystalloid

BLOOD LOSS: Minimal.

Electronically signed by: David Smith, M.D.

Surgical Coding Fee Ticket

Patient Name Mark Williams

Date of Facility Place of CPT® Diagnosis Modifier Quantity Fee

7/23/20XX AAPC 22 49568 K40.90 RT 1 $600.00

b. Diagnosis and CPT® codes are reported incorrectly.

c. One of the CPT® codes is reported incorrectly.

d. Diagnosis and CPT® codes reported correctly.

2. What documentation in the operative note appears to be missing?

Electronically Signed by: Ann Davis, MD

Surgical Coding Fee Ticket

Patient Name Tom Smith

Date of Facility Place of CPT® Diagnosis Modifier Quantity Fee

7/23/20XX AAPC 22 29515 51, LT 1 $100.00

1. The documentation supports what CPT® code(s)?

b. 27726-LT, 29515-51-LT, 76000-26

a. Diagnosis and CPT® codes are reported correctly.

b. The wrong CPT® and ICD-10-CM codes are reported.

c. X-ray of the ankle should be reported.

d. The place of service is incorrect.

Electronically Signed by: D. Smith, MD

Surgical Coding Fee Ticket

Patient Name Dan Williams

Date of Facility Place of CPT® Diagnosis Modifier Quantity Fee

3/14/20XX AAPC 22 11402 D23.5 51 1 $250.00

1. The documentation supports what CPT® code(s)?

b. 11403, 11402-51, 12002-51

2. Report the ICD-10-CM code:

Preoperative Diagnosis: Basal cell carcinoma.

Postoperative Diagnosis: Same.

Operation: Mohs Surgery .

Condition at Termination of Therapy: Carcinoma removed. Pathology report on file.

Electronically Signed by: Kaitlyn Smith, MD

Surgical Coding Fee Ticket

Patient Name Sally Clark

Date of Service Facility Place of CPT® Diagnosis Modifier Quantity Fee

12/05/20XX AAPC 22 17311 C44.311 59 1 $700.00

1. The documentation supports what CPT® code(s)?

b. 14060, 17311-51, 17315 x 2

a. The modifier, diagnosis, and CPT® codes are correct.

c. The modifier is incorrect

d. A CPT® code and modifier are reported incorrectly.

PREOPERATIVE DIAGNOSIS: Coronary artery disease.

POSTOPERATIVE DIAGNOSIS: Coronary artery disease .

2. Endoscopic vein harvest.

3. MediStim flow probe graft interrogation x 4.

WIRES: Atrial and ventricular.

TUBES: A 9 mm thoracostomy drainage tubes x 2 and 24 French x 1.

INDICATIONS: This patient is a gentleman with 3-vessel coronary artery disease .

Electronically Signed by: Landen Smith, MD

Surgical Coding Fee Ticket

Patient Name Kelly Adams

Date of Service Facility Place of CPT® Diagnosis Modifier Quantity Fee

03/05/20XX AAPC 22 33522 I25.10 1 $ 800.00

Physician _ Date of Audit _

Date of Visit___________ Insurance Carrier: _ MR# ________