Chapter 12

Practical Application Tips

Case 1 – There is one CPT® code and one ICD-10-CM code reported. The documented
procedure is a circumcision. In the CPT® Index look for Circumcision/Surgical Excision. The
age of the patient and surgical method used are key for selecting a circumcision code. For
the diagnosis code, look in the ICD-10-CM Alphabetic Index for Circumcision (in the absence
of medical indication) (ritual) (routine).

Case 2 – There is one CPT® code and one ICD-10-CM code reported. The documented
procedure is a radical retropubic prostatectomy with bilateral pelvic lymph node dissection.
In the CPT® Index look for Prostatectomy/Retropubic/Radical for the correct code range. The
documented diagnosis is prostate cancer. In the ICD-10-CM Table of Neoplasms locate
Neoplasm, neoplastic/prostate (gland)/Malignant Primary (column).

Case 3 – There is one CPT® code and one ICD-10-CM code reported. The
documented procedure is the placement of gold fiducial markers using ultrasonic guidance.
An interstitial device is placed into the prostate to administer radiation therapy. In the CPT®
Index look for Placement/Fiducial Markers/Prostate. The hospital ultrasound department
assisted with the ultrasound and it will not be reported by the surgeon. The documented
diagnosis is prostate cancer. In the ICD-10-CM Table of Neoplasms look for Neoplasm,
neoplastic/prostate (gland)/Malignant Primary (column).

Case 4 – There is one CPT® code and one ICD-10-CM code reported. The
documented procedure is an open right ureterolithotomy. “Open” means an incision rather
than with a scope (endoscopy). The stone fragments were removed from the proximal
(upper) one-third of the ureter which is key information in your code selection. In the CPT®
Index look for Ureterolithotomy. For the ICD-10-CM code, recall that a stone is a calculus.
In the ICD-10-CM Alphabetic Index look for Calculus, calculi, calculous/ureter. Validate code
in the Tabular List.

Case 5 – There is one CPT® code and one ICD-10-CM code reported. The documented
procedure is an ESWL (Extracorporeal Shock Wave Lithotripsy). Shock waves used to
pulverize the renal calculus is lithotripsy. In the CPT® Index look for Shock Wave Lithotripsy.
The kidney is a paired organ; use a HCPCS level II modifier to indicate which kidney, right
or left. The reason for the procedure is a left renal calculus. In the ICD-10-CM code
Alphabetic Index look for Calculus/kidney. Validate the code in the Tabular List.

Case 6 – There is one CPT® code and two ICD-10-CM codes reported. The
documented procedure is a cystoscopy. There was an examination of the urethra, bladder
and ureteric openings of the bladder. In the CPT® Index look for Bladder/Endoscopy. The
Findings indicate bladder lesions were found on the bladder wall. This will be the first
diagnosis. In the ICD-10-CM Alphabetic Index, look for Lesion/bladder. The patient has a
history of bladder cancer from January 2010; this will be the second diagnosis reported. In
the Alphabetic index look for History/personal (of)/malignant neoplasm (of)/bladder
directing you to the code. Validate codes in the Tabular List.
Case 7 – There is one CPT® code and two ICD-10-CM codes reported. The
documented procedure is a cystoscopy with Durasphere injection. An endoscopic injection of
synthetic (implant) material into the urethra is performed to prevent urinary incontinence.
In the CPT® Index look for Urethra/Endoscopy/Injection of Implant Material. The cystoscopy
is included in the procedure and not coded. The documented diagnoses are intrinsic
sphincter deficiency and stress incontinence. In the ICD-10-CM Alphabetic Index look for
Deficiency/intrinsic/sphincter. For the second code look in the Alphabetic Index for
Incontinence/urine (urinary)/stress (male) (female). Validate the codes in the Tabular List.

Case 8 – There is one CPT® code and three ICD-10-CM codes reported. This case is
like Case 1. There is a cystoscopy with excision of a 5.3 cm bladder tumor, the size of the
tumor resected is key information to your code selection. In the CPT® Index look for
Tumor/Bladder/Excision for code choices. For the diagnoses, be sure to read in the
Addendum for pathology findings of cancer in three separate locations. The last sentence in
the addendum is important, it gives you all three diagnoses; cancer of the trigone and
bladder neck, and recurrent prostate cancer. There is no indication that the cancers are
metastatic. All three codes are found in the ICD-10-CM Table of Neoplasms. Locate
Neoplasm, neoplastic/bladder (urinary)/trigone/Malignant Primary (column) for the first
diagnosis code; for the second code look for Neoplasm, neoplastic/bladder/neck/Malignant
Primary (column); for the third code look for Neoplasm, neoplastic/prostate (gland)
Malignant Primary (column). Validate codes in the Tabular List.

Case 9 – There are two CPT® codes and one ICD-10-CM code reported. The
documented procedure is a cystoscopy with excision of a 1 cm bladder tumor and a bilateral
retrograde pyelogram. The size of the tumor resected is key information in code selection.
In the CPT® index look for Tumor/Bladder for code choices. To locate the code for the
retrograde pyelogram, look in the CPT® Index for Pyelogram. You’re directed to see
Urography, Intravenous, Urography, Retrograde. Next in the CPT® Index look for
Urography/Retrograde for the second procedure code. Radiology procedures have a
technical and professional component. In this case a professional component modifier is
appended to the radiology code. Look in CPT® Appendix A to locate the modifier that
represents the professional component. The documented diagnosis is transitional cell
carcinoma of the bladder. In the ICD-10-CM Table of Neoplasms, look for Neoplasm,
neoplastic/bladder (urinary)/wall/posterior/Malignant Primary (column). Validate code in
the Tabular List.

Case 10 – There are three CPT® codes and three ICD-10-CM codes reported. The
documented procedures are bilateral orchiopexy, bilateral inguinal hernia repair and
circumcision.

1. The first CPT® code is the inguinal hernia repairs. In the CPT® Index look for Hernia
Repair/Inguinal. Code selection is determined by the age of the patient, if this is an
initial or recurrent hernia, and if the hernia is reducible, incarcerated or strangulated.
The procedure was performed bilaterally and the hernia code will need the bilateral
modifier appended.

2. The second CPT® code is the orchiopexy. In the CPT® Index look for Orchiopexy. The
approach for the orchiopexy was inguinal. The procedure was performed bilaterally.
This code will need a modifier to indicate bilateral and a modifier for an additional
 procedure during the same operative session. Use a dash between the CPT® code
and the first modifier and a dash between the first modifier and second modifier.

3. The third CPT® code is for the circumcision. In the CPT® Index look for Circumcision.
The age of the patient and surgical method used is key information in selecting a
circumcision code. Append a modifier to indicate this was an additional procedure
performed in the same surgical session.

Report each ICD-10-CM code in the order that the surgery codes are listed.
For the first diagnosis code, look in the ICD-10-CM Alphabetic Index for Hernia,
hernia/inguinal/bilateral. For the second diagnosis code the note is specific in where the
undescended testes are located. It indicates the testes are high in the scrotum. Start your
search by looking under the main term High. For the third diagnosis look in the Alphabetic
Index for Circumcision (in the absence of medical indication) (ritual) (routine). Validate the
codes in the Tabular List.