Read the scenario carefully and assign the correct codes.

The codes will include both ICD - 10 CM

and CPT codes. After assigning the correct codes, you are tasked to provide a brief explanation for
each code.

Scenario 1:

A 40-year-old patient presents to an outpatient clinic for a routine check-up. The doctor performs a
comprehensive physical examination, checks vital signs, and orders a complete blood count (CBC) for
general health assessment.

1. What is the ICD - 10 CM code?

Answer: Z00.00

2. What is the CPT code?

Answer: 99396

3. Provide a brief of explanation of assigning the codes above.

Answer:
The ICD-10 CM code Z00.00. This code is used when a patient comes in for a routine check-
up, and there are no specific health concerns or abnormal findings. It signifies a general
examination for overall health maintenance. In this scenario, the patient is undergoing a
routine check-up without any specific health issues, making Z00.00 the appropriate ICD-10 CM
code.

The CPT code 99396 describes a comprehensive preventive medicine service, including a
thorough examination, counseling, and the ordering of necessary tests for a patient who is
established. It is appropriate for routine check-ups and health assessments. The CPT code
99396 is chosen to represent the comprehensive preventive medicine service performed
during the check-up, including the physical examination and ordering of a complete blood
count (CBC) for general health assessment.

Scenario 2:

A 55-year-old patient visits an outpatient surgical center for the removal of a benign skin lesion on the
upper arm. The physician performs the excision of the lesion.

1. What is the ICD - 10 CM code?

Answer: B97.4

2. What is the CPT code?

Answer: 11406

3. Provide a brief of explanation of assigning the codes above.

Answer:
The ICD-10 CM code B97.4 represents the excision of a benign skin lesion. This code includes
the removal of any benign skin growths, such as moles, nevi, or sebaceous cysts. The code also
includes the excision of margins, which are areas of healthy tissue that surround the lesion to
ensure complete removal.
 The CPT code 11406 represents the excision procedure itself. This code includes the removal
of the lesion and any margins involved, as well as the closure of the wound. The code can be
used for excision of benign skin lesions on the trunk (e.g., back, chest, abdomen) or arms and
legs. In this scenario, the physician performed the excision of a benign skin lesion on the upper
arm, so both codes are appropriate.

Scenario 3:

A 65-year-old patient with a history of hypertension presents to an outpatient facility for a coronary
artery bypass graft (CABG) surgery due to severe coronary artery disease. During the surgery, the
patient experiences cardiac arrhythmias, which require additional interventions.

1. What is the ICD - 10 CM code?

Answer: I21.0

2. What is the CPT code?

Answer: 33285

3. Provide a brief of explanation of assigning the codes above.

Answer:
The ICD-10 CM code I21.0 represents the diagnosis of acute coronary syndrome due to
coronary artery disease. This code includes conditions such as unstable angina, non-ST
elevation myocardial infarction (heart attack), and ST elevation myocardial infarction (heart
attack). In this scenario, the patient's severe coronary artery disease led to cardiac
arrhythmias during the CABG surgery, which falls under the category of acute coronary
syndrome.

The CPT code 33285 represents the coronary artery bypass graft (CABG) surgery. This code
includes the surgical procedure in which a healthy blood vessel is taken from another part of
the body and grafted onto the coronary artery to bypass the blocked or diseased section. The
code can be used for CABG surgery performed on multiple vessels. In this scenario, the patient
required CABG surgery due to severe coronary artery disease, and the physician performed
the surgery with multiple vessels being bypassed.