PCRM A-Team

E/M

100

Chronic care management services, at least 20 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month, with the following required elements: multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient, chronic conditions place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline,comprehensive care plan established, implemented, revised, or monitored.

What is CPT 99490

200

Advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; each additional 30 minutes (List separately in addition to code for primary procedure)

What is CPT 99498

300

Subjective: Six-year-old girl twisted her arm on the play ground. She is seen in the ED complaining of pain in her wrist. Objective: Vital Signs: stable. Wrist: Significant tenderness laterally. X-ray is normal Assessment: Wrist sprain Plan: Over the counter Anaprox. give twice daily with hot packs. Recheck if no improvement

What is CPT 99281 Rationale: Emergency Department services must meet or exceed three of the three key components. The physician performed a problem focused history (brief HPI, no ROS, no PFSH), a problem focused exam (one body area is examined), and low MDM (for one new problem to the examiner, one data point for the X-ray, and low level of risk). The problem focused history and exam lead us to select 99281 as the appropriate code

400

An infant is born six weeks premature in rural Arizona and the pediatrician in attendance intubates the child and administers surfactant in the ET tube while waiting in the ER for the air ambulance. During the 45 minute wait, he continues to bag the critically ill patient on 100 percent oxygen while monitoring VS, ECG, pulse oximetry and temperature. The infant is in a warming unit and an umbilical vein line was placed for fluids and in case of emergent need for medications.

What is CPT code (s)99291, 31500, 36510, 94610When neonatal services are provided in the outpatient setting, Inpatient Neonatal Critical Care guidelines direct the coder to use critical care codes 99291 Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes and 99292 … each additional 30 minutes (List separately in addition to code for primary service). Care is documented as lasting 45 minutes with the physician in constant attendance. The physician also administered intrapulmonary surfactant (94610), placed an umbilical vein line (36510) and intubated the patient (31500). These services can be separately billed as they are not included in 99291.

500

Mr. Trumph loses his yacht in a poker game and experiences a sudden onset of chest pain which radiates down his left arm. The paramedics are called to the casino he owns in Atlantic City to stabilize him and transport him to the hospital. Dr. H. Art is in the ER to direct the activities of the paramedics. He spends 30 minutes in two-way communication directing the care of Mr. Trumph. When EMS reached the hospital Emergency Department, Mr. Trumph is in full arrest with torsades de pointes (ventricular tachycardia). Dr. H. Art spends another hour stabilizing the patient and performing CPR.

What is CPT Code (s)99288, 99291, 92950 Rationale: Documentation describes physician direction of the paramedics (99288) In the CPT® Index, look for Physician Services/Direction, Advanced Life Support. He spends another hour stabilizing the patient, reported with critical care code 99291. In the CPT® Index, look for Critical Care Services. CPR is not a service included in the critical care codes and may be reported separately with 92950.In the CPT® Index, look for CPR (Cardiopulmonary Resuscitation). See the CPT® guidelines under Critical Care Services.

RADIOLOGY

100

41-year-old male is in his doctor’s office for a follow up of an abnormality, which was noted, on an abdominal CT scan. He is to have a chest X-ray due to chest tightness. He otherwise states he feels well and is here to go over the results of his chest X-ray (PA and Lateral) performed in the office and the CT scan performed at the diagnostic center. The results of the chest X-ray were normal. CT scan was sent to the office and the physician interpreted and documented that the CT scan of the abdomen showed a small mass in his right upper quadrant.

What is CPT Code (s)71020, 74150-26 Rationale: The chest X-ray was taken in the doctor’s office and interpreted. This means the doctor’s office can bill for the code without appending a modifier. Modifier 26 is appended to the CT scan code, because, it was performed at another site and the physician only interpreted the image. Look in the CPT® Index for X-ray/Chest directing you to 71010-71035, and CT Scan/without Contrast/Abdomen directing you to 74150, 74176, 74178.

200

A patient has a history of chronic venous embolism in the superior vena cava (SVC) and is having a radiographic study to visualize any abnormalities. In outpatient surgery the physician accesses the subclavian vein and the catheter is advanced to the superior vena cava for injection and imaging. The supervision and interpretation of the images is performed by the physician.

What is CPT code (s)36010, 75827-26 Rationale: A radiographic study of the superior vena cava is performed to visualize and evaluate any abnormalities. For the insertion of the catheter look in the CPT® Index for Catheterization/Vena Cava referring you to code 36010. For the radiology code look in the CPT® Index for Venography/Vena Cava guiding you to code range 75825-75827. Radiology code 75827 is correct for the superior vena cava. Modifier 26 is appended to the radiology code, because the physician is performing the procedure in an outpatient facility setting.

300

70-year-old female presents with a complaint of right knee pain with weight bearing activities. She is also developing pain at rest. She denies any recent injury. There is pain with stair climbing and start up pain. An AP, Lateral and Sunrise views of the right knee are ordered and interpreted. They reveal calcification within the vascular structures. There is decreased joint space through the medial compartment where she has near bone-on-bone contact, flattening of the femoral condyles, no fractures noted. The diagnosis is right knee pain secondary to underlying localized degenerative arthritis

What is CPT Code (s)73562, 715.36Rationale: Look in the CPT® Index for X-ray/Knee 73560-73564, 73580. Code 73562 reports three views of one knee. The scenario is reported with one ICD-9-CM code. In the ICD-9-CM Index to Diseases (Alphabetical Index) look for Arthritis/degenerative, there is a see also note to go to Osteoarthrosis. Under Osteoarthrosis /localized, guides you to code 715.3 with the fifth digit being six, 715.36. If you look at chapter 13 in your ICD-9-CM codebook, you will see that the fifth digit 6, lower leg, includes the knee joint. Localized osteoarthrosis is appropriate to report, because it is stated as localized.You do not report the ICD-9-CM code for knee pain as this is a symptom of the degenerative arthritis and included in the code.

400

An oncology patient is having weekly radiation treatments with a total of seven conventional fractionated treatments. Two fractionated treatments daily for Monday, Tuesday and Wednesday and one treatment on Thursday.

What is CPT Code (S) 77427 Rationale: There are seven fractions given in this patient’s weekly treatment. According to CPT® guidelines,radiation treatment management is reported in units of five fractions or treatment sessions, regardless of the actual time-period in which the services are furnished. Code 77427 is also reported if there are three or four fractions beyond a multiple of five at the end of a course of treatment, one or two fractions beyond a multiple of five at the end of a course of treatment are not reported separately.” This instruction is found in CPT® under the heading “Radiation Treatment Management” in the Radiology/Radiation Oncology Section of the Radiology Chapter. In the CPT® Index look for Radiation Therapy/Treatment Management/Weekly directing you to 77427.

500

Magnetic resonance imaging of the chest is first done without contrast medium enhancement and then is performed with an injection of contrast.

What is CPT Code 71552

PATH/LAB

100

the code(s) for thawing 4 units of fresh frozen plasma

What is CPT Code (s) 86927 x 4Rationale: In the CPT® Index, look for Plasma/Frozen Preparation and you are directed to 86927. Code 86927 is specifically for plasma rather than whole blood. The code is used per unit thawed so the answer is 86927 x 4.

200

A patient will be undergoing a transplant and needs HLA tissue typing with DR/DQ multiple antigen and lymphocyte mixed culture.

What is CPT Code (s)86817, 86821Rationale: Code 86817 is the correct code to report for HLA tissue typing with DR/DQ. In the CPT® Index look under Tissue/Typing/Human Leukocyte Antigen (HLA)/Antibodies. Code 86821 is reported for the lymphocyte culture. This is indexed under Tissue/Typing/Lymphocyte Culture. Codes 86805 and 86806 are for lymphocytotoxicity, not lymphocyte mixed culture

300

A physician orders a quantitative FDP

What is CPT Code 85370

400

A patient’s mother and sister have been treated for breast cancer. She has blood drawn for cancer gene analysis with molecular pathology testing. She has previously received genetic counseling. Blood will be tested for full sequence analysis and common duplication or deletion variants (mutations) in BRCA1, BRCA2 (breast cancer 1 and 2).

What is CPT Code 81211Rationale: In the CPT® Index, look for Breast/Cancer Gene Analysis/BRCA1 (breast cancer 1) referring you to 81211-81215. The correct code is 81211. This is a blood test performed to look for any gene mutations affecting the BRCA1 and BRCA2 genes. These human genes are known as tumor suppressors, mutation of these genes has been linked to hereditary breast and/or ovarian cancer. A woman’s risk of developing breast or ovarian cancer is increased if she inherits this harmful mutation. Men with this mutation also have an increased risk of breast cancer. Be sure to read the parenthetical instructions.

500

A patient has partial removal of his lung. The surgeon also biopsies several lymph nodes in the patient’s chest which are examined intraoperatively by frozen section and sent with the lung tissue for Pathologic examination.

What is CPT Code (s)88309, 88305, 88313, 88331 Rationale: Separately code for each, the lung examination (all lung specimens are 88309), the lymph node biopsy (88305), the frozen section (first specimen 88331), and for the special trichrome stain (88313). In the CPT® Index, see Pathology/Surgical/Level IV and Level VI. Also, see Surgical Pathology//Consultation/Intraoperative directing you to code range 88329-88334.

MEDICINE

100

A female patient fell on the floor as she got out of bed. She has no known head trauma. She noticed some slight stiffness in her joints and weakness in her lower extremity muscles, with slight stiffness in her arm joints. The physician decided to test for possible multiple sclerosis (MS). She was sent to a clinic providing somatosensory studies.

What is CPT Code (s)95938, 728.87, 719.59 Rationale: In the CPT® Index, look for Somatosensory Testing. Studies are reported based on location. In this case the upper limbs and lower limbs were performed guiding you to code 95938. Since Because MS has not been confirmed, the weakness in her muscles (728.87) and stiffness of the joints (719.59) should be reported. In the Index to Diseases, look for Weakness/muscle (generalized). Also, look for Stiffness, joint/multiple sites.

200

A patient with Sickle cell anemia with painful sickle crisis received normal saline IV, 100 cc per hour to run over 5 hours for hydration in the physician’s office. She will be given Morphine & Phenergan, prn (as needed). W

What is CPT Code (s)96360, 96361 x 4, J7050 x 2, 282.62 Rationale: In the CPT® Index, look for Hydration, you are directed to codes 96360-96361. The hydration will run 5 hours at 100 cc per hour. Code the hydration therapy as 96360 for the first hour, then 96361 x 4 to get a total infusion time of 5 hours. Code for the normal saline with J7050 x 2 units for 500 cc (HCPCS Level II).

300

5-year-old is brought in to see an allergist for generalized urticaria. The family just recently visited a family member that had a cat and dog. The mother wants to know if her son is allergic to cats and dogs. The child’s skin was scratched with two different allergens. The physician waited 15 minutes to check the results. There was a flare up reaction to the cat allergen, but there was no flare up to the dog allergen. The physician included the test interpretation and report in the record.

What is CPT Code 95004 x 2Rationale: Code 95004 describes the scratch test with allergenic extracts. The test is reported twice for the number of substances that were tested on. In the CPT® Index, look for Allergy Tests/Skin Tests/Allergen Extract.

400

42-year-old patient presented to the urgent care center with complaints of slight dizziness. He had received services at the clinic about 2 years ago. The patient related this episode happened once previously and his 51-year-old brother has a pacemaker. A chest X-ray with 2 views and an EKG with rhythm strip were ordered (equipment owned by the urgent care center). The physician detected no obvious abnormalities, but the patient was advised to see a cardiologist within the next 2 - 3 days. The physician interpreted and provided a report for the rhythm strip and Chest X-ray.

What is CPT Code (s)99213-25, 71020, 93040, 780.4 Rationale: The patient is an established patient to an urgent care clinic. A code from 99211-99215 is reported. Level three is reported with 99213. Because an EKG was also performed, a modifier 25 is appended to the office visit. The X-ray & EKG equipment are owned by the clinic. The chest X-ray, 2 views, is reported with 71020. In the CPT® Index, look for X-ray/Chest. The EKG and rhythm strip are read, interpreted and a report is written by the physician. Modifiers 26 and TC are not appended to the radiology codes because the urgent care center owns the equipment and the radiologist is an employee of the urgent care center. In the CPT® Index, look for Electrocardiography/Rhythm/Tracing and Evaluation, you are referred to CPT® code 93040.

500

55-year-old male has had several episodes of tightness in the chest. His physician ordered a PTCA (percutaneous transluminal coronary angioplasty) of the left anterior descending coronary artery. The procedure revealed atherosclerosis in the native vessel. It was determined a stent would be required to keep the artery open. The stent was inserted during the procedure

What is CPT Code (s)92928-LD, 414.01 Rationale: PTCA is a percutaneous transluminal coronary angioplasty. In the CPT® Index, look for Transcatheter/Placement/Intravascular Stents directing you to 92928-92929. In this case, the angioplasty was followed by stent placement in the LD. Only one procedure can be performed in each of the coronary vessels (LC, LD, and RC). The hierarchy beginning with the lowest is angioplasty, stent, atherectomy, atherectomy & stent placement. Only the stent placement (92928) is reported. Modifier LD indicates the left anterior descending coronary artery. In ICD-9-CM Index to Diseases, look for atherosclerosis and you are directed to see arteriosclerosis. Under Arteriosclerosis/coronary/native artery, you are directed to 414.01. Verification in the Tabular List confirms code selection.

ICD-9

100

Use both ____ and ____ when locating and assigning a diagnosis code.

What is Alphabetic Index and Tabular List Rationale: According to the ICD-9-CM guidelines Section 1.B.1 both Alphabetical Index and Tabular List are used to locate and assign a code. Reliance on only using the Alphabetic Index or the Tabular List will lead to errors and less specificity in reporting codes.

200

Code both sequencing the acute first

What is how to report when a patient has a condition that is both acute and chronic and there are separate entries for both.Rationale: According to the ICD-9-CM Section 1.B.10 coding guidelines, if the same condition is described as both acute (subacute) and chronic, and separate entries exist in the Alphabetic Index at the same indentation level, code both and sequence the acute (subacute) first.

300

A patient with chronic back and neck pain developed a drug dependency on oxycodone (opoid). After being taken off the drug, he was seen in the clinic for withdrawal symptoms.

What is ICD-9 Code (s)292.0, 304.00, E935.2Rationale: Withdrawal symptoms are a result of unpleasant effects upon the body when there is a sudden discontinuation/separation of drugs and/or alcohol. In the Index to Diseases (Alphabetic Index) locate Withdrawal symptoms, syndrome/drug or narcotic. You are directed to code 292.0. In the Tabular List code 292.0 identifies Drug withdrawal. In the Tabular List there is a note under category code 292 stating to use an additional code for drug dependence and an E code to identify the drug. In the Index to Diseases (Alphabetic Index) locate Dependence/oxycodone. You’re directed to 304.0. In the Tabular List, use 5th digit ‘0’ for unspecified use. The patient took the medication for therapeutic reasons which had lead to a drug dependency. Look in the Table of Drugs for Opiates, opioids, opium. Use the code from the Therapeutic column (E935.2).

400

A patient with metastatic bone cancer (primary site unknown) presents to the oncologist’s office for a chemotherapy treatment. On examination, the oncologist finds the patient to be severely dehydrated and cancels the chemotherapy. The patient will receive intravenous hydration in the office and reschedule the chemotherapy treatment.

What is ICD-9 Code (s) 276.51, 198.5, 199.1 Rationale: Per ICD-9-CM Guidelines, Section I.C.2.c.3, when the admission/encounter is for management of dehydration due to the malignancy or therapy, or a combination of both, and only the dehydration is being treated (intravenous hydration); the dehydration is sequenced first, followed by the code(s) for the malignancy. When information is not available about the primary site of the cancer, the secondary site is coded first followed by code 199.1. In the Index to Diseases (Alphabetic Index), look for Dehydration 276.51. Look in the Index to Diseases (Alphabetic Index), in the Neoplasm Table for Neoplasm, neoplastic/bone. Use the code from the secondary column (198.5). Then look in the Neoplasm Table for unknown or unspecified site and use the code from the primary column (199.1).

500

. 22-year-old developed gas gangrene (gas bacillus infection) and went into septic shock after a surgical procedure.

What is ICD-9 Code (s) 040.0, 998.02, 995.92Rationale: Per ICD-9-CM Guidelines, Section I.C.1.b.6.(a), for cases of septic shock, the code for the systemic infection should be sequenced first, followed by codes 995.92, Severe sepsis and 785.52, Septic shock or 998.02, Postoperative septic shock. For the systemic infection, look in the Index to Diseases (Alphabetic Index) for Gangrene, gangrenous/gas (bacillus) 040.0. Look in the Index to Diseases (Alphabetic Index) for Shock/septic/due to surgical procedure 998.02. In the Tabular List, there is an instruction to code first the underlying infection (040.0) and to use an additional code to identify the severe sepsis (995.92).