Basic Coding

Intro to CPT

100

procedure/service descriptor

What is the words that follow a code number in the CPT manual are called:

200

stand alone

What is a code that has all of the words that describe the code that follows is what type of code?

300

hyphen

What is punctuation mark between codes in the index of the CPT manual indicates a range of codes is available?

400

Appendix A

What is the CPT appendix all modifiers are found?

500

revisions

What is the term that reflects the technologic advances made in medicine that are incorporated into the CPT manual?

E/M

100

This is a 15-year-old girl, never seen at this clinic. During a problem-focused history, she states that she noticed a lump on the back of her right wrist yesterday. P/E: There is a 2-cm freely movable, rubbery, round swelling on the dorsal surface of the right wrist. Distal neurovascular and tendon exam intact. This is not painful to palpation. (The MDM was of straightforward complexity.) Impression: Ganglion cyst, right wrist. Treatment: Refer to Dr. Andrews for further treatment.

What is 99201

200

CHART NOTE CC: This established patient presents to the office today with complaints of rectal bleeding and itching of 2 weeks’ duration. OBJECTIVE: This is a 50-year-old male in apparent good health. His BP is 119/78. Rectal examination showed a Grade I hemorrhoid in the 2 o’clock position approximately 2 cm across. The area around the hemorrhoid was slightly inflamed and a small amount of blood was noted. ASSESSMENT: Hemorrhoid. PLAN: Discussed conservative treatment options with the patient and explained surgical option. He wants to try the more conservative approach of stool softeners, warm and sitz baths. I discussed with him the importance of improved bowel habits. He is to return for a recheck in 2 months. The medical decision making was of straightforward complexity.

What is 99212

300

CLINIC NOTE CC: Patient presents for routine examination SUBJECTIVE: Sally is a 42-year-old female patient who presents today for a routine physical examination OBJECTIVE: BP 120/80. Pelvic exam: normal external genitalia. Vagina without discharge except for a scant amount of white discharge that appears normal. Cervix: Multiparous, clear. Bimanual exam is unremarkable. All systems are within normal limits. ASSESSMENT: 1. Normal BP. 2. Normal pelvic exam. PLAN: Return in 1 year or as needed.

What is 99396

400

This patient is seen in the clinic at the request of Dr. Jones for evaluation of suprapubic pain. Patient is a 22-year-old black female G1 P0, LMP 12/20/xx, EDC 10/16/xx by 14-week ultrasound taken on 4/16/xx, 18 weeks with twin gestation. Presents with complaint of suprapubic sharp to mild pain with onset 2 months ago. Pain has become progressively worse. Patient has been seen by Dr. Jones for this pregnancy and has also been seen by Dr. Smith for this current complaint 2 weeks ago. Patient denies urgency and frequency of nocturia, denies hematuria, and denies discharge. Labs: CBC and urinalysis performed. Allergies: none. Past medical history: genital wart 1986. Past surgical history: wart removed by laser 1986. Social history: no smoking, illicit drugs, or alcohol. PE: During an expanded problem-focused examination, the HEENT was found to be normal. FHT: A 148, B 146. Heart: normal. Lungs: CTA. Abdomen: gravid 20 cm. Slight tender suprapubic region. Vaginal exam: closed cervix, thick, long; no discharge. Extremities: negative for edema; UA loaded with bacteria and WBC. Impression: 1. IUP at 18 weeks with twin gestation. 2. Acute UTI (the MDM was straightforward). Recommendation: Keflex, 500 mg, and follow-up with Dr. Jones.

What is 99242

500

Subjective: This 17-year-old patient presents to the emergency department after racing motorcycles earlier today. He had his helmet on as well as all of his racing gear. He actively races motorcycles and has done this all summer long, winning a number of times. He came over a jump and lost control of the bike, going over the handlebars. He denies hitting his head but landed on his left elbow and his left knee and has had some discomfort in these areas since. He tells me that he was not going fast, approximately 30 mph. He denies any loss of consciousness. The main complaints center only on the left knee and the left elbow. Objective: The patient is in no acute distress, nontoxic appearing. During an expanded problem-focused examination, he is alert and oriented. Eyes: PERL, EOMI conjugate without nystagmus. Funduscopic exam reveals the discs to be sharp and the TMs normal. Throat: clear with teeth intact. Neck: nontender. No palpable discomfort or adenopathy. He has intact clavicles. Lungs: clear. Heart: regular rate and rhythm. Abdomen: soft; no hepatosplenomegaly, rebound, or guarding. He has good upper- and lower-extremity strength. His right arm is nontender to palpation. The left arm has a small amount of tenderness around the elbow joint, but there is no obvious deformity and he does have good, active motion. He has no tenderness with movement of the hips and no tenderness down the long bones of the lower extremities. There is mild tenderness at the left knee. The knee is intact with negative drawer sign and minimal tenderness along the lateral collateral ligament region. There is no real tenderness along the joint line or over the mediocollateral ligament. Both of these ligaments are intact with stress. X-rays of the left knee and left elbow are negative for fracture. Assessment: Contusion, left elbow and left knee (the MDM was of low complexity). Plan: Ice, Tylenol; recheck if not improving over the next few days, otherwise on a prn basis.

What is 99282

Anesthesia

100

Anesthesia for diagnostic arthroscopic procedure of the knee joint.

What is 01382

200

Anesthesia for bilateral vasectomy.

What is 00921

300

Anesthesia for tracheobronchial reconstruction

What is 00539

400

Daily hospital management of epidural, continuous drug administration.

What is 01996

500

Assign a CPT anesthesia code for repair of cleft palate.

What is 00172

Integumentary

100

Suction lipectomy, lower right leg.

What is 15879

200

Suture of superficial wounds of cheek: one 1 cm laceration, one 3 cm laceration, and one 2 cm laceration.

What is 12014

300

The patient is brought back to the operating room, for a staged procedure to a procedure that was performed 5 days previously. LOCATION: Inpatient, Hospital PATIENT: Soren Gademore SURGEON: Gary Sanchez, M.D. DIAGNOSIS: Status post open wound, right lower extremity. SURGICAL PROCEDURE: Split thickness skin graft, right thigh to right lower extremity. DESCRIPTION OF PROCEDURE: The patient’s right leg was prepped with Betadine scrub and solution and draped in the routine sterile fashion. A skin graft was taken from the right thigh on its anterolateral aspect, meshed with a 1:1.5 ratio mesher, and applied to the 66 sq cm defect on the right leg with staples. Dressing consisted of Xeroform, Kerlix fluffs, Kerlix roll, Kling, Sof-Rol, and a short leg fiberglass cast. Scarlet Red and ABD pads were applied to the donor site. The patient tolerated the procedure well and left the area in good condition. Pathology Report Later Indicated: Benign tissue

What is 15100

400

Location: Hospital PREOPERATIVE DIAGNOSIS: Pilonidal cyst. POSTOPERATIVE DIAGNOSIS: Same. PROCEDURE PERFORMED: Excision of pilonidal cyst, simple. ANESTHESIA: General endotracheal anesthesia with 30 cc of local infiltrated directly into the wound. PROCEDURE IN DETAIL: After good general endotracheal anesthesia, the patient was carefully placed in the prone position. Care was taken to pad dependent areas. The area around the pilonidal cyst was shaved, prepped and draped sterilely. After this, a total of 30 cc of Marcaine was injected into the area around the pilonidal sinus and a small elliptical incision was made to include the two sinuses. Wide dissection was carried down to the coccyx to include all inflamed tissue. After this, the wound was irrigated. Hemostasis was obtained with electrocautery. The wound was packed with Vaseline gauze and dressed. The patient tolerated the procedure well and was returned to the recovery room in good condition.

What is 11770

500

INDICATIONS: The patient had a YV advancement flap and advancement of the hamstring muscles about 3 weeks ago, but the wound separated and the muscles retracted over the area of the bone. She has had moderate separation of the wound but not complete separation, and we plan to minimally debride this area and resuture the wound with tension sutures. DIAGNOSIS: Wound dehiscence, left ischial area, partial. SURGICAL FINDINGS: A 6 cm long by about 4 cm deep wound dehiscence. PROCEDURE PERFORMED: Debridement of ischial wound by curettage with secondary wound closure. PROCEDURE: The patient was intubated and turned in the prone position. The area was prepped with Betadine scrub and solution and draped in routine sterile fashion. The area was curettaged and a piece of the tissue was placed in a culture tube. This was curettaged down to bleeding granulation tissue. I was reluctant to restart by complete debridement of all these areas, because there are factors operative in this wound that are probably beyond our control. We nevertheless completed debridement of the granulation down to bleeding tissue and put far/near, near/far tension type sutures in the wound using #2 Ethibond. I then put some Xeroform underneath the sutures that were holding the wound together and put three boxes of Kerlix Fluffs on top of this to cover some of the open areas on the thigh. The thigh sutures were also removed. I then taped the three boxes of Kerlix Fluffs to the ischial area with Elastoplast and taped around the leg to hold this in place, placing an ABD pad over the open areas where the sutures had been present. I then taped the buttock and leg up on the lumbar area with Elastoplast in such a manner as to support the ischial closure. A home health care nurse was in attendance at this time and she was advised as to how to retape and dress this on a daily basis. The patient had two open areas of the thigh and right lower leg, one of which was a donor site, the other of which was an old skin graft with open areas. We applied Scarlet Red and ABD pads to this area. Estimated blood loss 50 cc. Otherwise, the patient tolerated the procedure well and left the area in good condition.

What is 13160

Musculoskeletal

100

Jane was playing volleyball in her high school gymnasium, and during a dive for the ball she fell, landing hard on her right shoulder area. She presented to the orthopedic office in severe pain in the area of her collarbone. Radiologic exams were taken of the area, and it was found that the sternoclavicular joint had been dislocated. The physician applied pressure and moved the bone back into its proper location. Strapping was then applied. Report only the repair, not the x-ray. CPT Code: ____________________

What is 23525

200

Sally presents to the physician office with pain in the toes of her left foot. The physician took x-rays of her foot and toes and it was determined that she had fractures in her second, third, and fourth digit on her left foot. Strapping was applied (closed treatment).

What is 28510

300

Jackie had been complaining of pain in her knee for several months. The orthopedist suspected a torn medial and lateral meniscus and ordered a diagnostic arthroscopy. During the diagnostic arthroscopy it was found that Jackie had a torn medial and lateral meniscus. The physician repaired both these during the same operative session through the scope.

What is 29883

400

Arthroscopic medial meniscus repair.

What is 29882

500

Closed treatment of hip dislocation, status post hip arthroplasty, without anesthesia.

What is 27265