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1. A 49-year-old female with chronic DeQuervain's disease undergoes surgical release. What is the correct CPT® code to report? A. 25001 - LT B. 25000 - LT ✅ C. 25290 - LT D. 26055 - LT ✅ Correct Answer: B. 25000-LT Rationale: CPT® 25000 describes incision of the extensor tendon sheath for DeQuervain’s disease. The key distinction is that this is an incision , not an excision, and it involves the extensor , not flexor, tendon sheath. Modifier LT indicates the procedure was done on the left side. 2. A 63-year-old man undergoes excision of a 5 cm lipoma in the neck. What CPT® code should be reported? A. 11426 B. 21552 ✅ C. 11626 D. 21011 ✅ Correct Answer: B. 21552 Rationale: Code 21552 is correct for excision of a soft tissue tumor in the neck measuring over 3 cm. The mass was subcutaneous and not a skin lesion, ruling out codes in the 11400–11600 series. 3. A surgeon excises a 3 cm mass from a patient’s right groin beneath the femoral fascia. What is the correct CPT® code? A. 27043 B. 27048 ✅ C. 27045 D. 27059
✅ Correct Answer: B. 27048 Rationale: This code is for excision of a tumor in the pelvis or hip area , subfascial and 3 cm in size. The dissection went through the femoral fascia, confirming the subfascial depth.
4. A patient receives an injection for chronic right trochanteric bursitis. What codes are reported? A. 20610, J3301 x B. 20605, J3301 x C. 20610 - RT, J3301 x4 ✅ D. 20611 - RT, J3302 x ✅ Correct Answer: C. 20610-RT, J3301 x Rationale: 20610 is for major joint bursa injection (hip), and J3301 is the correct HCPCS code for Triamcinolone 10 mg. 40 mg was given, so 4 units are reported. 5. What is the correct ICD- 10 - CM code for right ankle joint effusion? A. M25. B. M25. C. M25.471 ✅ D. M25. ✅ Correct Answer: C. M25. Rationale: M25.471 specifies effusion in the right ankle joint , based on laterality and joint location. 6. A 14-year-old girl undergoes arthroscopic wrist surgery with debridement and repair of the TFCC. What is the CPT® code? A. 29845 B. 29846 - LT ✅ C. 25000 - LT D. 25115 ✅ Correct Answer: B. 29846-LT Rationale: Code 29846 covers arthroscopic repair and debridement of the triangular fibrocartilage complex (TFCC). Modifier LT indicates left wrist. 7. A patient undergoes neck exploration for a gunshot wound. A foreign body is found and removed. What CPT® code applies? A. 20500 B. 20100 ✅ C. 23100 D. 20525
✅ Correct Answer: B. 24640- 54 - LT, S53.032A, W50.2XXA Rationale: 24640 is the code for nursemaid elbow reduction. Modifier 54 means the ED doc only did the procedural part. LT is for left elbow. S53.032A is the correct ICD- 10 - CM code, and W50.2XXA captures the external cause (twisting by person).
12. What CPT® code describes arthroscopic removal of a degenerative flap tear in the medial meniscus of the right knee? A. 29880 B. 29875 C. 29881 ✅ D. 29877 ✅ Correct Answer: C. 29881 Rationale: Code 29881 is for arthroscopic meniscectomy , medial or lateral. The procedure involved medial meniscal flap tear debridement, fitting this code. 12. A 56-year-old female undergoes arthroscopic surgery of the right knee due to a degenerative posteromedial meniscal flap tear. The medial meniscus is debrided to a stable rim. What CPT® code is reported? A. 29880 B. 29875 C. 29877 D. 29881 ✅ ✅ Correct Answer: D. 29881 Rationale: CPT® 29881 describes arthroscopic partial meniscectomy , either medial or lateral. The documentation supports a medial meniscus tear that was trimmed arthroscopically. There’s no indication that both menisci were treated, which would require 29880. 9866 - 29868, 29871-29889. The medial meniscectomy and debridement are reported with 29881. In this case the synovectomy, code 29875, is a separate procedure and bundled with 29881; it is not reported separately. The patient is a 17 year-old male who was struck on the elbow by another player's stick while playing hockey. He is found to have a fracture of the olecranon process. The patient was brought to the OR, anesthetized and intubated. The right upper extremity was prepped with Betadine scrub and draped free in the usual sterile orthopedic manner. The arm was then elevated and exsanguinated and the tourniquet inflated to 250 mm/Hg. A five-inch incision was made with the scalpel on the extensor side of the elbow, beginning distally and proceeding in an oblique fashion up the proximal forearm. Dissection was carried through subcutaneous tissue and fascia, and bleeding was controlled with electrocautery. We then subperiosteally exposed the proximal ulna and olecranon to visualize the fracture site. The fracture could be seen at the base of the olecranon process. We irrigated the site thoroughly and reduced the fracture fragme -
ANSWER 24685-RT
Rationale: This is a fracture of the olecranon process which is located at the upper end of the ulna. An incision was made to expose the fracture site, making it an open treatment. Look in the CPT® Index for Fracture/Ulna/Olecranon/Open Treatment 24685. Modifier RT is appended to indicate the procedure was performed on the right side. A 45 year-old presents to the operating room with a right index trigger finger and left shoulder bursitis. The left shoulder was injected with 1 cc of Xylocaine, 1 cc of Celestone and 1 cc of Marcaine. An approximately 1-inch incision was made over the A1 pulley in the distal transverse palmar crease. This incision was taken through skin and subcutaneous tissue. The A1 pulley was identified and released in its entirety. The wound was irrigated with antibiotic saline solution. The subcutaneous tissue was injected with Marcaine without epinephrine. The skin was closed with 4-0 Ethilon suture. Clean dressing was applied. What CPT® codes are reported?
- ANSWER 26055-F6, 20610- 51 - LT Rationale: In the CPT® Index look for Trigger Finger Repair. You are referred to 26055. Review the code to verify accuracy. In the CPT® Index look for Injection/Joint. You are referred to 20600, 20604-20606, 20610, 20611. Review the codes to choose appropriate service. 20610 is the correct code for the shoulder injection. Modifier F6 is used to report the right index finger that was repaired. Modifier LT is used to indicate the left shoulder joint. Modifier 51 is used to indicate multiple procedures were performed. A 31 year-old secretary returns to the office with continued complaints of numbness involving three radial digits of the upper left extremity. Upon examination, she has a positive Tinel's test of the median nerve in the left wrist. Anti-inflammatory medication has not relieved her pain. Previous electrodiagnostic studies show sensory mononeuropathy. She has clinical findings of carpal tunnel syndrome. She has failed physical therapy and presents for injection of the left carpal canal. The left carpal area is prepped sterilely. A 1.5 inch 25-gauge needle is inserted radial to the palmaris longus or ulnar to the carpi radialis tendon at an oblique angle of approximately 30 degrees. The needle is advanced a short distance about 1 or 2 cm observing for any complaints of paresthesia or pain in a median nerve distribution. The mixture of 1 cc of 1% lidocaine and 40 mg of Kenalog-10 is injected slowly along the median nerve - ANSWER 20526, J3301 x 4 Rationale: For the CPT® code, look in the CPT® Index for Injection/Carpal Tunnel/Therapeutic, 20526. Verify in the numeric section. Look in your HCPCS Level II codebook in the Table of Drugs and Biologicals for
lateral incision was made. The fibula was dissected and approximately 6 cm of the fibula was removed for the autograft. There were a lot of free fragments of bone around the subtalar joint and the talus itself. The bone fragments were removed and a large defect consistent with avascular necrosis of the body of the talus was noted. An eggshaped burr was introduced and the articulating cartilage of the ankle joint was excised and debrided. The subtalar joint was approached and resection of the articulating surface of the subtalar joint was completed. Bone graft from the fibula was prepared on the back table. We made two large blocks to fill the defect in the talus and then additional small fragments of cortical cancellous bone to fill in smaller d - ANSWER 28705, 20902- 51 Rationale: The physician fused the tibiotalar, talonavicular, the calcaneocuboid and subtalar joints making this a pantalar arthrodesis. Look in the CPT® Index for Arthrodesis/Talus/Pantalar referring you to 28705. A pantalar arthrodesis is the fusion of the tibiotalar, subtalar, talonavicular and calcaneocuboid joints. Autograft was taken from the fibula (bone graft) for the arthrodesis, 20902. In the CPT® Index, look for Bone Graft/Any Donor Area referring you to 20900, 20902. Modifier 51 is required to indicate multiple procedures during the same session. What information is required to accurately code osteoarthritis in ICD- 10 - CM? - ANSWER Whether the osteoarthritis is primary, secondary, post-traumatic, the site and laterality. Rationale: To accurately code osteoarthritis in ICD- 10 - CM, the documentation needs to include whether the arthritis is primary, secondary, post-traumatic, the site and laterality (right/left). What is the acromion? - ANSWER Extension of the scapula Rationale: The acromion is an extension of the scapula that meets the clavicle at the shoulder to form the acromioclavicular joint. Most of the codes in ICD- 10 - CM Chapter 13 Diseases of the Musculoskeletal System and Connective Tissue have site and laterality designations. According to ICD- 10 - CM guidelines what is considered the site? - ANSWER The site may be the bone, joint or muscle involved. Rationale: According to ICD- 10 - CM guideline I.C.13.a., the site may be the bone, joint or muscle involved. A patient has a greenstick fracture of the right radial shaft. It is treated by surgically placing a bone plate on the distal radial shaft. What ICD- 10 - CM code is reported? - ANSWER S52.311A Rationale: A greenstick fracture occurs when the bone does not break completely through, and the bone does not protrude through the skin; this is a closed fracture. The
treatment to fix the fracture is an open approach to expose the bone to insert the plate across the fracture site; however, the fracture care treatment is not considered when coding for the diagnosis. In the ICD- 10 - CM Alphabetic Index look for Fracture, traumatic/radius/shaft/greenstick S52.31-. In ICD- 10 - CM codes are specific for laterality (left, right) and the episode of care. Check the Tabular List and seven characters are needed to complete the code. Right radial shaft is indicated in the question and because the encounter is being treated surgically, this meets the definition of initial encounter or active treatment (See ICD- 10 - CM guideline I.C.19.a.). The complete code is S52.311A. What is segmental instrumentation? - ANSWER A spinal fixation device attached at each end of a rod and at additional bony attachment Rationale: Segmental instrumentation of the spine is a procedure used to repair a spinal defect where the fixation device is attached in at least three places: at each end of the construct (rod) and at least one additional interposed bony attachment. A patient presented with a closed, displaced supracondylar fracture of the left elbow. After conscious sedation, the left upper extremity was draped and closed reduction was performed, achieving anatomical reduction of the fracture. The elbow was then prepped and with the use of fluoroscopic guidance, two K-wires were directed crossing the fracture site and piercing the medial cortex of the left distal humerus. Stable reduction was obtained, with full flexion and extension. K-wires were bent and cut at a 90-degree angle. Telfa padding and splint were applied. What CPT® code(s) is/are reported? - ANSWER 24538-LT Rationale: This is a supracondylar fracture of the elbow repaired by percutaneous fixation. In the CPT® Index look for Fracture/Humerus/Supracondylar/Percutaneous Fixation and you are referred to 24538. Modifier LT is appended to indicate the procedure is performed on the left side. The application of the first cast or splint is included in the fracture codes. See the guidelines before Application of Casts and Strapping in your CPT® codebook. Fluoroscopy guidance 76000, is listed as a separate procedure; therefore, is included in the procedure. A 27 year-old presents with right-sided thoracic myofascial pain. A 25-gauge 1.5-inch needle on a 10 cc controlled syringe with 0.25% bupivacaine was used. After negative aspiration, 2 cc were injected into each trigger point. A total of four trigger points were injected. A total of 8 cc of bupivacaine was used on the rhomboid major, rhomboid minor, and levator scapular muscles. What CPT® code(s) is/are reported for this procedure? - ANSWER 20553 Rationale: In the CPT® Index look for Injection/Trigger Point(s)/Three or More Muscles. You are referred to 20553. Review the code to verify accuracy. 20553 covers the three
C) 38520 D) 38542 D - Which CPT® code(s) describes VATS therapeutic wedge resection of the left upper lobe followed by left upper lobectomy? A) 32480 B) 32505, 32480 C) 32663, 32666 D) 32663 B - Which CPT® code describes a pneumonectomy? A) 32442 B) 32440 C) 32440 - 50 D) 32445 C - Patient is a mouth-breather. He is diagnosed with inflamed inferior turbinates and a superficial ablation is performed. What CPT® code is reported? A) 30802 B) 30140 C) 30801 D) 30802 - 52 B - A thoracotomy procedure was performed for repair of hemorrhage and lung tear. What CPT® code is reported? A) 32100 B) 32110 C) 32120 D) 32420 B - What is the major muscle used during respiration? A) Intercostal muscles of the ribs B) Diaphragm C) Abdominal muscles D) Chest wall or pectoral muscles A - What portion of the thoracic cavity lies between the lungs and contains the heart? A) Mediastinum B) Diaphragm C) Lymphatic channels D) Bone marrow D - What is the ICD- 10 - CM code selection for a patient with COPD presenting with an acute bronchitis? A) J44. B) J21. C) J44. D) J44.0, J20.
B - Which CPT® code describes a pneumonectomy? A) 32442 B) 32440 C) 32440 - 50 D) 32445 D - A patient has a mass in her left axilla that is a suspected recurrence of lymphoma. She has a left axillary node excisional biopsy. The lymph node biopsied is under the pectoralis minor. What CPT® code is reported? A) 38500 B) 38562 C) 38745 D) 38525 B - Can bronchoscopy codes be coded together by a physician, and if yes, how? Are multiple procedures reported with modifier 51? A) No B) Yes: Report multiple procedures with modifier 51 (if required by the payer) C) Yes: Report distinct procedures with modifier 59 D) Yes: Report multiple bronchoscopy codes together because no modifier is required CPT code: 32650-RT ICD- 10 - CM codes: J90, C34.91 - CASE 1 Preoperative Diagnosis: Recurrent pleural effusion, stage IV right lung cancer. Postoperative Diagnosis: Recurrent pleural effusion, stage IV right lung cancer.(Report this diagnosis if no further findings are found in the notes.) Procedure Performed: Video-assisted thoracoscopy,(Indication the procedure is being performed by Video Assisted Thoracic Surgery (VATS).) lysis of adhesions, talc pleurodesis Procedure: Patient was brought to the operating room and placed in supine position. IV sedation and general anesthesia were administered, per the anesthesia department. A double-lumen endotracheal tube was placed, per anesthesia. The position was confirmed by bronchoscopy. The patient was placed in the decubitus position with the right side up. The chest was prepped in the standard fashion with ChloraPrep, sterile towels, sheets, and drapes. A small incision is made between two ribs and a standard port placement was utilized to gain access to the tho-racic cavity. The endoscope is inserted into the chest cavity. We had excellent isolation of the lung; however, we had poor exposure because there were a number of fibrous adhesions, a few were actually very dense. We immediately evacuated approximately 700 ml of fluid;(Indicating of pleural effusion(fluid around the lung, in the pleural space).) however, once we entered the chest we encountered a number of loculated areas. We did not break down the adhesions. We gained enough exposure to do a complete talc pleurodesis. After lysing of adhesions,(Removal of the adhesions to get to the thoracic cavity was necessary to
We identified a large bleb at the apex of the lower lobe of the left lung, which was likely to CPT® codes: 31259-50, 31267- 50 - 51 ICD- 10 - CM codes: J33.0, J33.8, J32.9 - CASE 4 Preoperative diagnosis: 1. Chronic hyperplastic rhinosinusitis 2. Allergies 3. Status postprior polypectomy and sinus surgery Postoperative diagnosis:
- Intranasal and sinus polyps (Report the diagnoses if no further positive findings are found in the operative note.)
- Chronic hyperplastic rhinosinusitis (Report the diagnosis if no further positive findings are found in the operative note.) Operative procedure: Left sinusotomy (three or more sinuses) including: • Nasal and sinus endoscopy • Endoscopic intranasal polypectomy • Endoscopic total sinus ethmoidectomy • Endoscopic sphenoidotomy • Endoscopic nasal antral windows, middle meatus, and inferior meatus • Endoscopic removal of left maxillary sinus contents Right sinusotomy (three or more sinuses) including: • Nasal and sinus endoscopy • Endoscopic intranasal polypectomy(Indication the surgery will be performed through an endoscope.) • Endoscopic total sinus ethmoidectomy • Endoscopic sphenoidotomy • Endoscopic nasal antral windows, middle meatus, and inferior meatus • Endoscopic removal of right maxillary sinus contents Specimens sent to pathology: 1. Left ethmoid and sphenoid contents for routine and fungal cultures 2. Right maxillary contents for routine and fungal cultures 3. Left intranasal ethmoid, sphenoid, and maxillary specimens for pathology
- Right ethmoid, sphenoid, maxillary, and right intranasal contents for pathology Findings: Complete nasal obstruction by polyps(Report this diagnosis for the intranasal polyps.) obscuring of all of the normal landmarks. The right middle turbinate was found and preserved. The residual body of the left middle turbinate was found and preserved. There was thickened hyperplastic mucosa throughout the sinuses with some polyps in the sinuses,(Documentation supports the presence of sinus polyps.) and the majority CPT® code: 39000 ICD- 10 - CM codes: D86.1, R59.0 - CASE 5 Preoperative Diagnoses
- Sarcoid of lymph nodes(Diagnosis if no further positive findings are found in the operative note.)
- New onset paratracheal adenopathy(Diagnosis if no further positive findings are found in the operative note.) Postoperative Diagnoses
- Sarcoid of lymph nodes
- New onset paratracheal adenopathy Procedure Performed: Mediastinotomy(Indication of what procedure is being performed.) Description of Procedure:
The patient was brought to the operating room and placed in supine position. IV sedation and general anesthesia was administered by the anesthesia department. The neck was prepped in standard fashion with betadine scrub, sterile towels and drapes. A standard linear incision was made over the trachea.(Procedure performed with the anterior cervical approach.) We were able to dissect down the pretracheal fascia into the mediastinum without difficulty. The extensive adenopathy was immediately apparent just below the innominate artery on the right paratracheal side. One exceedingly large lymph node was identified and biopsied extensively.(Biopsy performed.) The specimen was sent to pathology. Hemostasis was obtained without difficulty. The region was infused with a marcaine, lidocaine, and epinepherine mixture. The wound was closed in layers. The skin was closed with subcutaneous stitches and covered with Dermabond. The patient tolerated the procedure well and was taken to the recovery room in stable condition. What are the CPT® and ICD- 10 - CM codes reported? CPT® code: ICD- 10 - CM codes (2): CPT® code: 32555-LT ICD- 10 - CM code: J90 - CASE 6 Preoperative Diagnosis
- Loculated left pleural effusion, chronic Postoperative Diagnosis
- Loculated left pleural effusion, chronic Procedure Performed: Attempted, ultrasound guided thoracentesis Description of Procedure: The patient was prepped and draped in the sitting position. Using ultrasound guidance and 1% lidocaine, the thoracic catheter was introduced into the pleural space where we encountered very thick fibrous type pleura. The catheter was advanced, and we were unable to aspirate fluid. The catheter was removed. Sterile dressings were applied. Chest x-ray will be obtained for follow-up. Patient tolerated the procedure well. What are the CPT® and ICD- 10 - CM codes for this procedure? CPT® code: ICD- 10 - CM code: CPT® code: 32663-RT ICD- 10 - CM code: C34.11 - CASE 8 Preoperative Diagnosis:
- Mass, right upper lobe. Postoperative Diagnosis:
- Carcinoma, right upper lobe. Procedure Performed: VATS, right superior lobectomy. Description of Procedure:
24 hours. Patient tolerated the procedure well and was transferred to recovery in stable condition. What CPT® and ICD- 10 - CM codes are reported? CPT® code: ICD- 10 - CM codes (2): CPT® codes: 31625-RT, 31623- 51 - RT ICD- 10 - CM code: C34.81 - CASE 10 Preoperative Diagnosis: Carcinoma, right lung and bronchus intermedius. Procedure Performed: Bronchoscopy. DESCRIPTION OF PROCEDURE: Two liters of oxygen were supplied nasally. The right nostril was anesthetized with two applications of 4% lidocaine and two applications of lidocaine jelly. The posterior pharynx was anesthetized with two applications of Cetacaine spray. The Olympus PF fiberoptic bronchoscope was introduced into the patient's right nostril. The posterior pharynx, epiglottis, and vocal cords were normal. The trachea and main carina were normal. The entire tracheobronchial tree was then visually examined and the major airways. No abnormalities were noted on the left side. There was, however, extrinsic compression of the posterior segment of the right upper lobe. There also appeared to be a submucosal tumor involving the bronchus intermedius between the right upper lobe and right middle lobe. Multiple washings, brushings, and biopsies were taken from the right upper lobe bronchus and bronchus intermedius. The specimens were sent for cytology and routine pathology. The patient tolerated this without complications. The CPT® and ICD- 10 - CM codes to report are: CPT® codes (2): ICD- 10 - CM code: D - What ICD- 10 - CM code is reported for a patient that has RSV (respiratory syncytial virus) pneumonia? A) J18. B) B97. C) J21.0 D) J12. B - In ICD- 10 - CM, codes for Factors Influencing Health Status and Contact with Health Services begin with which letter? A) A B) Z C) V D) E B - What CPT® code is reported for an emergency endotracheal intubation to save the patient's life? A) 31600 B) 31500
C) 31603 D) 31502
A - Johnny has a penny removed from his left nostril in the provider's office. What CPT® code is reported? A) 30300 B) 30320 C) 30160 D) 30100 D - What CPT® code is reported for a major thoracotomy for post-op hemorrhage following an endoscopic upper lobectomy? A) 32310 B) 32110 C) 32100 D) 32120 A - A 43 year-old female is seen in the emergency room with severe epistaxis. She said this is a common occurrence for her during the cold dry months of winter and this is why she is here for the third time this week. Extensive bilateral posterior cautery and packing is again required to control the hemorrhage. What CPT® code is reported for the procedure? (Note: Do not code the E/M) A) 30906 - 50 B) 30905 - 50 C) 30903 - 50 D) 30905- 22 D - Most nasal passages have how many turbinates present on the lateral wall of each nasal cavity? A) 5 B) 2 C) 6 D) 3 C - An operative report lists excisional bilateral biopsies of deep cervical nodes and biopsy of right deep axillary nodes as the procedures performed. The pathology report comes back confirming lymphadenitis. What CPT® codes are reported? A) 38520 - 50, 38525- 51 - RT B) 38520 - 50, 38505-59, 38740- 59 - RT C) 38510 - 50, 38525- 51 - RT D) 38510, 38525- 51 - RT B - What CPT® codes are reported for an extrapleural pneumonectomy as well as empyemectomy performed during the same surgical session? A) 32440, 32540- 51 B) 32445, 32540- 51 C) 32440, 32036-51 D) 32445, 32036- 51
C - A patient with AML (Acute Myelogenous Leukemia) has just learned his sister is an HLA (Human Leukocyte Antigen) match for him. Stem cells taken from the donor (the patient's sister) will be transplanted into the patient to help with his treatment. What CPT® code is used to report the harvesting of the stem cells from the donor (his sister)? A) 38206 B) 38204 C) 38205 D) 38207 D - A patient underwent bilateral nasal/sinus diagnostic endoscopy. Finding the airway obstructed the provider fractures the middle turbinates to perform the surgical endoscopy with total bilateral ethmoidectomy and nasal septoplasty. What CPT® codes are reported? A) 31231, 30130-51, 31255- 50 B) 30930, 30520-51, 31255- 51 C) 30520, 31255- 51 D) 30520, 31255- 50 - 51 D - A patient presents to the emergency department (ED) with a sucking chest wound. The ED provider on duty performs an immediate tube thoracostomy in order to restore normal breathing to the patient before rushing him to surgery for another provider to address other injuries. What CPT® code is reported by the ED provider? A) It is not coded, as it will be bundled with any procedures performed during surgery. B) 31500 C) 31603 D) 32551 B - A returning 2 year-old child is seen in the pediatrician's office with stridor and a bark like cough. The pediatrician examines the child quickly and determines the child has stridulous croup. The child is given a nebulizer breathing treatment in the office to improve PO2 levels. Medication used is breathable Epinephrine. What CPT® and ICD10-CM codes are reported? A) 94644, R06.1, R B) 94640, J38. C) 94644, J04. D) 94642, J38.5, R05, R06. C - A patient with recurrent pneumothoraces presents for chemopleurodesis. Under local anesthesia a small incision is made between the ribs. A catheter is inserted into the pleural space between the parietal and pleural viscera. Subsequently, 5g of sterile asbestos free talc was introduced into the pleural space via the catheter. What CPT® and ICD- 10 - CM codes are reported? A) 32601, 32560, J95. B) 32650, 32560, J93.
C) 32560, J93.
D) 32650, J95.
A - The surgeon makes an incision in the neck near the cricothyroid membrane for an emergency tracheostomy for a patient who arrives in the emergency room with tracheal crushing injuries suffered in a car accident in which the patient was riding as the passenger. What CPT® and ICD- 10 - CM codes are reported? A) 31605, S17.0XXA, V49.9XXA B) 31603, S11.10XA, V49.9XXA C) 31612, S21.309A, V86.19XA D) 31600, S21.309A, V86.19XA C - A 45 year-old presents with acute pericarditis. The surgeon makes a small incision between two ribs and enters the thoracic cavity. An endoscope is introduced and the pericardial sac is examined by direct visualization. Using an instrument introduced through the endoscope, the surgeon creates an opening in the pericardial sac for drainage purposes. What CPT® code is reported? A) 32662 B) 32658 C) 32659 D) 32661 B - An ICU diabetic patient who has been in a coma for weeks as the result of a head injury becomes conscious and begins to improve. The provider performs a tracheostomy closure and since the scar tissue is minimal, the plastic surgeon is not needed. What CPT® and ICD- 10 - CM codes are reported for this procedure? A) 31825, Z43.0, E11.641, S06.9X9D B) 31820, Z43.0, S06.9X9D, E11. C) 31820, E11.641, Z93. D) 31825, Z43.0, E11.9, S06.9X9D C - A 27 year-old girl has been on the lung transplant list for months and today she will be receiving a LT and RT lung from an individual involved in an MVA. This person was DOA at the hospital and is an organ donor. The donor pneumonectomy was performed by physician A, the backbench work by physician B and the transplant of both lungs into the prepped and waiting patient by physician C. What is the correct coding for the removal (physician A), preparation (physician B) and insertion (physician C) of the lungs? A) 32850, 32856, 32851 x 2 B) 32850, 32855, 32851 C) 32850, 32856, 32853 D) 32850, 32855 x 2, 32850- 50 C - A patient with partial vocal cord paralysis requires bilateral removal of the arytenoids cartilage to improve breathing. The laryngoscope with operating microscope is inserted.
