2020 official cpc®—certification study guide · 2021. 2. 16. · the official cpc®...

CERTIFIED PROFESSIONAL CODER

CERTIFICATIONCPC®

OFFICIAL STUDY GUIDE

2021

Official Study Guide CPC® Certification

ii 2021 Official Study Guide CPC® Certification CPT ® copyright 2020 American Medical Association. All rights reserved.

DisclaimerThis course was current when it was published. Every reasonable effort has been made to assure the accuracy of the informa-tion within these pages. The ultimate responsibility lies with readers to ensure they are using the codes, and following applicable guidelines, correctly. AAPC employees, agents, and staff make no representation, warranty, or guarantee that this compilation of information is error-free, and will bear no responsibility or liability for the results or consequences of the use of this course. This guide is a general summary that explains guidelines and principles in profitable, efficient healthcare organizations.

US Government RightsThis product includes CPT®, which is commercial technical data and/or computer data bases and/or commercial computer soft-ware and/or commercial computer software documentation, as applicable, which was developed exclusively at private expense by the American Medical Association, 515 North State Street, Chicago, Illinois, 60610. U.S. Government rights to use, modify, reproduce, release, perform, display, or disclose these technical data and/or computer data bases and/or computer software and/or computer software documentation are subject to the limited rights restrictions of DFARS 252.227-7015(b)(2) (November 1995),as applicable, for U.S. Department of Defense procurements and the limited rights restrictions of FAR 52.227-14 (June 1987) and/or subject to the restricted rights provision of FAR 52.227-14 (June 1987) and FAR 52.227-19 (June 1987), as applicable, and any applicable agency FAR Supplements, for non-Department of Defense Federal procurements.

AMA DisclaimerCPT® copyright 2020 American Medical Association. All rights reserved.

Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT®, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.

CPT® is a registered trademark of the American Medical Association.

Regarding HCPCS Level IIHCPCS Level II codes and guidelines discussed in this book are current as of press time.

Clinical Examples Used in this BookAAPC believes it is important in training and testing to reflect as accurate a coding setting as possible to students and examinees. All examples and case studies used in our study guides, exams, and workbooks are actual, redacted office visits and procedure notes donated by AAPC members. To preserve the real world quality of these notes for educational purposes, we have not re-written or edited the notes to the stringent grammatical or stylistic standards found in the text of our products. Some minor changes have been made for clarity or to correct spelling errors originally in the notes, but essentially they are as one would find them in a coding setting.

© 2020 AAPC2233 South Presidents Dr. Suites F-C, Salt Lake City, UT 84120

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Print ISBN: 978-1-646310-593 e-Book ISBN: 978-1-646311-255

CPC®, CIC™, COC™, CPC-P®, CPMA®, CPCO™, and CPPM® are trademarks of AAPC.

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CPT ® copyright 2020 American Medical Association. All rights reserved. www.aapc.com iii

Contributors:Katherine Abel, CPC, CPB, CPMA, CPPM, CMRS, AAPC Approved InstructorPaula Allard, CPC, CDEOQuitrina Carter, CPC, CEMC, AAPC Approved InstructorBerrie Corley, CPC, AAPC Approved InstructorLori A Cox, MBA, CPC, CPMA, CEMC, CGSC, CHONC, AAPC Approved InstructorBrad Ericson, MPC, CPC, COSCCindy Hagle, CPC, CPMA, CRCChristine Hall, CPC, CPB, CPMA, CRC, AAPC Approved InstructorEllen Hinkle, CPC, CPMA, CRC, CEMC, CFPC, CIMC, AAPC Approved InstructorCarol Hoppe, CPC, CCS-P, AAPC Approved InstructorNgina Lynch, CPC, AAPC Approved InstructorRachelle Marting, JD, MHSA, CPC, CPMA, CEMC, RHIA, AAPC Approved InstructorDanielle Price, CPC, RHIT, AAPC Approved InstructorGerald Robinson, CPC, AAPC Approved InstructorJacqueline J Stack, BSHA, CPC, CPB, CEMC, CFPC, CIMC, CPEDC, AAPC Approved InstructorPeggy A Stilley, CPC, CPB, CPMA, COBGC, AAPC Approved InstructorToni Toone, CPC, CPMA, CRC, AAPC Approved InstructorKathy Ware, RN, CPC, CPB, RHIA, CCS, AAPC Approved InstructorEssie White, CPC, COC, CPMA, CGSC, AAPC Approved InstructorRenee Whiting, CPC, AAPC Approved InstructorWendy WillesKathryn L Williams, COC, CPC, CPMA, CRC, CANPC, COSCMary Wood, CPC, AAPC Approved Instructor

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CPT ® copyright 2020 American Medical Association. All rights reserved. www.aapc.com v

Contents

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Chapter 1The Business of Medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Coding as a Profession . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

The Hierarchy of Providers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

The Different Types of Payers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Understanding RBRVS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Medical Necessity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

The Need for Privacy and Security . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Fraud and Abuse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Need for Compliance Rules and Audits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

The OIG Work Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

What AAPC Will Do for You . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Chapter 2Medical Terminology and Anatomy Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Medical Terminology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Integumentary System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Musculoskeletal System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

Cardiovascular System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Lymphatic System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

Respiratory System (Pulmonary System) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

Digestive System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

Urinary System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

Reproductive Systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

Nervous System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

Endocrine System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

Hematologic (Hemic) System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

Immune System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

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Contents

Chapter 3Introduction to ICD-10-CM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

Overview of ICD-10-CM Layout. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

Steps to Look Up a Diagnosis Code . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35

ICD-10-CM Official Guidelines for Coding and Reporting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35

Chapter 22: Codes for Special Purposes (U00–U85) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60

Diagnosis Coding Guidelines for Outpatient Reporting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60

Glossary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62

Chapter 4Introduction to CPT®, Surgery Guidelines, HCPCS Level II, and Modifiers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65

Introduction to CPT® . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65

National Correct Coding Initiative (NCCI) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68

Sequencing CPT® Codes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69

CPT® Assistant . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70

CPT® Category II Codes - Performance Measurement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70

CPT® Category III Codes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70

CPT® Appendices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71

Surgery Guidelines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72

HCPCS Level II . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73

HCPCS Level II Modifiers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75

Modifiers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75

Glossary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82

Chapter 5Integumentary System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85

Anatomy and Medical Terminology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86

ICD-10-CM Coding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86

CPT® Coding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90

Glossary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96

Chapter 6Musculoskeletal System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101

Anatomy and Medical Terminology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101

ICD-10-CM Coding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106

CPT® Coding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108

HCPCS Level II . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111

Modifiers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111

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Contents

Chapter 7Respiratory, Hemic, & Lymphatic Systems; Mediastinum, and Diaphragm . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115


ICD-10-CM Coding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 116

CPT® Coding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119

HCPCS Level II . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124

Modifiers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124

Glossary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124

Chapter 8Cardiovascular System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129


ICD-10-CM Coding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131

CPT® Coding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 134

Modifiers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 142

HCPCS Level II . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 142

Glossary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143

Chapter 9Digestive System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149


ICD-10-CM Coding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 150

CPT® Coding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 152

HCPCS Level II Coding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 156

Modifiers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 156

Glossary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 156

Chapter 10Urinary System and Male Genital System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161


ICD-10-CM Coding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163

CPT® Coding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 166

HCPCS Level II . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 170

Modifiers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 170

Glossary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171

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Chapter 11Female Reproductive System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 179

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 179


ICD-10-CM Coding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 180

CPT® Coding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 182


Modifiers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 184

Glossary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 184

Chapter 12Endocrine and Nervous System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 191

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 191


ICD-10-CM Coding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 194

CPT® Coding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 196

HCPCS Level II . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 203

Modifiers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 203

Glossary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 205

Chapter 13Eye and Ocular Adnexa, Auditory Systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 209

Eye: Introduction and Anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 209

Ear: Introduction and Anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 210

ICD-10-CM Coding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 211

CPT® Coding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 213

Medicine Codes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 214

HCPCS Level II . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 215

Modifiers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 215

Glossary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 215

Chapter 14Anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 221

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 221

Types of Anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 221

Anesthesia Providers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 221

Anesthesia Coding Terminology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 221

Postoperative Pain Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 222

ICD-10-CM Coding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 223

CPT® Coding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 223

Anesthesia-Related Teaching Rules . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 227

Glossary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 228

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Chapter 15Radiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 233

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 233


ICD-10-CM Coding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 233

CPT® Coding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 234

Types of Radiological Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 235

The Components of a Radiology Service . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 235

Diagnostic Ultrasound . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 236

Radiologic Guidance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 236

Breast, Mammography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 237

Bone/Joint Studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 237

Radiation Oncology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 237

Nuclear Medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 238


Modifiers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 238

Glossary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 239

Chapter 16Pathology and Laboratory . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 245

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 245


ICD-10-CM Coding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 246

CPT® Coding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 247


Modifiers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 250

Glossary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 251

Chapter 17Evaluation and Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 255

Introduction and Objectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 255

E/M Services Defined . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 255

CPT® E/M Services Guidelines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 256

E/M Service Categories . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 256

Choosing the E/M Service Level . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 262

Diagnosis Coding for E/M Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 281

Glossary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 282

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Contents

Chapter 18Medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 287

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 287

Anti-infective Immunizations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 287

Vaccines and Toxoids . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 287

Psychiatry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 288

Biofeedback . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 288

Dialysis and End Stage Renal Disease Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 288

Gastroenterology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 289

Ophthalmological Services & Special Otorhinolaryngologic Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 289

Cardiovascular Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 289

Noninvasive Vascular Diagnostic Studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 289

Pulmonary Studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 290

Allergy and Immunology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 290

Endocrinology & Neurology and Neuromuscular Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 290

Medical Genetics and Genetic Counseling Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 290

Central Nervous System Assessments/Tests . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 290

Hydration, Therapeutic, Prophylactic, Diagnostic Injections/Infusions and Chemotherapy, Highly Complex Drugs, or Highly Complex Biologic Agent Administration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 290

Photodynamic Therapy & Special Dermatological Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 291

Physical Medicine and Rehabilitation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 292

Education and Training for Patient Self-Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 293

Non-Face-to-Face Nonphysician Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 293

Special Services, Procedures, and Reports . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 294

Qualifying Circumstances for Anesthesia & Moderate (Conscious) Sedation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 294

Other Services and Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 294

Home Health Procedures and Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 295

Home Infusion Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 296

Medication Therapy Management Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 297

Glossary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 297

Chapter 19Tips for Taking an AAPC Certification Exam . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 303

CPC® Exam . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 303

Preparing for Your Exam . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 303

Exam Registration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 304

Day of the Exam. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 304

During the Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 304

Exam Completion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 305

CPT ® copyright 2020 American Medical Association. All rights reserved. www.aapc.com xi

Contents

Chapter 20Test Your Knowledge . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 307

Appendix AAnswers and Rationalesfor Chapter Review Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 325

Chapter 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 325

Chapter 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 326

Chapter 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 327

Chapter 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 329

Chapter 5 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 330

Chapter 6 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 332

Chapter 7 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 334

Chapter 8 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 335

Chapter 9 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 337

Chapter 10 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 338

Chapter 11 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 340

Chapter 12 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 342

Chapter 13 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 343

Chapter 14 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 344

Chapter 15 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 346

Chapter 16 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 347

Chapter 17 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 349

Chapter 18 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 351

Appendix BAnswers and Rationalesfor Test Your Knowledge . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 353

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 361

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CPT ® copyright 2020 American Medical Association. All rights reserved. www.aapc.com 1

The Official CPC® Certification Study Guide, (2021 edition) is organized to help you prepare for the exam certifying you as a professional medical coder. The Certified Professional Coder (CPC®) credential is awarded by AAPC, the primary organiza-tion of more than 190,000 medical coders, billers, scribes, and auditors.

This study guide, developed in cooperation with AAPC staff and members, can help you understand and practice the concepts, elements, and rules of medical coding. Throughout the Official CPC® Certification Study Guide are easy-to-under-stand explanations, examples, coding tips, and exercises meant to help you prepare for your exam.

Medical coding continues to grow and mature as a profession. Medical coders report the diagnoses, procedures, and supplies reported by physicians and other medical professionals to commercial and federal payers, such as Aetna or Medicare. They work closely with medical staff and must master medical terminology, anatomy, and physiology and apply this to health-care providers’ notes or operative reports.

As healthcare evolves so does medical coding. Medical coders perform in a variety of situations for physicians and facilities. They may participate in the actual billing process or audit claims sent to payers. They may code in independent billing companies. Medical coders often become the officers in charge of compliance with federal and state medical billing and coding regulations. They may work for the payers themselves as adjustors or auditors. Experienced coders often become consultants, serving clients who need coding, billing, auditing, or compliance assistance.

Medical coders will prove even more important as elements of healthcare reform and standardized electronic medical records are implemented. Coders will be instrumental as advisers, decision makers, technicians, medical coders, and auditors in the coming years.

CPC® Confirms CredibilityThe CPC® credential (and its derivative credentials: COC®, for example) illustrates to employers and colleagues that you understand the many facets of coding. A CPC® possesses the following:

Introduction

l Knowledge of anatomy, physiology, and medical terminology necessary to correctly code provider diagnoses and services

l Skill in accurate medical coding for diagnoses, procedures, and services in physician-based settings

l Proficiency across a wide range of services, which include evaluation and management, anesthesia, surgical services, radiology, pathology, and medicine

l Sound knowledge of medical coding rules and regulations including compliance and reimbursement

l Understanding of issues such as medical necessity, claims denials, bundling, and charge capture

l Expertise of how to integrate medical coding and reimbursement rule changes into a practice’s reimbursement processes

A CPC® successfully completes a 150-question examination in a 5-hour, 40 minute period. You should bring the latest CPT®, ICD-10-CM, and HCPCS Level II code books to the exam for code and guideline look-up. More information about the examination is available at www.aapc.com. A CPC® must hold membership in AAPC to sit for the exam and maintain a regimen of continuing education to keep the credential.

The Study GuideThe Official CPC® Certification Study Guide begins with a view of the business of medicine to help you understand the overall view of the medical office and how the coder fits in. After a review of anatomy, you will learn about ICD-10-CM guidelines with real life examples of how to apply them. Each body system is reviewed in its entirety, includes a review of the anatomy, related ICD-10-CM diagnosis coding, CPT® coding, HCPCS Level II coding, and modifiers. End of chapter reviews provide certification questions similar to those you will find on the exam, along with operative notes for each section for you to code. The study guide concludes with testing techniques and a 50-question review to test your knowledge for the CPC® certification exam.

Unlike most coding certification study guides that focus on each code set, this one more realistically prepares the coder not only for the examination but for the field, where each case more likely will include at least two code sets and require

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The Business of MedicineChapter

1

Coding as a ProfessionEach time an individual receives healthcare, a record is maintained of the resulting observations, medical or surgical interventions, diagnostic test and studies, and treatment outcomes. Coding is the process of translating this written or dictated medical record into a series of numeric and alphanu-meric codes. There are separate code sets to describe diagnoses, medical and surgical services/procedures, and supplies. These code sets serve as a common language to ease data collection (for example, to track disease), to evaluate the quality of care, and to determine costs and reimbursements.

Proper code assignment is determined both by the content (documentation) in the medical record and by the unique rules that govern each code set in that instance. Coding rules also may vary depending on who pays for the patient care, such as self-pay or health insurance.

Coding is typically performed by either the physician or a coder. When the physician performs the coding, the coder may take on the role of an auditor to verify that the documentation supports the codes the physician selected. In some practices, the coder will receive the medical record and code the services based on what is documented in the notes.

If the medical record is inaccurate or incomplete, it will not translate properly to the language of codes. The coder must evaluate the medical record for completeness and accuracy and communicate regularly with physicians and other healthcare professionals to clarify diagnoses or to obtain additional patient information.

Outpatient coding focuses on physician professional services and outpatient facility coding. Outpatient coders will focus on learning CPT®, HCPCS Level II, and ICD-10-CM codes. They will work in physician offices, outpatient clinics, and facility outpatient departments. Outpatient facility coders will also work with Ambulatory Payment Classifications (APCs).

Hospital inpatient coding focuses on a different subset of skills, where coders will work with ICD-10-CM and ICD-10-PCS. These coders also will assign medical severity diagnosis related groups (MS-DRGs).

Regardless of the setting, code updates and insurance payment policies may change as often as quarterly. Coders require continuing education to stay abreast of these changes.

The Hierarchy of ProvidersA variety of medical providers staff physician offices and hospi-tals, including physicians and non-physician providers (NPPs) (also known as mid-level providers or physician extenders), such as physician assistants (PA) and nurse practitioners (NP). NPPs are often reimbursed at a lower rate than physicians and require physician oversight. Different providers have different levels of education, and each state has scope of practice guide-lines for the various provider levels. Check your state health board’s website for scope of practice information.

The Different Types of PayersAlthough some patients will pay in full for their own medical expenses, most patients will have some type of insurance coverage. There are two primary types of insurers: commercial and government.

Commercial carriers are private payers that may offer both group and individual plans. The contracts they provide vary, but may include hospitalization, basic, and major medical coverage. For example, Blue Cross Blue Shield organizations are private payers who usually operate in the state in which they are based.

The most significant government insurer is Medicare. Medi-care is a federal health insurance program — administered by the Centers for Medicare & Medicaid Services (CMS) — that provides coverage for people over the age of 65, blind or disabled individuals, and people with permanent kidney failure or end-stage renal disease (ESRD). CMS regulations determine the coding requirements for Medicare and non-Medicare payers alike. The Medicare program is made up of several parts:

l Medicare Part A helps cover inpatient hospital care, as well as care provided in skilled nursing facilities, hospice care, and home healthcare.

l Medicare Part B helps cover medically necessary physicians’ services, outpatient care, and other medical services (including some preventive services) not covered under Medicare Part A. Medicare Part B is an optional benefit for which the patient must pay a premium, and which generally requires a yearly deductible and co-insurance.

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Medical Terminology and Anatomy ReviewChapter

2

Introduction This chapter will review medical vocabulary and terminology and introduce the basic elements of human anatomy. You may encounter terms not covered here within subsequent chapters. Objectives for this chapter include:

l Review word elements such as combining forms, prefixes, and suffixes

l Acquire an understanding of procedural and diagnostic terms

l Understand anatomy as it relates to coding

Medical Terminology The best way to learn medical terminology is by understanding word parts and elements of medical language—root words, prefixes, and suffixes—that serve as the foundation of the medical vocabulary.

The base of the word is considered the root. Root words can stand alone as the main portion of a medical term and the part that holds its fundamental meaning. A word can have more than one root.

Combining vowels are attached to root words to link the root word with the suffix, or one root word to another root word. Combining vowels also make medical terms easier to pronounce. The most common combining vowels are O and I. Occasionally, these vowels are dropped altogether, such as when the suffix begins with a vowel; however, the combining vowel is always placed between two root words, even when the second root word begins with a vowel.

Examples may include:

Root word/Definition

Blephar/o eyelidBucc/o cheekCholecyst/o gallbladderColp/o vaginaCyst/o a fluid sac or pouch, urinary bladderDerm/o skinEncephal/o brainEnter/o intestineHem/o, hemat/o bloodMy/o muscle

Myel/o spinal cord, bone marrowOnych/o nailOste/o bonePhleb/o veinPulm/o, pulmon/o lungsSynov/i synovial fluid, joint, or membrane

A prefix typically is attached to the beginning of a word to modify or alter its meaning. Prefixes often indicate location, time, or number.

Some common prefixes include:

Prefix/Definition

Ab- away fromAd- toward, nearAnte- beforeEc-, ecto- out, outsideEnd/o- in, withinMon/o- onePoly- many, muchPost- after, behind

A suffix is attached to the end of a word to modify or alter its meaning. In medical terms, suffixes frequently indicate the procedure, condition, disorder, or disease.

Some common suffixes include:

Suffix/Definition

-centesis puncture, tap-desis binding, fusion-ectomy excision, surgical removal-graphy act of recording data-pexy surgical fixation-plasty plastic repair, plastic surgery,

reconstruction-tripsy crushing

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Chapter 2 Medical Terminology and Anatomy Review

The human body contains three types of blood vessels: 1. Most arteries carry oxygenated blood away from the

heart. These vessels get smaller and turn into arteri-oles as they go into the extremities. Eventually they comprise the arterial side of the capillary bed.

2. Most veins carry deoxygenated blood back to the heart. The venous side of the circulation begins in the venous side of the capillary bed, enlarging to form venules and eventually forming veins and returning the blood to the heart. The left ventricle has a muscle mass that is much greater than any other chamber in the heart.

3. Capillaries are tiny vessels, usually a single cell layer thick. They are semi-permeable and facilitate the exchange of fluids, oxygen, nutrients, and waste between local tissues and the blood stream.

Heart

Heart Flow

Superior vena cava

Right pulmonary artery

Sinoatrial node

Right pulmonary veins

Atrioventricularnode

Right atrium

Tricuspid valve

Chordae tendinae

Right ventricle

AortaSeptum

Purkinje fibers

Left ventricle

Left atrium

Left pulmonary veins

Left pulmonary artery

Aorta

Arteries

Mitral (bicuspid)valve

Inferior vena cava

To right lung

From upper body To upper body

To left lung

From left lungFrom right lung

From lower body To lower body

Source: ShutterStock.com

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Chapter 7 Respiratory, Hemic, & Lymphatic Systems; Mediastinum, and Diaphragm

ICD-10-CM Chapter 10: Diseases of the Respiratory System has notes at the beginning of the chapter for reporting of respi-ratory codes:

l A respiratory condition affecting more than one site, and is not specifically indexed, the coder should classify the condition to the lower anatomic site. For example, tracheobronchitis is classified to bronchitis.

l An additional code is reported, when applicable, to identify the patient’s exposure to, history of, or current use or dependence of tobacco (smoke).

Acute Respiratory Infections (J00–J06)Infection may be caused by a virus or bacteria. Viral infections usually are self-limiting. Bacterial acute respiratory infections (ARIs) typically are treated with antibiotics (viral infections are not). ICD-10-CM codes for ARIs are separated by the anatomy: nose, pharynx, larynx, bronchus, and bronchioles.

Irritation and inflammation of the vocal cords cause laryngitis. Category J04 includes both laryngitis and tracheitis. Tracheitis codes are reported based on whether there is an obstruction.

Croup (J05.0) is a common, high pitched, barking cough found in infants and children with nasal type symptoms. Croup usually is caused by parainfluenza viruses; however, respira-tory syncytial virus (RSV), measles, adenovirus, and influenza all can cause croup. A milder form of croup, stridulus croup (J38.5), also known as laryngismus stridulus or false croup, is a sudden onset of spasmodic laryngeal closure with crowing inspiration.

Pneumonia and Influenza (J09–J18)Pneumonia, like ARI, can be caused by a virus, fungi, or bacteria. An acute respiratory infection can lead to pneumonia if not treated. ICD-10-CM codes for pneumonia are based on the causative agent and may require you to report an addi-tional code to describe the underlying disease.

Influenza is a viral infection that can be very serious. ICD-10-CM coding is based on the influenza strain: Avian (J09.X2), H1N1/novel influenza A (J10.1), unspecified with pneumonia or other respiratory manifestations. Code only confirmed cases of avian flu (see ICD-10-CM guideline 1.C.10.c).

Acute bronchitis (category J20) and acute bronchiolitis (cate-gory J21) commonly are diagnosed when a patient presents with symptoms of a severe or productive cough.

Lower respiratory infections that are not otherwise specified and are associated with documented COVID-19, are reported with codes U07.1 COVID-19 and J22 Unspecified acute lower respiratory infection.

Other Diseases of the Upper Respiratory Tract (J30–J39)Most codes in this section pertain to chronic conditions and include code J34.2 for an acquired deviated septum of the nose. This condition is commonly caused by trauma. The septum is the bone and cartilage that separates the right and left nostrils. Note the code for a congenital deviated septum is Q67.4. Nasal polyps (category J33) are sac-like growths inside the nose and are often associated with chronic sinusitis (category J32). Code selection will depend on which sinus is infected and inflamed.

Chronic Lower Respiratory Diseases (J40–J47)In emphysema (category J43), the walls between the air sacs are damaged causing them to lose their shape and elasticity. Chronic obstructive pulmonary disease (COPD) is a progres-sive disease that causes coughing, wheezing, shortness of breath, and difficulty breathing. Most people who have COPD have both emphysema and chronic obstructive bronchitis. The number one cause of COPD is smoking.

Asthma is a chronic inflammatory disease of the airway. When coding for asthma, the severity of the asthma physician docu-mented as intermittent, mild persistent, moderate persistent and severe persistent. The codes in categories J44 Other chronic obstructive pulmonary disease and J45 Asthma distinguish between uncomplicated cases and those in acute exacerbation, which is a worsening or a decompensation of a chronic condition.

Lung Diseases Due to External Agents (J60–J70)Pneumoconiosis (J60–J65) is a restrictive lung disease caused by inhalation of dust, causing irreversible scarring of the lungs. Other ICD-10-CM codes in this section include exposure to chemical fumes, vapors, solids, and liquids.

Respiratory Failure The codes for respiratory failure are selected by acute, chronic, unspecified and if there is the presence of hypoxia or hyper-capnia. The sequencing of acute respiratory failure (ARF) is determined by the reason for the encounter. If a patient is admitted for acute respiratory failure, a code from subcat-egory J96.0 Acute respiratory failure or J96.2 Acute and chronic respiratory failure is sequenced first. If the patient is admitted for multiple reasons, select the condition that required the most care.

Other Diseases of the Respiratory System Pulmonary edema is found in the ICD-10-CM Alphabetic Index by looking for Edema/lung and is reported with a code from category J81.

Interstitial lung disease (ILD), or diffuse parenchymal lung disease (DPLD), refers to a group of lung diseases affecting the interstitium (the tissue and space around the air sacs of the lungs). ILD (category J84) often is the result of pulmonary fibrosis from exposure to contaminants like asbestos.

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206 2021 Official Study Guide CPC® Certification CPT ® copyright 2020 American Medical Association. All rights reserved.

Endocrine and Nervous System Chapter 12

Chapter Review Questions

1. Which cells produce hormones to regulate blood sugar?

A. Eosinophils

B. Pancreatic islets

C. Hemoglobin

D. Target cells

2. What are chemicals which relay, amplify, and modulate signals between a neuron and another cell?

A. Neurotransmitters

B. Hormones

C. Interneurons

D. Myelin

3. A 35-year-old has neuroplasty performed in the wrist for carpal tunnel syndrome. The palm is opened through a curved incision, and further skin flaps are developed. The median nerve of the transverse carpal ligament is divided, decom-pressing the carpal tunnel. Tension of the nerve is released, and the incision is sutured in layers. What CPT® code describes this procedure?

A. 64721

B. 64719

C. 64708

D. 64704

4. A 30-year-old male has lumbar facet syndrome. Under fluoroscopic guidance, the affected nerve in the facet joints of the lumbar region is destroyed by a neurolytic agent in the right segmental medial branches innervating facet joints L3–L4, and L4–L5. What CPT® codes are reported?

A. 64493, 64494

B. 64635, 64636

C. 64483, 64484

D. 64633, 64634-50

5. A patient has spinal stenosis and disc displacement in the L3–L4 and L4–L5 interspaces and underwent a removal of the posterior arch of a vertebra to provide additional space for the nerves and to widen the spinal canal. The back was prepped, and an incision was made down to the deep fascia and the spinous processes of L5, L4 and L3 were identified performing the laminectomy of L4 up to L3 and a resection of the flavum ligament. There was resection of the facet L3 and L4 on the right and decompression was carried out laterally to the level of the medial border of the pedicle. Foraminotomies of L3–L4 and L4–L5 the right was performed with the Kerrison punch and there was plenty of room for the nerve roots to exit in these regions with no further stenosis above or below this area. What procedure code(s) is/are reported?

A. 63047, 63048

B. 63042, 63044

C. 63017

D. 63005


Chapter 13 Eye and Ocular Adnexa, Auditory Systems

Eye: Introduction and Anatomy

Eye Structures

Ciliary body

Anterior chamber with aqueous humor

Conjunctiva

Pupil

Cornea

Lens

Ora serrata

Rectus medialis

Vein

Optic nerve

Artery

Posterior chamber with vitreous humor

Macula

Retina

Sclera

Iris

Source: AAPC

The eyeball is composed of a tough membrane called sclera. This white outer skin of the eye is covered with a thin protec-tive layer of conjunctiva. Light first enters the eye through the cornea. The cornea has five layers; sometimes corneal defects will be managed by removing one or two layers, rather than full-thickness cornea. The cornea meets the sclera in a ring called the limbus, also known as the sclerocorneal junction. Behind the cornea is the anterior segment of the eye, which is filled with a clear, salty fluid called aqueous humor.

Next, light from the aqueous humor enters the crystalline lens, a convex disc suspended on threads just behind the iris. The iris is a muscle that expands and contracts to regulate the amount of light entering the posterior chamber of the eye through the pupil. If the light is too bright, the iris expands so the size of the pupil shrinks. If there is too little light, the iris

contracts to enlarge the pupil and allow more light into the eye. The threads holding the lens and the ciliary body to which they are connected automatically tug at the lens to change its shape to help focus on items near or far.

After the light has been bent by the crystalline lens, it enters the vitreous humor, a gel-like mass that fills the large poste-rior chamber of the eye. The vitreous humor presses against the inner layer of the eye, maintaining the eyeball’s shape and keeping the blood-rich choroid layer in contact with the retina. The light is placed upon the retina’s rods and cones like a projected image at a movie theater, and these images are transmitted via the optic nerve to the brain.

The eyeball’s shape affects the way light is focused and directed (refraction). Any reduction in fluid within the eye will affect

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Chapter 17 Evaluation and Management

To select an overall MDM level, at least two of three compo-nents (number and complexity of problems addressed; amount and complexity of data to be reviewed and analyzed; risk of complications and morbidity or mortality) for that level must be met.

Table D: Medical Decision Making (MDM)

Final Results of Tables A, B, C = Level of Medical Decision Making (MDM) l Must consider 2 of the 3 MDM elements for the overall MDM level

£ Use any two components that meet or exceed £ Drop the lowest one

Table A Number/Complexity of Problems Addressed

Minimal Low Moderate High

Table B Amount and/or Complexity of Data to be Reviewed and Analyzed

Minimal or none Limited Moderate Extensive

Table C Risk of Complications and/or Morbidity or Mortality of Patient Management

Minimal Low Moderate High

MDM Level Straightforward Low Moderate HighNew Patient Code 99202 99203 99204 99205Established Patient Code 99212 99213 99214 99215

EXAMPLE

CHIEF COMPLAINT: Right knee pain secondary to underlying degenerative primary arthritis.

HISTORY OF PRESENT ILLNESS: This 70-year-old female returns to schedule total knee arthroplasty. She was evaluated last week. She continues to have constant pain with her activities for about 7 months. Symptoms are present with both weight bearing and rest. She was found by recent radiograph to have tricompart-mental degenerative changes.

PHYSICAL EXAMINATION: She is intact to sensation, has palpable pulses. There is bogginess of the synovium. She has retropatellar crepitation. There is tenderness through both the medial and lateral joint line. There is valgus alignment of the knee.

IMPRESSION: Right knee pain with underlying degenerative arthritic changes.

PLAN: We will proceed with surgical intervention for right total knee arthroplasty. Risks and benefits of surgery have been reviewed. These include the risks of anesthesia, infection, damage to nerve, vessel, soft tissue, residual loss of motion or weakness, residual pain, blood clot, blood loss, knee instability, fracture of bone. A complete history and physical obtained in the office.

Rationale: This patient is an established patient. The level is selected based on the AMA CPT® Office or Other Outpatient E/M Services guidelines.

l The number and complexity of problems addressed – moderate (chronic problem with exacerbation).

l The amount and complexity of data to be reviewed and analyzed – none.

l The risk of complications and morbidity or mortality of patient management – moderate (elective major surgery).

The moderate number and complexity of problems and moderate risk make 99214 the correct code.

TimeTime can be an element of code selection for a variety of E/M services. Because different categories use time differently, it is important to review the instructions for the use of time in each category of E/M service. In this section, we will discuss time as it relates to Office or Other Outpatient Services. The amount of time spent on the encounter must be documented by the provider.

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Chapter 20 Test Your Knowledge

The following 50 questions will test your comprehension of the information covered in this study guide. You should be able to complete this exercise in approximately 115 minutes. Answers are found in Appendix B.

Important Note: Although this exercise is a useful assessment tool, the best means to gauge your preparedness to pass the CPC exam is to take our online practice exams (found at https://www.aapc.com/training/practice-exams.aspx#cpc) which mirror the actual test format and difficulty level. The practice exams are timed and are created by the CPC exam development team.

1. A 30-year-old is brought into the burn unit with burns covering 30% of his total body. He has third-degree burns to his chest wall (10%), second-degree burns on his arm and both legs (15%), and first-degree burns on his face (5%).

What ICD-10-CM codes are reported for the burns?

A. T21.30XA, T22.239A, T24.231A, T24.232A, T20.10XA

B. T30.0, T21.60XA, T30.4

C. T21.31XA, T22.20XA, T24.201A, T24.202A, T20.10XA, T31.31

D. T20.10XA, T22.20XA, T21.31XA, T24.201A, T23.202A, T31.31

2. Two malignant lesions on the scalp measuring 1.1 cm and 2.0 cm, and one malignant lesion on the neck measuring 2.2 cm were destroyed. Electrocautery was used for the first two lesions and laser was used for the third lesion.

What procedure code(s) is/are reported?

A. 17276

B. 17273, 17272-51

C. 17273, 17272-51, 17272-51

D. 17274, 17273-51

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Appendix B

Answers and Rationales for Test Your Knowledge

1. C. T21.31XA, T22.20XA, T24.201A, T24.202A, T20.10XA, T31.31

RATIONALE: The ICD-10-CM guidelines for reporting the burn codes are found in Section I.C.19.d. The guidelines indicate that when there is more than one burn, sequence first the code that reflects the highest degree burn. In this case, there are third degree burns to the chest. In the ICD-10-CM Alphabetic Index, look for Burn/chest wall/third degree T21.31-. Look for Burn/arm (lower) (upper) - see Burn, upper, limb. Burn/upper/limb/second degree T22.20-. Look for Burn leg(s) (lower) (upper) - see Burn, lower, lower limb. Burn/lower/limb/right/second degree T24.201- and left/second degree T24.202-. Look for Burn/face - see Burn, head. Burn/head (and face) (and neck)/first degree T20.10-. A code from category T31 is also reported to identify the extent of the burn. These codes identify the total body surface areas that were burned (TBSA) and the percentage of third degree burns. In the Alphabetic Index, look for Burn/extent/30-39 percent/with 10-19 percent third-degree T31.31.

In the Tabular List, a 7th character is required on these injury codes to identify the episode of care. Based on the ICD-10-CM guidelines for 7th characters, A is assigned for initial encounter (active treatment). For the codes that are less than six characters in length, the X placeholders are required to maintain the 7th character in the seventh position.

2. C. 17273, 17272-51, 17272-51

RATIONALE: Codes are selected for the destruction of malignant lesions based on the location and size of the lesion. When multiple malignant lesions are destroyed, a code is selected for each lesion. Destruction can be accomplished by multiple methods including electrocautery, cryosurgery, chemosurgery, laser, and curettement. The malignant lesion of the neck is 2.2 cm, which is reported with CPT® code 17273. The 1.1 cm malignant lesion on the scalp is reported with code 17272. The 2.0 cm of the scalp is also reported with code 17272. Modifier 51 is appended to indicate multiple procedures were performed. To locate the codes in the CPT® Index, look for Destruction/Lesion/Skin/Malignant, which refers you to codes 17260–17286.

3. B. 11606, 15220, 15221, C44.719

RATIONALE: An excision of a malignant lesion is performed. Look in the CPT® Index for Excision/Skin/Lesion/Malig-nant referring you to codes 11600–11646. The code is selected based on the site and size of the malignant lesion removal. The largest diameter of the lesion is 4.3 cm. The margins are 0.75 cm. The excised diameter (4.3 + 0.75 + 0.75) is 5.80 cm. The excision is reported with CPT® code 11606. The repair is performed using a full thickness skin graft. Look in the CPT® Index for Full Thickness Graft and you are referred to codes 15200–15261. The code is selected according to the sq cm of the graft. The measurement is 5 cm x 5 cm, which is 25 sq cm, reported with code 15220 for the first 20 sq cm and code 15221 for the additional 5 sq cm. The patient is diagnosed with basal cell carcinoma. From the ICD-10-CM Alphabetic Index, look for Carcinoma/basal cell. You are directed to see also Neoplasm, skin, malignant. Go to the Table of Neoplasms, look for Neoplasm, neoplastic/skin/limb/lower/basal cell carcinoma and refer to the Malignant Primary column, C44.71-. A 6th character is required. The correct code is C44.719.

4. C. 11056, L85.9

RATIONALE: In the CPT® Index, look for Paring/Skin Lesion/Benign Hyperkeratotic referring you to codes 11055-11057. The procedure code for removal of the hyperkeratotic lesion is 11056 Paring or cutting of benign hyperkeratotic lesion; 2 to 4 lesions. The evaluation and management documentation is all related to the surgery and is not reported separately. In the ICD-10-CM Alphabetic Index, look for Lesion(s)/hyperkeratotic - see Hyperkeratosis. Look for Hyperkeratosis referring you to L85.9.

5. B. 20610, M10.062

RATIONALE: The knee is aspirated by drawing out fluid from the knee joint using a needle. In the CPT® Index, look for Aspiration/Joint. Code selection is dependent on the size of the joint and if ultrasound guidance is used. Code 20610

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Index

SA node, 130

Sarcoma, 166

Scar revision, 93, 110

Schwannomas, 198

Sclerosis, 34, 131

Scoliosis, 293

Scope instrument, 105

Screening codes, 59, 215 examination, 233 mammogram, 58, 233, 237 test, 58, 59, 294

Scrotal destruction, 170 reconstruction, 170

Seborrheic keratosis, 88

Segmental instrumentation, 105

Selective catheterization, 137, 197

Semi-quantitative, 245, 249

Sensory information, 192

Sepsis, 38, 39, 51

Septic shock, 38, 39, 51

Septicemia, 38, 39

Septoplasty, 119

Sequelae, 36, 47, 49, 52, 58, 133

Seroma, 90

Sexual dysfunction, 44

Shave biopsy, 91 removal, 91

Shoulder disarticulation, 110 pain, 95

Shunt reservoir, 240

Shuntogram, 240

Sigmoidoscopy, 154, 156

Simulation, 237, 238, 304

Sinus, 88, 96, 117, 120, 131, 139, 162, 167, 198

Sinusitis, 117

Sinusotomy, 120

Skin biopsies, 91, 279 cancer, 94 disease, 291, 292 flap, 93, 94 graft, 93 infections, 87 substitutes, 93 tag, 91 ulcers, 88

Smoking cessation, 260

Snare technique, 154

Solar keratosis, 88

Sonohysterography, 236

Sore throat, 255

Spastic colitis, 151 colon, 151

SPECT, 139

Spectral Doppler, 141

Speech therapy, 295

Sphenoidotomy, 120

Spina bifida, 205

Spinal instrumentation, 110 lesions, 293 manipulation, 293 neurostimulators, 200 puncture, 57, 199, 205, 291 stenosis, 293 stereotaxis, 200

Spine surgeries, 111

Spirometry, 123

Splenic flexure, 25, 154 rupture, 119

Splenoportography, 123

Splenorrhaphy, 123

Spondylosis, 293

Staged procedure, 73, 79, 123

Standby services, 255, 294

Statin therapy, 65

Status asthmaticus, 48 migrainosus, 196

STEMI, 47, 133

Stenosis, 119, 121, 131, 133, 165, 289, 293

Stent, 138, 140, 166-169, 172, 289

Stent exchange, 169 insertion, 167 placement, 140, 167

Stereoscopic guidance, 238

Stereotactic radiosurgery, 198, 200, 205

Stereotaxis, 198, 200

Steri-Strips, 14

Strabismus, 44, 211, 212

Strain, 39, 105, 117

Strep throat, 249

Streptococcus, 38, 57, 96, 249

Stress echo, 141

Stricture, 131, 144, 165, 167, 170, 173

Stroboscopy, 121

Stromal tumors, 166

ST-segment elevation, 47

Suboccipital bone, 27 muscles, 27

Substance abuse, 60, 260

Suicide, 58

Suspected condition, 53, 59

Suspicious lesion, 91

Suture closure, 91 removal, 67

Suturing, 91, 163, 201

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