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Principles of CPT Coding

1. Select CPT code for biopsy for eyelid margin.


(B)
(a)11100
(b)67810
(c) 6!10
(d)"one of t#e abo$e
Rationale: CPT code 11100 s#o%ld be reported only if a more speci&c
code of t#e anatomic area t#at is biopsied does not e'ist in t#e medical
record.
(. CPT code for debridement of 11.) of infected s*in
(C)
(a)11000
(b)11000+(
(c) 11000, 11001
(d)11001
Rationale: To %se CPT code 11001 t#e proced%re need not to #a$e
doc%mentation of additional 10) debridement.
-. CPT code for &ne needle aspiration of li$er cyst %nder %ltraso%nd
g%idance
(.)
(a)!7000
(b)!7000, !7001, 76/!(
(c) !7000, 8817(
(d)100((, 76/!(
Rationale: 100(1 and 100(( are %sed for 0"1 of any site of t#e body.
!. 1 dermatologist performed re2e'cision of a malignant lesion of ( cm
diameter 3it# 0. cm margins from t#e nec* of a patient after initial
e'cision of t#e lesion d%ring t#e post2operati$e period. Code t#e
proced%re. (C)
(a)116(-
(b)11!(-
(c) 116(- 4 8
(d)11!(- 4 78
Rationale: 1ccording to CPT g%idelines a re2e'cision of malignant
lesion s#o%ld be reported 3it# modi&er 8 if done d%ring global period.

. 1 dermatologist performed intralesional in5ection administration on
t#e scalp of a patient on / di6erent lesions of alopecia. 7n eac#
lesion ( in5ections 3ere gi$en.
(C)
(a)11/00, 11/01
(b)11/01+(
(c) 11/01
(d)/6!06
Rationale: "%mber of in5ections gi$en in t#e lesion is not a factor in
deciding t#e code. 1lopecia is not a malignant condition so
c#emot#erapy code is not applicable.
6. 1 dermatologist remo$ed t3o benign lesions of s*in from t#e face of
a patient of 0. cm diameter eac#, sit%ated 0.7 cm apart by a single
e'cision 3it# 0. cm margins. Code t#e proced%re.
(C)
(a)11!!1+(
(b)11!!(+(
(c) 11!!-
(d)11!!1, 11!!128
Rationale: Since single e'cision is done so collecti$e si8e of t#e t3o
lesions 3it# t#e distance bet3een t#em and margins are added 9
coded 3it# a single code. So :esion 1 0.cm ; :esion B 0.cm ;
.istance 0.7cm ; <argins 0.cm ; 0.cm = (.7cm.
7. 1 dermatologist performed e'cision of a 0. cm malignant lesion
3it# 0. cm margins from t#e scalp of a patient in t#e morning.
0ro8en section st%dy re$eals incomplete e'cision> #e #as to perform
a re2e'cision on t#e same day in t#e same session for additional 0.
cm margins. (1)
(a)116(-
(b)116((
(c) 116((, 116((2/
(d)116((, 116((28
Rationale: 1 re2e'cision performed for complete t%mor remo$al
d%ring t#e same session 3it# a single code by ta*ing t#e 3idest
diameter si8e after t#e last e'cision.
8. .estr%ction of 16 &broc%taneo%s s*in tags electroca%tery may be
coded as
(C)
(a)1700!
(b)17111
(c) 11(00, 11(01
(d)17000, 1700-
Rationale: .estr%ction of s*in tags are not coded from t#e destr%ction
codes instead it is coded 3it# codes %nder remo$al of s*in tags.
/. ?o%nd repair done by %sing ad#esi$e strips only may be coded as
(.)
(a)Simple repair
(b)7ntermediate repair
(c) Comple' repair
(d)"one of t#e abo$e
Rationale: ?o%nd clos%re %tili8ing ad#esi$e strips as t#e sole repair
material s#o%ld be coded by appropriate @A< code.
10. 7f a lesion is e'cised and t#e defect is closed 3it# ad5acent tiss%e
transfer> code t#e enco%nter for
(B)
(a)@'cision only
(b)1d5acent tiss%e transfer only
(c) Code for bot#
(d)"one of t#e abo$e
Rationale: T#e lesion e'cision is incl%ded in t#e ad5acent tiss%e
transfer code and is not coded separately.
11. 7f dressings are done for t#e treatment of b%rn in5%ry of partial
t#ic*ness on an area abo%t 6) of body s%rface on eac# arm, code
t#e enco%nter as (C)
(a)160(+(
(b)160(20
(c) 160-0
(d)160-020
Rationale: 7f dressings are done on t3o e'tremities report only one
code by c%m%lating t#e total body s%rface area of bot# sides.
1(. 7n case prior biopsy is not performed for a lesion and biopsy 9
<o#s s%rgery is performed on t#e same day
(.)
(a)Bot# <o#s s%rgery 9 Biopsy may be coded on same day
(b)Biopsy codes may not be reported only <o#s s%rgery s#o%ld
be coded
(c) Bnly biopsy s#o%ld be coded
(d)Bot# <o#s s%rgery 9 biopsy may be coded on same day 3it#
modi&er / to biopsy code(s)

1-. 7f a s%rgeon performed ablated t3o ad5acent &broadenomas by
one insertion of t#e cryoprobe, code it as
(1)
(a)1/10
(b)1/10+(
(c) 1/10, 76/!(
(d)1/10+(, 76/!(
Rationale: 7nstances 3#en t3o ad5acent &broadenomas are treated
3it# one insertion of t#e cryoprobe, code 1/10 s#o%ld be reported
once. T#e code also incl%des %ltraso%nd g%idance.
1!. Closed treatment is %sed to describe proced%res t#at treat
fract%res by t#e follo3ing met#odsC
(@)
(a)?it#o%t manip%lation
(b)?it# manip%lation
(c) ?it# or 3it#o%t traction
(d)1 9 B only
(e)1, B 9 C
1. CPT codes (0( and (0- are %sed to report trigger2point
in5ections
(C)
(a)Bnce per session regardless of n%mber of trigger points
(b)Bnce per session regardless of n%mber of m%scles in5ected
(c) Bot# 1 9 B
(d)"one of t#e abo$e
Rationale: Codes (0( and (0- are %sed to report trigger2point
in5ections once per session, regardless t#e n%mber of trigger points or
m%scles in5ected.

16. 7f t3o s%rgeons 3or* toget#er on a spine s%rgery as primary
s%rgeons performing distinct parts of a proced%re, eac# s%rgeon
s#o%ld report #is or #er distinct operati$e 3or* by adding modi&er
6( to t#e proced%re code and any associated add2on codes for t#at
proced%re (C)
(a)Tr%e
(b)0alse
(c) Tr%e b%t e'cept instr%mentation 9 bone graft codes
(d)Tr%e b%t e'cept bone graft codes
Rationale: <odi&er 6( s#o%ld not be appended to bone graft codes
and spinal instr%mentation codes, b%t to ot#er add2on codes it can be
appended.
17. CPT codes ((! and ((6-0 (.)
(a)S#o%ld not be reported 3it# modi&er 0
(b)S#o%ld not be reported t3ice
(c) Bnly 1 is correct
(d)Bot# 1 9 B are correct
Rationale: T#e proced%re in ((! in$ol$es a midline approac# and
t#e code description in CPT code ((6-0 does not di6erentiate t#e
proced%re as %nilateral or bilateral. So modi&er 0 s#o%ld not be %sed
3it# t#em.

18. 7f t3o metal cages are placed d%ring spine s%rgery one bet3een
:-2:! and anot#er bet3een :2S1 report t#e ser$ice as
(B)
(a)((81 once
(b)((81+(
(c) ((812((
(d)"one of t#e abo$e
Rationale: T#is code is to be reported only one time per interspace,
regardless of t#e n%mber of de$ices placed at t#at interspace.
Do3e$er, if metal cages are placed at t3o di6erent interspaces t#en
t#e add2on code ((81 may be reported t3ice.
1/. Code t#e proced%re for closed treatment of distal radial fract%re
3it# manip%lation along 3it# closed repair of %lnar styloid process
fract%re done on rig#t side.
(.)
(a)(60, (60
(b)(602ET2((
(c) (602ET, (602ET
(d)(602ET
Rationale: CPT code (600 and (60 incl%des t#e 3or* of (60.
(0. CPT codes (8(/02(8(// incl%des (@)
(a)Caps%lotomy
(b)Syno$ectomy
(c) Tenodesis
(d)1ll t#e abo$e
(e)1 9 B only
Rationale: Tenodesis is not incl%ded in (8(/02(8(//
(1. 1 PCP performed application of s#ort leg cast on a patient 3it#
sprain in t#e an*le and remo$ed t#e same after - 3ee*s of
immobili8ation. Code for bot# enco%nters.
(1)
(a)(/!0
(b)(/!0, (/7//
(c) (/!0, (/7//
(d)(/!0
Rationale: T#e codes for application of casts and strapping incl%de
t#e remo$al proced%re. Eemo$al is reported only 3#en a p#ysician is
remo$ing a cast t#at 3as applied by anot#er p#ysician.
((. CPT codes -1(-1 4 -1(- incl%de inspection of t#e follo3ing
str%ct%res.
(@)
(a)"asal ca$ity
(b)<iddle 9 s%perior meat%s
(c) T%rbinates
(d)Sp#enoet#moid recess
(e)1ll t#e abo$e
(-. Code t#e direct laryngoscopy proced%re, diagnostic performed in
a - year old female %nder general anest#esia
(.)
(a)-112(-
(b)-1(0
(c) -1(2(-26-
(d)-1(2(-
Rationale: <odi&er (- is %sed for %n%s%al anest#esia.
(!. Code t#e CPT proced%re for collection of t3o bronc#ial m%cosal
biopsy specimens in a single session by bronc#oscopy %tili8ation
endobronc#ial %ltraso%nd.
(C)
(a)-161
(b)-16(, -16(021
(c) -16(, -16(0
(d)-16(/,-16--
Rationale: Bronc#ial m%cosal biopsies are reported once only 3it#
CPT code -16( regardless of t#e n%mber of specimens collected. CPT
code -16(0 is an add2on code so modi&er 1 s#o%ld not be appended.
(. Code t#e proced%re for remo$al of t3o lobes of l%ngs. Bne from
t#e rig#t 9 t#e ot#er from t#e left l%ng.
(C)
(a)-(!8(
(b)-(!8(20
(c) -(!8020
(d)-(!8!20
Rationale: Bilobectomy code -(!8( is not to be reported for remo$al
of one lobe from t#e rig#t l%ng and one lobe from t#e left l%ng. 7t is
%sed only for bilobectomy of rig#t l%ng.
(6. Code t#e proced%re for coronary artery bypass proced%re done
by t3o sap#eno%s $ein grafts on rig#t coronary artery branc#es.
.%ring t#e same session t#e p#ysician also performed
transmyocardial laser re$asc%lari8ation of left coronary artery.
(.)
(a)--11, --1!0
(b)--10,
(c) --18, --1!1
(d)--11, --1!1
Rationale: CPT code --1!1 is %sed to report transmyocardial laser
re$asc%lari8ation done along 3it# ot#er open cardiac proced%res.

(7. 1 single c#amber cardio$erter2de&brillator may possess
(C)
(a)Bne electrode
(b)<ore t#an one electrode
(c) Bot# 1 9 B
(d)T3o electrodes
(8. 1ssessment and reassessment of t#e pacing cardio$erter2
de&brillator electrodes related to sensing, pacing and electrode
impedance c#aracteristics at t#e time of insertion, repair, re$ision
or replacement is additionally reported %sing codes
(C)
(a)/-6!0
(b)/-6!0, /-6!1, /-6!(
(c) /-6!0, /-6!1
(d)/-6!(
Rationale: CPT codes /-6!0 and /-6!1 are %sed for electrodes
assessment 9 reassessment. CPT code /-6!( is %sed for assessment 9
reassessment of cardio$erter2de&brillator.
(/. T3o p#ysicians operating as primary s%rgeons performed
insertion of a d%al c#amber pacema*er system 3it# electrodes
placement. S%rgeon 1 performed insertion 9 placement of t#e
electrode and s%rgeon B performed creation of s%bcla$ic%lar s*in
poc*et for p%lse generator. Code t#e proced%re. (C)
(a)S%rgeon 1 --(08, S%rgeon B --(!0
(b)S%rgeon 1 --(082(, S%rgeon B --(082(
(c) S%rgeon 1 --(0826(, S%rgeon B --(0826(
(d)S%rgeon 1 --(11, S%rgeon B --(1-
Rationale: S%rgical creation of a poc*et for t#e p%lse generator is
incl%ded 3#en t#e codes for pacema*er and pacing cardio$erter2
de&brillator proced%res are reported. Fse of modi&er 6( becomes
necessary 3#en t3o p#ysicians participate as primary s%rgeons d%ring
a single proced%re.
-0. 1 cardiologist performed repair of atrial trans$eno%s electrode in
a patient 3#o is on a d%al c#amber cardio$erter2de&brillator pacing
system. (1)
(a)--(18
(b)--((0
(c) --(182((
(d)--((02(
Rationale: T#e appropriate met#od for reporting t#e repair of only one
trans$eno%s electrode for a d%al2c#amber de$ice is to append modi&er
(, to code --((0.
-1. 1 cardiot#oracic s%rgeon performed redo triple coronary bypass
operation after t#ree years of t#e original proced%re in a patient
%sing t3o sap#eno%s $ein grafts and an internal mammary artery
graft. (B)
(a)----, --18
(b)----, --18, ---0
(c) ----, --18, -00
(d)--1(
Rationale: CPT code ---0 is reported to reGect t#e increased
diHc%lty associated 3it# t#e redo proced%re.
-(. 1 s%rgeon performed open repair of an infrarenal abdominal
aortic ane%rysm in$ol$ing iliac $essels %sing t%be prost#esis after
endo$asc%lar repair by %sing t3o doc*ing limb prost#esis failed.
(B)
(a)-!80-2-, -!8-0
(b)-!8-0
(c) -!80-, -10(2/
(d)-!80-, -!8-0
Rationale: CPT codes -!8-02-8!-( are reported to describe t#e
con$ersion to an open s%rgical proced%re for repair of complications
in$ol$ing a pre$io%sly placed prost#esis.
--. 1n @"T s%rgeon performed control of %ncontrolled bleeding in a
1! year old boy after (! #o%rs of s%rgery by s%rgical inter$ention.
T#e boy %nder3ent tonsillectomy on left side only for regro3n tonsil
after t#e initial tonsillectomy in 1( years age.
(C)
(a)!(/7028
(b)!(/6(28
(c) !(/6(278
(d)!(8(62(
-!. Do3 do yo% report diagnostic endoscopy of %pper
gastrointestinal tract along 3it# t#at of diagnostic lo3er
gastrointestinal tract endoscopy performed by t#e same p#ysician
on t#e same day on t#e same patientI (C)
(a)!-(-2((
(b)!-78, !-(-276
(c) !-78, !-(-2/
(d)!-782((
-. Do3 3ill yo% code transnasal endoscopic e'amination of
esop#ag%s for diagnostic p%rpose in a patient 3it# $err%co%s
carcinoma of tong%e ca%sing diHc%lty in passing t#e scope t#ro%g#
mo%t#I (.)
(a)!-(00
(b)!-(002((
(c) !-(002(-
(d)!-!//
Rationale: Trans2nasal endoscopy, a proced%re 3#ere a t#in Ge'ible
endoscope is passed t#ro%g# nares into t#e esop#ag%s, is coded by
%nlisted code !-!//.
-6. 1 (! year old at#lete reported to #is p#ysicianJs oHce 3it#
complaint of s3elling in t#e rig#t groin region 3it# mild pain %pon
e'ertion. T#e p#ysician performed a midle$el #istory 9 e'amination
of t#e patient and con&rmed t#e condition as rig#t ing%inal #ernia,
red%cible, initial. T#e p#ysician performed medical red%ction of t#e
#ernia, applied #ernia belt immediately and as* t#e patient to
report after ! days for f%rt#er management.
(C)
(a)!/0
(b)!/0, //(1-2(
(c) //(1-
(d)!/0, //(1-27

Rationale: <edical red%ction is a temporary meas%re and does
not#ing to c%re t#e %nderlying pat#ology. Kenerally, t#is red%ction is
performed as part of @A< ser$ice and is not reported separately. "o
s%rgery is done so no s%rgical CPT code is applicable. 0%rt#er no CPT
code e'ists for medical red%ction of #ernia also.
-7. Select t#e correct statement (.)
(a)Dernia repairs are commonly done 3it# %se of mes#
(b)CPT code !/68 is %sed to report placement of mes# d%ring
#ernia repair
(c) !/68 may be %se 3it# all #ernia repair codes if mes# is
placed
(d)1 9 B only
(e)B 9 C only
Rationale: CPT code !/68 is reported only 3it# codes !/602!/66

-8. Code t#e complete left renal transplantation proced%re
performed in a patient s%6ering 3it# c#ronic renal fail%re. T#e
s%rgeon performed t#e proced%re by #ar$esting t#e left *idney of a
li$ing donor by laparoscopy, and after standard bac*benc#
preparation 3it#o%t any reconstr%ction. T#e non f%nctional left
*idney of t#e patient 3#o #ad rig#t nep#rectomy ( year before 3as
also done d%ring t#e same session.
(.)
(a)0-(2:T, 0-602:T, 0-(02:T
(b)0-(2:T, 0-62:T, 0-(02:T
(c) 0-62:T, 0-(2:T, 0!72ET
(d)0-62:T, 0-(2:T, 0!72:T
-/. 1n %rologist performed trans%ret#ral electros%rgical resection of
prostate in a patient on t#e &rst day. T#e ne't post2operati$e day #e
performed $asectomy, and %ret#ral dilation of prostatic %ret#ra.
Code t#e entire ser$ice. (1)
(a)(601
(b)(601, -601, (02/
(c) (601, -600, (02/
(d)(601, -60028, (028, /
Rationale: T#e minor proced%res indicated in t#e descriptor of code
(601 3o%ld need to be performed before, d%ring, or after t#e s%rgery
and cannot be reported separately.
!0. Code t#e proced%re for cysto%ret#roscopic resection of bladder
t%mor of -cm si8e sit%ated ad5acent to t#e left %reteral ori&ce by
f%lg%ration. (C)
(a)((-!
(b)((-2:T
(c) ((-
(d)((82:T
Rationale: CPT codes ((0! 4 ((8 are ne$er reported 3it# modi&er
0 so also ET, :T.
!1. 1 gynecologist performed instillation of a topical antif%ngal agent
in t#e $agina of a patient 3#o is #a$ing #istory of allergy to
imida8ole gro%p of oral antif%ngal agents.
(C)
(a)7180
(b)7010
(c) 710
(d)71
!(. 1 gynecologist performed loop electrode coni8ation proced%re by
colposcopy to obtain a large tiss%e specimen from a patient 3it#
abnormal Pap smear 3it# endocer$ical c%rettage in a single session.
(B)
(a)7!61, 7!62/
(b)7!61
(c) 7(0
(d)7(0, 761
Rationale: @ndocer$ical c%rettage is incl%ded in 7!61. @ndocer$ical
c%rettage 9 dilatation and c%rettage are di6erent proced%re.
!-. Do3 do yo% report loop electrode ablation of endometrial polyps
performed by #ysteroscopy.
(B)
(a)88
(b)86-
(c) 8--
(d)8-6
Rationale: Proced%re in code 86- in$ol$es t#e %se of #ysteroscope
%tili8ing loop electrode (electros%rgery), roller ball or laser to ablate t#e
tiss%e.
!!. 1 gynecologist performed complete obstetric care 3it# forceps
assisted deli$ery and post part%m care to a patient on #er (
nd
pregnancy. T#e ne't day after t#e deli$ery s#e performed t%bal
ligation as desired by t#e patient. T#e patient 3as disc#arged on
t#e t#ird day after t#e deli$ery. Code bot# t#e ser$ices.
(C)
(a)/!002((
(b)/!00, 8600
(c) /!00, 860
(d)/!00, 8602/
Rationale: CPT code 860 is reported to t%bal ligation done d%ring
same #ospitali8ation of a deli$ery episode.
!. 1 blig#ted o$%m res%lting in prolonged retention of t#e embryo
in t#e &rst #alf of pregnancy is terminated by a gynecologist. Code
t#e proced%re. (B)
(a)/81(
(b)/8(0
(c) /8!0
(d)/86
Rationale: 1 blig#ted o$%m is a fertili8ed egg t#at fails to de$elop. 1
missed abortion refers to t#e prolonged retention of an embryoAfet%s
t#at died in t#e &rst #alf of pregnancy. So t#e appropriate code for t#is
proced%re is /8(0.
!6. Code t#e proced%re for placement of an endoscope in t#e
epid%ral space for diagnostic epid%roscopy.
(.)
(a)6(160
(b)6(161
(c) 6((81
(d)6!///
Rationale: "o codes e'ist in CPT for t#is proced%re. So report t#e
%nlisted ner$o%s system code for diagnostic epid%roscopy.
!7. Code t#e proced%re for repair of cerebrospinal G%id lea* from t#e
sp#enoidal region by nasal sin%s endoscopy performed in a patient
3it# #ead in5%ry. (.)
(a)61618
(b)6161/
(c) 6180
(d)-1(/1
!8. 1 ne%ros%rgeon performed craniotomy for implantation of t3o
ne%rostim%lator electrode arrays in t#alam%s, glob%s pallid%s,
s%bt#alamic n%cle%s, gray matter of peri$entric%lar and
periaL%ed%ctal area along 3it# microelectrode recording for
min%tes. Code t#e proced%re. (B)
(a)61867
(b)61867, 61868
(c) 61867, 61868, //61
(d)61861, //61
Rationale: 7f anot#er p#ysician performs t#e ne%rop#ysiologic
mapping, d%ring t#e s%rgery t#e second p#ysician s#o%ld report CPT
codes //61, //6(.
!/. 1 ne%ros%rgeon performed laminectomy of t#oracic spine
bet3een T!2T8 and placed a ne%rostim%lator electrode plates
epid%rally and performed a test stim%lation of t#e de$ice. Code t#e
ser$ice. (1)
(a)6-6
(b)6-6, //70
(c) 6-60, //70
(d)6-6, //71
Rationale: Test stim%lation $ia t#e implanted electrode is in#erent in
code 6-6. Do3e$er, for initial programming of generator or
transmitter2recei$er d%ring andAor immediately at t#e end of t#e
implantation operation, %se //70 4 //7-.
0. Eemo$al of t#e entire eyeball (intraoc%lar contents and scleral
s#ell), typically lea$ing only t#e e'traoc%lar m%scles and orbital fat.
Code t#e proced%re
(B)
(a)60/1
(b)6101
(c) 6110
(d)61102(

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