Appendix D text AC200610: Basic CPT and HCPCS Coding Page 1 of 26 

Answers to Chapter Review Exercises,

Appendix D

Chapter 1: Introduction to Clinical Coding

Chapter 1 Review
1. The American Medical Association (AMA) updates the CPT codes, and the Centers for Medicare
and Medicaid Services (CMS) updates the HCPCS National Codes (Level II).
2. Four
3. ICD-9-CM and CPT/HCPCS
4. a. Diagnosis: ICD-9-CM
Procedure: CPT/HCPCS
b. Diagnosis: ICD-9-CM
Procedure: CPT/HCPCS
c. UB-04 (CMS-1450)
5. ICD-9-CM
6. Procedure code 11440 is linked with diagnosis code #1 (216.3). Procedure code 82951 is linked with
diagnosis code #3 (790.29).
Note: Depending on the carrier, you may link more than one reference number in block 24E, whereas
some payers require just one. When reporting more than one code on a CMS-1500 claim, enter the
code with the highest fee in line 1 of block 24 and the remaining in descending order of charges.

Chapter 2: Application of the CPT System

Exercise 2.1 Organization of CPT
1. Surgery
2. Evaluation and Management
3. Pathology and Laboratory
4. Category II codes
5. Medicine
6. Radiology
7. Anesthesia
8. Category III codes
9. Maternity Care and Delivery
10. StandbyServices
Appendix D text AC200610: Basic CPT and HCPCS Coding Page 2 of 26 

11. Radiation Oncology

12. Surgical Pathology

Exercise 2.2 CPT Conventions

1. Repair blood vessel, direct; hand, finger
2. Two
3. Revised descriptor
4. Esophagoscopy, rigid or flexible, with insertion of plastic tube or stent
5. New descriptor
6. No
7. No
8. 13152, 13153
9. 40814
10. 31578, 31576

Exercise 2.3 Use of the Alphabetical Index

1. 23400 Green operation, see scapulopexy
2. 10021 Fine Needle Aspiration
3. 35556 Graft, see Bypass graft, Femoral Artery or Popliteal Artery
4. 49555 Hernia repair, femoral, recurrent
5. 26991 Incision and drainage, bursa, hip
6. 01680 Anesthesia, shoulder
7. 31525 Laryngoscopy, direct
8. 72149 MRI see magnetic resonance imaging, spine, lumbar
9. 11055 Paring, skin lesion, benign hyperkeratotic, single lesion
10. 86701 HIV-1, antibody
11. 41105 Biopsy, tongue
12. 43239 Esophagogastroduodenoscopies, see Endoscopy, gastrointestinal, upper, biopsy
13. 29881 Arthroscopy, surgical, knee
14. 95827 EEG, see Electroencephalography, sleep
15. 65220 Removal, foreign body, cornea, without slit lamp
16. 58356 Endometrial Ablation (this exercise is difficult find in the alphabetic index, but a good lesson
on how locating correct entries in the index is not a perfect science). Endometrial ablation directs coder
to 58363, which is endometrial ablation (thermal). Alert students to look at the code below 58363—
58356.
17. 4008F Beta-blocker therapy, see Performance Measures, Therapeutic, preventive or other
interventions, Beta-Blocker therapy
18. 0184T Excision, Tumor, Rectum, Transanal Endoscopic
19. 77082 DXA, see Dual X-ray Absorptiometry, vertebral fracture
Appendix D text AC200610: Basic CPT and HCPCS Coding Page 3 of 26 

20. 25112 Ganglion, Cyst, Wrist Excision

Exercise 2.4 CPT Coding Process

1. Colonoscopy and polypectomy
2. 45384–45385
3. How was the polyp removed (hot biopsy forceps, snare, and so on)?
4. “Was removed with hot biopsy forceps and retrieved”
5. 45384

Exercise 2.5 CPT Coding Process

1. Excision
2. Can be located under Excision, lesion, skin; or Lesion, skin, excision
Selections: Benign 11400–11471
Malignant 11600–11646
3. Pathologic diagnosis indicates that the lesion was malignant (11600–11646).
4. Documentation is needed to code malignant lesion, size of lesion + margins (or size of excision)
(2.0 cm + 0.5 cm + 0.5 cm = 3.0 cm excision site) and site (arm).
5. 11603

Exercise 2.6 CPT Coding Process

1. Hernia repair
2. Index entries: Hernia repair, umbilicus; Repair, hernia, umbilical. Codes to review:
49580–49587
3. Age of patient; incarcerated or strangulated hernia
4. Review of documentation (38-year-old patient and no documentation for incarcerated/strangulated
hernia). Using the abstracted documentation and process of elimination, the correct code would be
49585.
5. Wound closure would be an integral part of the procedure and would not be assigned a CPT code.

Exercise 2.7 Coding References

1. 45380
2. CPT Assistant, January 1996, page 7, instructs the coder to assign 45385. CPT Assistant, January
2004, states that if a small polyp is removed via cold knife biopsy, the appropriate code is 45380.
This is a good example of the need to research the most current coding advice.
Appendix D text AC200610: Basic CPT and HCPCS Coding Page 4 of 26 

Exercise 2.8 Coding References

1. When a biopsy of a lesion is obtained and the remaining portion of the same lesion is then
excised/fulgurated, only the code for the excision/fulguration should be used. When the biopsy is
taken from a different lesion than the one excised, the biopsy code and an additional code for the
removal of the separate lesion are reported. It would be appropriate to append modifier 59 to the
code reported for the biopsy procedure.
2. Reference: CPT Assistant, October 2004, Skin Biopsy Coding Guidelines.
Exercise 2.9 Coding References
1. No. Code 36479 would be reported only once. The code descriptor for code 36479 states, “second and
subsequent veins treated in a single extremity, each through separate access sites,” indicating that
the second, third, fourth, etc. vein(s) are represented in code 36479. No additional reporting occurs
after the second vein is treated.
2. Reference: CPT Assistant, July 2012, pages 12-13 (Frequently Asked Questions)

Exercise 2.10 Chapter 2 Review

1. Bullet
2. 11100 and 11101
3. Category III
4. 42320
5. 40843
6. Removal of less than 80% of vulvar area, and there was removal of skin and deep subcutaneous
tissue. (See the note before CPT code 56405.)
7. Method of removal
8. No. Versed is a type of conscious sedation. The symbol appears before code 43235; therefore,
administration/monitoring of conscious sedation would be inherent in the procedure.
9. 76857, based on the definitions provided in the note before code 76830
10. 11730, 11732, 11732

Chapter 3: Modifiers
Exercise 3.1 Chapter 3 Review
1. 55
2. 77
3. 22
4. 62
5. 53
6. 64721–50 Carpal tunnel syndrome, decompression
7. 11730–FA Avulsion, nails
Appendix D text AC200610: Basic CPT and HCPCS Coding Page 5 of 26 

8. 11043–73 Debridement, muscle

9. 64611-52 Chemodenervation, salivary glands
10. 19102–LT Biopsy, breast
11. 28485–RT Fracture, metatarsal, open treatment
Note: –T9 is not applicable in this case because the procedure refers to the bones of the foot, not the toes.

Chapter 4: Surgery
Exercise 4.1 Integumentary System‐ Debridement

1. 11042 Debridement, skin, subcutaneous tissue

2. 11010 Debridement, skin, with open fracture

3. 11005 Debridement, skin, infected

11008 Removal, mesh, abdominal wall

Exercise 4.2 Integumentary System ‐ Lesions

1. 11421 Excision, skin, lesion, benign; or
11402 Lesion, skin, excision, benign
2. 17110 Lesion, skin, destruction, benign
3. 11642 Excision, skin, lesion, malignant; or Lesion, skin, excision, malignant
4. 11200 Skin, tags, removal
5. 11403 Lesion, skin, excision, benign
6. 11644 Lesion, skin, excision, malignant
7. 11641 Lesion, skin, excision, malignant
11640

Exercise 4.3 Integumentary System

1. 11442 Excision, skin, lesion, benign; or Lesion, skin, excision, benign
Exercise 4.4 Integumentary System
1. 11308 Lesion, skin, shaving

Exercise 4.5 Integumentary System – Wound Repairs

1. 12002 Wound, repair; or Repair, wound, simple
2. 12032 Wound, repair; or Repair, wound, intermediate
3. 12041 Wound, repair; or Repair, wound, intermediate
Appendix D text AC200610: Basic CPT and HCPCS Coding Page 6 of 26 

12002 Wound, repair; or Repair, wound, simple (sum of repairs)

Exercise 4.6 Integumentary System

1. 12001 Wound, repair; or Repair, wound, simple

Exercise 4.7 Integumentary System

1. 12032 Wound, repair; or Repair wound (simple and intermediate)
12005

Exercise 4.8 Integumentary System

1. 13121 Wound, repair (complex)
13122

Exercise 4.9 Integumentary System

1. 11603 Lesion, skin, excision, malignant
12031 Wound, repair (intermediate)

Exercise 4.10 Integumentary System – Skin Grafts

1. 14021 Skin Graft and Flap, tissue transfer
2. 15150 Skin Graft and Flap, tissue-cultured
15151
3. 15220 Skin Graft and Flap, free skin graft, full thickness

Exercise 4.11 Integumentary System

1. 15120 Autograft, skin, epidermal
11646 Excision, skin, lesion, malignant; or Lesion, skin, excision, malignant

Exercise 4.12 Integumentary System

1. 15100 Skin, grafts, free

Exercise 4.13 Integumentary System

1. 19000–LT Breast, cyst, puncture aspiration

Exercise 4.14 Integumentary System

1. 19125–LT Excision, breast, cyst; or Breast, excision, lesion by needle localization
Note: The hospital also would assign 19290 for placement of the wire. The surgeon would not assign this
code because the radiologist performed the procedure. In addition, a radiology code would be
submitted for both the facility and the radiologist. Radiology is introduced in chapter 5.

Exercise 4.15 Integumentary System

1. 19120–RT Breast, excision, cyst; or Excision, breast, cyst
Note: The entire nodule was excised, not just a piece of tissue, which is implied with the term biopsy.
Appendix D text AC200610: Basic CPT and HCPCS Coding Page 7 of 26 

Exercise 4.16 Integumentary System Review Review

1. 16020 Burns, dressings
2. 14020 Skin Graft and Flap, tissue transfer
Note: Excision of lesion is included and should not be assigned an additional code.
3. 12032 Wound, repair, intermediate
Note: Anatomic modifiers (LT, RT) are not appropriate.
4. 19102–LT Breast, biopsy
19295–LT Breast, metallic localization clip placement
5. 11606 Lesion, skin, excision, malignant
6. 11770 Pilonidal cyst, excision (Single-layer closure indicates “simple.”)
7. 11750–TA Nails, removal
8. 15781 Dermabrasion
9. 17273 Skin, destruction, malignant lesion
10. 11043 Debridement, skin, subcutaneous tissue

Exercise 4.17 Musculoskeletal System ‐ Fractures

1. 25545–LT Fracture, ulna, shaft, open treatment
2. 21800 Fracture, rib, closed treatment
21800
3. 23605–RT Fracture, humerus, closed with manipulation
4. 27532–RT Fracture, tibia, closed treatment (initial cast application included with treatment code)
5. 27562–RT Dislocation, patella, closed treatment
6. 27514–LT Fracture, femur, distal
7. 24516–RT Fracture, humerus, shaft

Exercise 4.18 Musculoskeletal System

1. 29515–RT Splint, leg, short
Note: E/M code 99283–25 is applicable in this case.

Exercise 4.19 Musculoskeletal System

1. 27788–LT Fracture, fibula, closed treatment; or Fracture, fibula, with manipulation
Appendix D text AC200610: Basic CPT and HCPCS Coding Page 8 of 26 

Exercise 4.20 Musculoskeletal System ‐ Arthroscopy

1. 29875–LT Arthroscopy, surgical, knee
2. 29827–RT Arthroscopy, surgical, shoulder
3. 29846–LT Arthroscopy, surgical, wrist
4. 29837–LT Arthroscopy, surgical, elbow

Exercise 4.21 Musculoskeletal System

1. 29882–RT Arthroscopy, surgical, knee

Exercise 4.22 Musculoskeletal System Review

1. 28475–LT Fracture, metatarsal, closed
28475–LT
2. 28285–T1 Hammertoe repair
3. 27766–RT Fracture, ankle, medial
4. 20101 Wound, exploration, penetrating, chest
5. 23030 Hematoma, shoulder, drainage
6. 24343–RT Ligament, repair, elbow
7. 28740–LT Arthrodesis, tarsal joint
8. 29844–RT Arthroscopy, surgical, wrist
9. 28108–T2 Excision, cyst, phalanges, toe
10. 27372–RT Removal, foreign body, knee joint

Exercise 4.23 Respiratory System ‐ Endoscopy

1. 31255–50 Ethmoidectomy, endoscopic
2. 31238–LT Endoscopy, nose, surgical; or Nose, endoscopy, surgical
3. 31233–50 Sinusoscopy, sinus, maxillary

Exercise 4.24 Respiratory System

1. 30520 Septoplasty
31267–50 Endoscopy, nose, surgical
30140–50 Turbinate, excision

Exercise 4.25 Respiratory System ‐ Laryngoscopy

1. 31540 Laryngoscopy, direct
2. 31577 Laryngoscopy, fiberoptic
3. 31510 Laryngoscopy, indirect
Appendix D text AC200610: Basic CPT and HCPCS Coding Page 9 of 26 

4. 31541 Laryngoscopy, direct

Exercise 4.26 Respiratory System

1. 31536 Laryngoscopy, direct

Exercise 4.27 Respiratory System ‐ Bronchoscopy

1. 31628 Bronchoscopy, biopsy
2. 31641 Bronchoscopy, removal, tumor
3. 31625 Bronchoscopy, biopsy
31623 Bronchoscopy, brushing

Exercise 4.28 Respiratory System

1. 31623 Bronchoscopy, brushing

Exercise 4.29 Respiratory System Review

1. 32666 Thoracoscopy, surgical with wedge resection of lung
2. 30110 Polyp, nose, excision, simple
3. 31625 Bronchoscopy, biopsy
4. 30300 Removal, foreign body, nose
5. 31237 Endoscopy, nose, surgical
6. 30903–50 Epistaxis
7. 31540 Laryngoscopy, direct
8. 32556 Puncture, pleural cavity, drainage
9. 31576 Laryngoscopy, fiberoptic
10. 30130 Excision, turbinate

Exercise 4.30 Cardiovascular System

1. 33207 Pacemaker, heart, insertion; or Insertion, pacemaker, heart

Exercise 4.31 Cardiovascular System

1. 36590 Removal, venous access device

Exercise 4.32 Cardiovascular System

1. 36556 Insertion, venous access device, central

Exercise 4.33 Cardiovascular System

Review
1. 33222 Pacemaker, heart, revise pocket, chest
Appendix D text AC200610: Basic CPT and HCPCS Coding Page 10 of 26 

2. 36833 Arteriovenous Fistula, Revision, with thrombectomy

3. 33824 Ductus Arteriosus, repair
4. 36215 Catheterization, brachiocephalic artery
5. 36582 Venous Access Device, replacement
6. 36870 Arteriovenous Fistula, thrombectomy, graft; or Thrombectomy, arteriovenous fistula, graft
7. 37224 Angioplasty, Femoral artery, intraoperative
8. 33464 Valvuloplasty, tricuspid valve
9. 33217 Insertion, pacing cardio-defibrillator, leads
10. 37722–50 Vein, stripping, saphenous

Exercise 4.34 Digestive System ‐ Endoscopy

1. 43202 Endoscopy, esophagus, biopsy
43217 Endoscopy, esophagus, removal, polyp
Note: Modifier 59 would apply.
2. 45305 Proctosigmoidoscopy, biopsy
3. 43258 Endoscopy, gastrointestinal, upper, destruction of lesion
4. 45380 Endoscopy, colon, biopsy
5. 43264 Bile Duct, endoscopy, removal, calculi

Exercise 4.35 Digestive System

1. 43247 Endoscopy, gastrointestinal, upper, foreign body

Exercise 4.36 Digestive System

1. 45384 Colonoscopy, removal, polyp; or Endoscopy, colon, removal, polyp

Exercise 4.37 Digestive System

1. 45330 Sigmoidoscopy, exploration

Exercise 4.38 Digestive System – Hernia Repairs

1. 49500 Hernia, repair, inguinal
2. 49561–RT Hernia, repair, incisional, incarcerated
49568 Implantation, mesh
3. 49651 Laparoscopy, hernia repair, inguinal, recurrent
4. 49521 Hernia, repair, inguinal, incarcerated
5. 49585 Hernia, repair, umbilicus, reducible
6. 49656 Hernia, repair, incisional, laparoscopic

Exercise 4.39 Digestive System

Appendix D text AC200610: Basic CPT and HCPCS Coding Page 11 of 26 

1. 49505–LT Hernia, repair, inguinal

Note: Mesh code is only coded with incisional and ventral hernia repairs.

Exercise 4.40 Digestive System Review

1. 46930 Hemorrhoids, destruction
2. 43644 Laparoscopy, gastric restrictive procedures
3. 43245 Endoscopy, gastrointestinal, upper, dilation
4. 42200 Palatoplasty
5. 45383 Colonoscopy, destruction, lesion
6. 47564 Laparoscopy,cholecystectomy
7. 49521 Hernia Repair, inguinal, recurrent, incarcerated
8. 49322 Laparoscopy, aspiration
9. 46610 Anoscopy, removal, polyp
10. 42809 Removal, foreign body, pharynx

Exercise 4.41 Urinary System ‐ Cystoscopy

1. 52332 Cystourethroscopy, insertion, indwelling ureteral stent
2. 52234 Cystourethroscopy, with fulguration, tumor
3. 52353 Cystourethroscopy, lithotripsy
4. 52282 Cystourethroscopy, insertion, urethral stent

Exercise 4.42 Urinary System

1. 52352 Cystourethroscopy, removal, calculus
52332–51–RT Insertion, stent, ureteral
Note: Because the stent was inserted at the conclusion of the procedure, one can presume it is an
indwelling ureteral stent.

Exercise 4.43 Urinary System

1. 52234 Cystourethroscopy, with fulguration, tumor

Exercise 4.44 Urinary System Review

1. 51992 Sling Operation, stress incontinence
2. 53260 Excision, polyp, urethra
3. 52235 Cystourethroscopy, with fulguration, tumor
4. 51525 Cystotomy, excision, bladder diverticulum
5. 50200 Kidney, biopsy
6. 52351 Cystourethroscopy
Appendix D text AC200610: Basic CPT and HCPCS Coding Page 12 of 26 

7. 52290 Cystourethroscopy, with ureteral meatotomy (bilateral modifier not appropriate because
code description specifies “unilateral” or “bilateral”)
8. 51785 Electromyography, sphincter muscles, urethral, needle
9. 51701 Insertion, catheter, urethral
10. 50920 Fistula, ureter

Exercise 4.45 Male Genital System

1. 54057 Lesion, penis, destruction, laser surgery
2. 10060 Incision and drainage, abscess, skin
3. 55845 Prostatectomy, retropubic, radical
4. 54861 Epididymectomy, bilateral
5. 54150 Circumcision, surgical excision, newborn

Exercise 4.46 Male Genital System

1. 55875 Prostate, brachytherapy, needle insertion

Exercise 4.47 Male Genital System

1. 54520–LT Orchiectomy, simple

Exercise 4.48 Male Genital System Review

1. 54840 Spermatocele, excision
2. 54415 Penile Prosthesis, removal, inflatable
3. 54690 Orchiectomy, laparoscopic
4. 54322 Hypospadias, one stage, meatal advancement
5. 54865 Epididymis, exploration, biopsy
6. 55100 Scrotum, abscess, incision and drainage
7. 54240 Penis, plethysmography
8. 54060 Penis, lesion, destruction, surgical excision
9. 54640–50 Orchiopexy, inguinal approach
10. 55866 Laparoscopy, prostatectomy

Exercise 4.49 Female Genital System

1. 58670 Laparoscopy, oviduct surgery
2. 58120 Dilation and curettage, corpus uteri
3. 59812 Abortion, incomplete
4. 49322 Laparoscopy, aspiration
5. 58545 Laparoscopy, removal, leiomyomata
Appendix D text AC200610: Basic CPT and HCPCS Coding Page 13 of 26 

6. 58262 Hysterectomy, vaginal, removal tubes/ovaries

Exercise 4.50 Female Genital System

1. 57461 LEEP Procedure

Exercise 4.51 Female Genital System

1. 58558 Hysteroscopy, surgical with biopsy
Exercise 4.52 Female Genital System Review
1. 57455 Colposcopy, biopsy (range of codes)
2. 56620 Vulvectomy, simple, partial (use definitions at beginning of section)
3. 58662 Laparoscopy, destruction, lesion
4. 58150 Hysterectomy, abdominal, total
5. 57023 Incision and Drainage, hematoma, vagina
6. 56605 Biopsy, vulva (external genitalia)
57105 Biopsy, vagina
7. 58554 Hysterectomy, vaginal
8. 58561 Hysteroscopy, removal, leiomyomata
9. 58290 Hysterectomy, vaginal
10. 58356 Ablation, endometrium, ultrasound guidance

Exercise 4.53 Endocrine System Review

1. 60280 Thyroglossal Duct, cyst, excision
2. 60650 Laparoscopy, adrenal gland, excision
Note: There are several misleading index entries for this example. Adrenalectomy, laparoscopic, leads to
50545. Same is true for Laparoscopy, adrenalectomy.
3. 60260–50 Thyroid Gland, excision, total, removal of all thyroid tissue
4. 60300 Thyroid gland, cyst, aspiration
5. 60500 Parathyroid Gland, excision

Exercise 4.54 Nervous System

1. 64445 Injection, nerve, anesthetic
2. 64702–F8 Neuroplasty, digital nerve
69990 Operating microscope
3. 62281 Epidural, injection
4. 64831–F5 Neurorrhaphy
64832–F8
Appendix D text AC200610: Basic CPT and HCPCS Coding Page 14 of 26 

Exercise 4.55 Nervous System

1. 63075 Discectomy

Exercise 4.56 Nervous System Review

1. 62220 Creation, shunt, ventriculo
2. 64712 Neuroplasty, peripheral nerve
3. 64782 Excision, neuroma
4. 64840 Suture, nerve
5. 63272 Laminectomy
6. 62311 Epidural, injection
7. 63688 Neurostimulators, removal, pulse generator
8. 63706 Myelomeningocele, repair
9. 64408 Nerves, injection, anesthetic
10. 61312 Craniotomy, surgery

Exercise 4.57 Eye and Ocular Adnexa

1. 66984–LT Phacoemulsification, removal, extracapsular cataract

Exercise 4.58 Eye and Ocular Adnexa Review

1. 65222 Removal, foreign body, cornea with slit lamp
2. 67810–E1 Biopsy, eyelid
3. 68110 Lesion, conjunctiva, excision
4. 67800–E3 Chalazion, excision, single
5. 67311 Strabismus, repair, one horizontal muscle
6. 67700–E3 Eyelid, abscess, incision and drainage
7. 67906–E1 Blepharoptosis, repair, superior rectus technique with fascial sling
8. 67961 Eyelid, repair, excisional
9. 67914 Ectropion, repair, suture
10. 67413–RT Orbitotomy, with removal of foreign body

Exercise 4.59 Auditory System

1. 69436–50 Tympanostomy (–50 for bilateral)

Exercise 4.60 Auditory System Review

1. 69910 Labyrinthectomy with mastoidectomy
2. 69205–LT Removal, foreign body, auditory canal, external, with anesthesia
3. 69636 Tympanoplasty, with mastoidotomy, with ossicular chain reconstruction
Appendix D text AC200610: Basic CPT and HCPCS Coding Page 15 of 26 

4. 69005–LT Abscess, ear, external, complicated (would expect to see documentation to explain why
the procedure took an extensive amount of time)
5. 69401 Eustachian Tube, inflation, without catheterization

Exercise 4.61 Chapter 4 Review: Coding for Facility

1. 42305 Incision and drainage, abscess, parotid gland
2. 69436–50 Tympanostomy
3. 57455 Colposcopy, biopsy
4. 52234 Cystourethroscopy, with fulguration, tumor
5. 19101–LT Biopsy, breast
6. 12051 Repair, wound, intermediate
7. 26750–F5 Fracture, phalanges, closed treatment, distal
8. 31536 Laryngoscopy, direct
9. 36569 Catheter, venous, central line
10. 45333 Sigmoidoscopy, removal, polyp
11. 49507–50 Hernia repair, inguinal, incarcerated
12. 29834–LT Arthroscopy, surgical, elbow
13. 26010–FA Finger, abscess, incision and drainage
26010–F1
14. 63266 Laminectomy
15. 69666 Fistula, oval window
16. 28261 Capsulotomy, foot
17. 54060 Lesion, penis, surgical excision
18. 11305 Lesion, skin, shaving
19. 59000 Amniocentesis
20. 58558 Polypectomy, uterus

Exercise 4.62 Chapter 4 Review: Coding for Physician Services

1. 61520–62 (physician #1)
Cerebellopontine angle tumor, see brain, tumor, excision
61520–62 (physician # 2)

2. 59840 Abortion, induced by dilation & curettage

3. 29821–RT Arthroscopy, surgical, shoulder
4. 33208–54 Pacemaker, heart, insertion (modifier for surgical care only)
5. 43268 ERCP, see Pancreatic duct, endoscopy, tube placement
6. 58661–22 Laparoscopy, removal, fallopian tube
7. 68811–50 Nasolacrimal duct, exploration, with anesthesia
Appendix D text AC200610: Basic CPT and HCPCS Coding Page 16 of 26 

Note: Bilateral modifier applies because

the code describes one duct.
8. 31267–50 Endoscopy, nose, surgical
9. 44151 Colectomy, total, open, with ileostomy
10. 27786–79 Fracture , fibula, closed treatment
11. 15783 Dermabrasion

Chapter 5: Radiology
Exercise 5.1 Diagnostic Radiology
1. 74182 MRI, see Magnetic resonance imaging, abdomen
2. 72131 CT scan without contrast, spine, lumbar
3. 72170 X-ray, pelvis
4. 74241 X-ray, gastrointestinal
5. 74430 Cystography
6. 74261 CT scan, without contrast, colon, colonography
7. 74177 CT scan, with contrast, abdomen (Note: The note under code 74170 directs the coder to
assign a code for a combined CT of abdomen and pelvis)

Exercise 5.2 Diagnostic Ultrasound

1. 76831 Hysterosonography, see Ultrasound; Sonohysterography
2. 76815 Ultrasound, pregnant uterus
3. 76645 Ultrasound, breasts
4. 76800 Ultrasound, spine
5. 76770 Ultrasound, kidney

Exercise 5.3 Chapter 5 Review

1. 73090–26 X-ray, arm, lower
Note: Modifier 26 is reported to identify the professional component of the procedure which in-
cludes supervising the procedure, reading and interpreting the results, and documenting the interpre-
tation in a report.
2. 72142–26 MRI, see magnetic resonance imaging, spine, cervical
3. 74430 Cystography
Note: Modifier 26 was not appended to the code because the description includes supervision and
interpretation.
4. 78451 Myocardial, Perfusion imaging

5. 77057 Mammography, screening

6. 74178 CT Scan, without and with Contrast, Abdomen
Appendix D text AC200610: Basic CPT and HCPCS Coding Page 17 of 26 

7. 70460–TC CT scan, with contrast, head

Note: In this case, the radiology facility would report modifier TC to identify the technical
component of the procedure, which includes performance of the actual procedure and expenses for
supplies and equipment.
8. 76817 Ultrasound, pregnant uterus
9. 76942 Ultrasound, guidance, needle biopsy
10. 78306 Bone, nuclear medicine, imaging
11. 74270 Barium enema
12. 78205 SPECT, liver
13. 77404 Radiation therapy, treatment delivery, single area
14. 78707 Scan, see Specific site, nuclear medicine, Kidney, Nuclear medicine, imaging
15. 71020 X-ray, chest
16. 77761 Radioelement, application
17. 72240 Myelography, spine, cervical
18. 76775 Ultrasound, retroperitoneal
19. 73540 X-ray, hip
20. 78262 Reflux study
21. 76775 Ultrasound, kidney (Code 76775, limited, is for a single organ.) (See CPT Assistant,
May 1999.)
22. 73500–LT X-ray, hip
72170 X-ray, pelvis (1 to 2 views)
23. 71020 X-ray, chest
24. 74247 X-ray, gastrointestinal
25. 70450 CT scan, without contrast, head

Chapter 6: Pathology and Laboratory Services

Exercise 6.1 Chapter 6 Review
1. 88305 Pathology, gross and micro exam
2. 83880 Natriuretic peptide
3. 80402 ACTH, see adrenocorticotropic hormone, stimulation panel
4. 81003 Urinalysis, automated
5. 85055 Platelet assay
6. 88309 Pathology, surgical, gross and micro exam
7. 86485 Candida skin test
8. 86689 Antibody, HTLV-1
Appendix D text AC200610: Basic CPT and HCPCS Coding Page 18 of 26 

9. 80061 Organ- or disease-oriented panel, lipid panel

80051 Organ- or disease-oriented panel, electrolyte
10. 80198 Drug assay, theophylline
11. 82803 Blood gases—pO2, pCO2
12. 86706 Hepatitis antibody, B surface
13. 85730 Thromboplastin, partial time
85610 Prothrombin time
14. 88027 Autopsy, gross and micro examination
15. 88331 Pathology, surgical, consultation, intraoperative

Chapter 7: Evaluation and Management Services

Exercise 7.1 Evaluation and Management (History)
1. HPI is brief (location, quality, and duration). Review of system(s) is problem specific. No PFSH
documented. The history component of this visit would be expanded problem focused (brief HPI,
problem-specific ROS, and expanded problem-focused PFSH including past, family, and social
history). The history component is equal to the lowest category documented.
2. HPI is brief (location, severity, and duration). Review of system(s) is extended (two to nine
systems), and PFSH is pertinent (medications). The history is determined by the lowest level from
all three categories; therefore, the history level would be expanded problem focused.
3. HPI is extended (location, severity, duration, and context). Review of systems is extended (two to
nine systems). The PFSH is complete (two history areas documented). The history level is detailed;
all three categories met this level.

Exercise 7.2 Evaluation and Management (Physical Examination)

1. Comprehensive examination: eight body systems were reviewed.
2. Expanded problem-focused examination: two systems reviewed (constitutional and integumentary)
3. Detailed examination. Note that the criteria for expanded problem focused and the detailed category
are the same except in the level of specificity in the examination. Decisions on the level of
specificity can be somewhat subjective.

Exercise 7.3 Evaluation and Management (Medical Decision Making)

1. Moderate complexity
Appendix D text AC200610: Basic CPT and HCPCS Coding Page 19 of 26 

2. Low complexity

3. Straightforward

Exercise 7.4 Evaluation and Management Case Study

Established Patient History
Appendix D text AC200610: Basic CPT and HCPCS Coding Page 20 of 26 

Medical Decision Making

1. Review the code descriptions for 99211–99215. Need two out of the three key components. The case study revealed a
detailed history and comprehensive examination, and the medical decision making was of moderate complexity. The
correct E/M code selection is 99214.

Exercise 7.5 Evaluation and Management

1. True
2. False
3. False
4. False
5. False
6. Extended—Four elements: yesterday (duration); getting ready to go to church (context); vomited
bile (quality); deafness at the start (associated signs/symptoms)
7. Expanded problem focused—Systems reviewed: respiratory, integumentary, ENT (ears, nose,
throat), cardiovascular, gastrointestinal. Expanded problem focused (two to nine systems)
8. Pertinent—One area (past history)

Exercise 7.6 Chapter 7 Review

1. 99211
2. 99203
3. 99245
4. 99202
5. 99291
6. 99281
Appendix D text AC200610: Basic CPT and HCPCS Coding Page 21 of 26 

7. 99396
8. 99213
9. 99235
10. 99212
11. 99203
Chapter 8: Medicine

Exercise 8.1 Immunizations

1. 90460 Immunization administration, one vaccine/toxoid, with counseling
90461 x 3 (each additional vaccine/toxoid component)

90710 Vaccines, Measles, Mumps, Rubella and Varicella

2. 90471 Immunization administration, one vaccine/toxoid
90703 Vaccines, tetanus toxoid
3. 90471 Immunization administration, one vaccine/toxoid
90472 (add-on code) Immunization administration, each additional vaccine/toxoid
90632 Vaccines, hepatitis A
90658 Vaccines, influenza
4. 90470 Immunization administration, one vaccine/toxoid
90650 Vaccine, Human Papilloma Virus
5. 90471 Immunization administration
90472 each additional vaccine
90748 Vaccines, hepatitis B and Haemophilus influenzae B

Exercise 8.2 Psychiatry

1. 90885 Psychiatric diagnosis, evaluation of records or reports
2. 90847 Psychotherapy, family
3. 90834 Psychotherapy, Individual Patient/Family Member

Exercise 8.3 Dialysis

1. 90962 Dialysis, end-stage renal disease
2. 90945 Dialysis, peritoneal
3. 90969 Dialysis, end-stage renal disease
90969 (per day)

Exercise 8.4 Ophthalmology

1. 92018 Gonioscopy (See note under code 92020)
Appendix D text AC200610: Basic CPT and HCPCS Coding Page 22 of 26 

2. 92004 Ophthalmology, Diagnostic, Eye Exam, New patient

Exercise 8.5 Cardiovascular Services

1. 93025 Electrocardiography, Rhythm, Microvolt T-wave Alternans
2. 93452 Cardiac Catheterization, Left Heart, with Ventriculography
3. 92977 Thrombolysis, coronary vessels
4. 93015 Stress Tests, cardiovascular
5. 92924–LC Artery, coronary, atherectomy
6. 92920–LD Percutaneous Transluminal Angioplasty, artery, coronary
7. 93293 Telephone, Pacemaker Analysis

Exercise 8.6 Pulmonary Services

1. 94060 Spirometry, see Pulmonology, diagnostic, spirometry, evaluation
2. 94660 CPAP, see Continuous Positive Airway Pressure
3. 94450 Hypoxia, breathing response

Exercise 8.7 Allergy and Clinical Immunology

1. 95010 Allergy Tests, skin tests, venoms
2. 95120 Allergen Immunotherapy, allergen, prescription/supply/injection

Exercise 8.8 Injections and Infusions

1. 96372 Injection, intramuscular, therapeutic (Also, J3420 would be assigned for specific
substance- B12.)
2. 96360 Infusion, Intravenous, Hydration
3. 96413 Chemotherapy, intravenous
96415 (add-on code)
Note: J code for Cisplatin would also be assigned.
4. 96420 Chemotherapy, intra-arterial

Exercise 8.9 Physical Medicine and Rehabilitation

1. 97032 x 2 TENS, see Physical Medicine, modalities, electric stimulation, attended, manual
2. 97113 x 2 Physical Medicine, aquatic therapy
3. 97006 Physical Medicine, athletic training, re-evaluation
4. 97602 Wound debridement, nonselective

Exercise 8.10 Chapter 8 Review

1. 90966 Dialysis, end-stage renal disease
2. 90471 Immunization administration, one vaccine/toxoid
90719 Vaccines, Diphtheria Toxoid
3. 93010 EKG, see electrocardiography, evaluation
Appendix D text AC200610: Basic CPT and HCPCS Coding Page 23 of 26 

4. 96413 Chemotherapy, intravenous

96415 x2
5. 93600 Electrophysiology Procedure
6. 92556 Audiometry, speech
7. 96372 Injection, intramuscular
99070 supply, materials
Note: If this were a Medicare patient, the J code to identify the substance (steroid) would be
reported
8. 90832 Psychotherapy, Individual Patient/Family Member
Note: CPT provides guidance to choose the code closest to the actual time.
9. 92920 Atherectomies, coronary, see Artery, coronary, atherectomy
92921 (additional branch)
10. 92014–25 Ophthalmology, diagnostic, eye exam, established patient
92283 Opththalmology, diagnostic, color vision exam
11. 92920-RC Percutaneous Transluminal Angioplasty, artery, coronary
92973 Thrombectomy, percutaneous, coronary artery
92928-LC Coronary Artery, insertion, stent
12. 97761 x 3 Prosthesis training
13. 99050 Special services, after-hours medical services
Note: An E/M code would also be assigned in addition to this service.
14. 93925 Duplex scan, arterial studies, lower extremity
15. 95863 EMG, see electromyography, needle, extremities
16. 96920 Psoriasis Treatment
17. 98926 Manipulation, osteopathic
18. 99605 Medication Therapy Management
99607 (additional 15 minutes)
19. 99502 Home Services, newborn care
20. 94640 Inhalation Treatment, Pressurized or Nonpressurized
21. 95807 Sleep Study

Chapter 9: Anesthesia
Exercise 9.1 Chapter 9 Review
1. 00406–P2 Anesthesia, breast
2. 01730–P1 Anesthesia, arm, upper
99100
3. 00567–P4 Anesthesia, heart, coronary artery bypass grafting
4. 00540–P3 Anesthesia, lungs
Appendix D text AC200610: Basic CPT and HCPCS Coding Page 24 of 26 

5. 00350–P1 Anesthesia, neck

6. 00862-P2 Anesthesia, nephrectomy
7. 00580–P5 Anesthesia, Heart, transplant
99100
99140
8. 00350–P3 Anesthesia, neck
99100
9. 00944–P1 Anesthesia, Hysterectomy, Vaginal
10. 00103-P1 Anesthesia, Eyelid

Chapter 10: HCPCS Level II

Exercise 10.1 HCPCS Level II Codes
1. A4611 Battery, heavy duty; ventilator
2. H1010 Education, family planning, nonmedical
3. J8520 Capecitabine, oral, 150 mg
4. M0076 Prolotherapy
5. Q0113 Pinworm Examination

Exercise 10.2 Chapter 10 Review

1. E0196 Mattress, gel pressure
2. A4550 Surgical, tray
3. J3420 Vitamin, B12
4. A4490 Surgical, stocking
5. J1710 Hydrocortisone-sodium phosphate
6. 51702 Insertion, catheter, urethra
A4355 Tubing set, Indwelling Foley catheter, each
7. 29540 Strapping, ankle
E0112 Crutches
8. 12011 Wound, repair, simple
Note: CMS instructs coders not to assign a modifier: “Do not use a modifier to indicate an
anatomical site location on body (modifier 50 or Level II modifiers) if the narrative definition of a
code indicates multiple occurrences.”
9. 11730–TA Avulsion, nails
11732–T1
10. 26055–F8 Trigger finger repair
Appendix D text AC200610: Basic CPT and HCPCS Coding Page 25 of 26 

Chapter 11: Reimbursement in the Ambulatory Setting and Optional

ICD‐10‐CM Coding Exercise

1. Incorrect. Because all repairs were of the same type (simple) and same site classification, the lacera-
tions may be added together. The correct CPT code is 12014. Note that the use of modifiers is not appro-
priate with these codes.

ICD-10-CM Codes: S01.81xA (Laceration, forehead)

S01.112A (Laceration, left eyelid)

S01.111A (Laceration, right eyelid)

(an addition external cause code would also be assigned to the specific nature of the injury)

2. Incorrect. The CPT codebook provides codes 11200–11201 to report any type of removal of skin tags.
The correct code is 11200.

ICD-10-CM Code: L91.8 (Tag, skin)

3. Incorrect. A diagnostic colonoscopy is included in a surgical colonoscopy; only the code for the surgi-
cal colonoscopy is assigned (45385).

ICD-10-CM Code: D12.0 (Polyp, cecum)

4. Incorrect. Code 52214 is in the urethra and bladder section and does not correctly identify the proce-
dure. The correct code is 52354.

ICD-10-CM Code: N28.89 (Polyp, ureter)

5. Incorrect. Code 58720 is identified as a separate procedure and thus should not be used with 58150.

ICD-10-CM Code; D25.0 (Leiomyoma, uterus, submucous)

Note: Answers to exercises 6-10 are only in the Instructor’s Guide.

6. Incorrect. Code 80076 is an incorrect code. The test to measure alanine aminotransferase (ALT)
(SGPT) was not performed. Total protein was not performed. The correct answer is 82040, 82247, 82248,
84075, 84450.

ICD-10-CM Code: R17 (Jaundice)

7. Incorrect. The D&C is included in the hysteroscopy code and does not warrant the additional code of
58120. NCCI lists 58558 as a comprehensive code and 58120 as a component.

ICD-10-CM Code: N93.8 (Hemorrhage, uterus, dysfunctional)

8. Correct.
Appendix D text AC200610: Basic CPT and HCPCS Coding Page 26 of 26 

ICD-9-CM Code: N63 (Mass, breast)

9. Incorrect. The lesion was incorrectly coded as benign. CPT code 11642 is the correct code.

ICD-10-CM Code: C44.319 (Carcinoma, basal cell—see Neoplasm, skin, chin, malignant, primary).
There is a “see also” note for Neoplasm, skin, face and basal cell is indented under this entry. This code is
difficult to find in the index, the final decision should be from the tabular list.

10. Incorrect. CPT code 31622 is a separate procedure code and should not be used with 31623. The only
code needed is 31623.

ICD-10-CM Code: J20.9 (Bronchitis, acute)