Exercise Answer Key CCW: Practice Exercises for Skill Development With Online Answers 515

CHAPTER 5

Case Studies from Ambulatory

Health Records

Unless otherwise stated, code set answers given in chapter 5 are ICD-10-CM and/or CPT.

Disorders of the Blood and Blood-Forming Organs

5.1. a. K57.33, 45382, 36430-59
Correct answer. There is a combination code available in ICD-10-CM to describe both the
diverticulitis and bleeding—K57.33.The Alphabetic Index main term is Diverticulitis, subterms
intestine, large, with bleeding. 45382 is the correct code capturing the laser control of
hemorrhage via colonoscopy. 36430 is reported only one time. A -59 modifier is necessary to
indicate the transfusion is a separate procedure from the colonoscopy.
b. K92.2, K57.33, 45382, 36430, 36430, 36430
Incorrect answer. The diverticultis of the colon is listed first, and the only code required is the
combined code for the diverticulitis with hemorrhage. The 36430 is only reported one time with
a modifier -59 to indicate it is a separate procedure from the colonoscopy.
c. K92.2, 45382, 36430-59
Incorrect answer. The GI bleed is reported with the diverticulitis code (K57.33), which includes
the associated hemorrhage.
d. K57.32, K92.2, 45382
Incorrect answer. There is a specific combination code available for diverticulitis of the large
intestine with bleeding (K57.33). Code K92.2 is not required. Code 36430 (with modifier -59)
also should be reported for the administration of the transfusion.
5.2. a. D65.9, 38220
Incorrect answer. The admitting diagnosis was anemia, but the pathologist gave more
clarification by providing the diagnosis of iron deficiency anemia.
b. D50.9, 38220
Correct answer. The admitting diagnosis was anemia, but the pathologist gave more
clarification by providing the diagnosis of iron deficiency anemia. The Alphabetic Index main
term is Anemia with subterm iron deficiency. The pathology report states bone marrow
aspiration and biopsy; however, the technique reported by the surgeon shows that the
procedure performed was a bone marrow aspiration, bone trabecula not seen.
c. D64.9, 38220, 38221-59
Incorrect answer. The admitting diagnosis was anemia, but the pathologist provided further
clarification with the diagnosis of iron deficiency anemia. The pathology report states bone
marrow aspiration and biopsy; however, the technique reported by the surgeon shows that the
procedure performed was a bone marrow aspiration, bone trabecula not seen. Code 38221
would not be reported.

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d. D50.8, 38230
Incorrect answer. The iron deficiency anemia has not been specified as to the type, so code
D50.8 is not correct. The procedure codes listed here would only be used for bone marrow
harvesting for transplantation purposes.
5.3. C91.00, 38220
Rationale: The diagnosis is acute lymphoblastic leukemia—C91.00. The Alphabetic Index main
term is Leukemia, leukemic, subterm acute, lymphoblastic. There is no remission because this is a
new diagnosis. The procedure described is bone marrow aspiration. The code is only assigned
once, even though the needle was repositioned to obtain more than one specimen. This is
common in this procedure.
5.4. C43.62, C77.3, 38525-LT, 38792
Rationale: The primary diagnosis is the melanoma, followed by a code for the secondary
malignancy of the axillary lymph nodes. The Alphabetic Index main term is Melanoma with
subterms skin, arm. Also reference main term Neoplasm Table with subterms lymph, gland, axilla,
axillary. Select the Malignant Secondary column. CPT codes are assigned for the lymph node
excision and the radioactive tracer for identification of the sentinel node. Assign modifier -LT to
show that the left axillary lymph node was biopsied.
5.5. ICD-10-CM Reason for Visit Code(s): R07.9, R91.8
ICD-10-CM Primary Diagnosis Code(s): D57.01
Rationale: The patient presents to the ER with chest pain and pulmonary infiltrates, which are
coded as R07.9 and R91.8. After study, it is determined that the patient has sickle cell crisis and
acute chest syndrome, which is coded as D57.01 for the primary diagnosis, which is found in the
Alphabetic Index at the main term Disease, subterm sickle cell with crisis, with acute chest
syndrome.

Disorders of the Cardiovascular System

5.6. a. 33240
Incorrect answer. This code describes only the insertion of the pacing ICD. To completely code
the insertion of the leads and the pacing ICD, the coder should choose code 33249. In addition,
the documentation states that defibrillator threshold testing was performed. Code 93641
describes the process of testing both the leads and the pulse generator.
b. 33225, 33240
Incorrect answer. Biventricular pacing is not described in the documentation, and therefore,
code 33225 cannot be assigned. Code 33240 describes only the insertion of the pacing ICD.
To completely code the insertion of the leads and the pacing ICD, the coder should choose
code 33249. In addition, the documentation states that defibrillator threshold testing was
performed. Code 93641 describes the process of testing both the leads and the pulse
generator.
c. 33249, 93641
Correct answer.
d. 33249, 93640, 93641
Incorrect answer. Code 93640 should not be coded with code 93641. Code 93641 includes
testing of both the leads and the pulse generator.
5.7. a. Q21.1, 93315
Incorrect answer. The diagnosis code is not specific to an atrioventricular septal defect. The
correct diagnosis code is Q21.2.

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b. Q21.2, 93315
Correct answer. The diagnosis is atrioventricular canal defect – Q21.2. The Alphabetic Index
main term is Defect, subterm atrioventricular canal. The CPT code for the transesophageal
echocardiogram (93315) may be assigned by the chargemaster.
c. Q21.2, 93312
Incorrect answer. The diagnosis code is correct.
Code 93312 is not specific for congenital cardiac anomalies (that is, present at birth). The
correct CPT code is 93315.
d. I51.0, 93312
Incorrect answer. The ICD-10-CM code is for an acquired cardiac septal defect, which means
it is not present at birth; the correct diagnosis code is Q21.2. Code 93312 is not specific for
congenital cardiac anomalies (that is, present at birth). The correct CPT code is 93315.
5.8. C22.8, 36563, 77001, 96416
Rationale: The primary diagnosis is the liver cancer—C22.8, which is found in the Neoplasm table,
access the subterm Liver and select the code present in the Malignant Primary column. Reporting
of the chemotherapy agent 5-FU is reported with an HCPCS “J” code and usually assigned by the
chargemaster. The infusion pump was centrally inserted as the catheter was placed in the
superior vena cava. The fluoroscopic guidance is captured using code 77001. This code is an
add-on code that must be assigned in addition to the primary central venous access device
placement. Code 96416 is assigned for the initiation of prolonged chemotherapy services over 8
hours that require the use of an implantable pump.
5.9. ICD-10-CM Reason for Visit Code(s): R07.89
ICD-10-CM and CPT Code(s): I21.09, I50.22, I10, I48.2, 93458
Rationale: The reason for visit is chest wall pain—R07.89.The primary diagnosis is acute anterior
myocardial infarction (STEMI), followed by codes for the chronic systolic heart failure,
hypertension, and chronic atrial fibrillation. The acute myocardial infarction code is found in the
Alphabetic Index at the main term Infarction, subterms myocardial, ST Elevation, anterior. The
chronic systolic heart failure, hypertension, and atrial fibrillation meet additional diagnosis
reporting to describe coexisting conditions that require and/or affect patient care treatment or
management. The hypertension is coded separately from the heart failure because there is no
cause-effect documentation provided. I50.22 can be found by accessing the Alphabetic Index
main term Failure, failed, subterm systolic (congestive), chronic. The scenario only specifies that
the patient has chronic systolic heart failure rather than acute and chronic. Hypertension is coded
to I10, which is found under main term Hypertension. Locate the atrial fibrillation code in the Index
at main term Fibrillation, subterm atrial. A code is not assigned for the unstable angina as it is
inherent in the acute myocardial infarction. Code 93458 includes the left heart catheterization
coronary angiography and left ventriculogram.
5.10. ICD-10-CM Reason for Visit Code(s): I46.9
ICD-10-CM Code(s): I46.9, Y93.H1, Y92.014, Y99.8
Rationale: The probable myocardial infarction may not be coded on an outpatient record. The
ICD-10-CM Official Guidelines for Coding and Reporting states: “Do not code diagnoses
documented as ‘probable,’ ‘suspected,’ ‘questionable,’ ‘rule out,’ or ‘working diagnosis’ or other
similar terms indicating uncertainty. Rather code the condition to the highest degree of certainty”
(CMS 2016a, Section IV.H). The cardiac arrest is coded as the reason for visit and the primary
diagnosis code. The Alphabetic Index main term is Arrest, with subterm cardiac.
External cause place of occurrence, activity and status codes may also be assigned to this
encounter although there is no national mandatory requirement. The External Cause Index main
term is Activity, subterms shoveling, snow. The External Cause Index main term is Place of

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occurrence, subterms residence, house, single family, driveway. The External Cause Index main
term is External cause status, specified.
5.11. a. 36475-RT
Correct answer. CPT code 36475 is accessed using index entry Ablation, vein, endovenous.
b. 36475-RT, 36000
Incorrect answer. The introduction of the catheter into the vein is included in the procedure
code, per the instructional note following code 36476.
c. 36478-RT
Incorrect answer. Code 36478 describes laser ablation of incompetent veins. The scenario for
coding specifies radiofrequency ablation, 36475.
d. 36475-RT, 76942
Incorrect answer. Per the description of code 36475, the procedure code is inclusive of all
imaging guidance and monitoring.
5.12. C61, 36556
Rationale: The diagnosis is prostate carcinoma—C61. The Alphabetic Index main term is Prostate
in the Neoplasm Table. Then select the Malignant Primary column code.
There are several factors that must be considered when coding insertion of access devices,
including the age of the patient and whether or not it is a tunneled or non-tunneled insertion of the
central venous catheter. Another consideration is whether or not a port or reservoir is implanted.
CPT provides the “Central Venous Access Procedure Table,” which is invaluable in assigning
these codes. For this encounter the patient is aged 5 years or older and the device is a non-
tunneled centrally located central venous catheter. This procedure meets the definition of central
VAD as it terminates in the subclavian vein.

Disorders of the Digestive System

5.13. a. K44.9, 43327
Incorrect answer. The diagnosis code is correct. The procedure code is an open abdominal
procedure rather than a laparoscopic approach for this Nissen procedure. The correct code
is 43281.
b. K44.9, 43281
Correct answer. The diagnosis code is correct per Alphabetic Index entry, Hernia, hiatal. The
procedure describes a Nissen fundoplication performed via a laparoscope with the hernia
repair.
c. K44.0, 43281
Incorrect answer. Code K44.0 would be assigned only when gangrene was documented. The
procedure code is correct.
d. K44.9, 43328
Incorrect answer. The diagnosis code is correct. The CPT code is for a thoracotomy
esophagogastric fundoplasty. When the procedure is performed via a laparoscope, as
designated in this operative report by the use of insufflation, trocars, ports, and direct
visualization, and the hernia repair is also performed, code 43281 is reported.
5.14. ICD-10-CM Reason for Visit Code(s): K92.1
ICD-10-CM and CPT Code(s): K92.1, 43235
Rationale: The duodenal ulcer is not coded because it has not been confirmed. Coding guidelines
for outpatients state that rule-outs or possible diagnoses are not coded. Code to the highest
degree of certainty that in this case is the melena. Both the reason for visit code and primary

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diagnosis code are melena—K92.1, which is found at the main term Melena in the Alphabetic
Index.
The patient had an esophagoscopy, but the scope also went into the stomach and duodenum.
Code 43235 is correct as it includes the examination of the esophagus, stomach and
duodenum. Code 43200 is a separate procedure code, and the esophagoscopy is included in
code 43235. It would be incorrect to assign the separate procedure code in this case. The
documentation only states that the endoscopy was done. It does not specify that any techniques
were used to control the bleeding.
5.15. E44.0, I69.351, 43246
Rationale: The primary diagnosis code is E44.0 for the moderate malnutrition. The Alphabetic
Index main term is Malnutrition, subterms, degree, moderate. A secondary diagnosis code is
assigned for the residual hemiparesis—I69.351. The Alphabetic Index main term is Sequelae,
subterms, stroke NOS, hemiplegia. The coder completes the code using the Tabular List. Code
Z86.73, Personal history of transient ischemic attack and cerebral infarction without residuals is
not assigned as the patient has right sided hemiparesis and code I69.351 describes that the
patient previously had a stroke.
The percutaneous endoscopic gastrostomy (PEG) tube placement is coded 43246, which is found
with index entry Tube placement, gastrostomy.
5.16. K80.00, 47562
Rationale: The diagnosis is cholelithiasis with cholecystitis—K80.00. The Alphabetic Index main
term is Cholelithiasis. This term refers the coder to the main term Calculus with subterms
gallbladder, with cholceystitis, acute.
The adhesions did not prohibit the surgeon access to the organ and were not documented to be
clinically significant. It is not appropriate to assign an additional code for the adhesions in this
instance (CMS 2016a, Section III). Code 44180 is a separate procedure code and per CPT
guidelines would not be added on when performed as part of a more extensive, related procedure.
CPT 47562 is found with index entry Cholecystectomy, laparoscopic.
5.17. K62.3, K62.1, K57.30, K52.9, 45380
Rationale: Code the postoperative diagnosis rather than the preoperative diagnosis, which
includes rectal prolapse (K62.3), rectal polyps (K62.1), sigmoid diverticulosis (K57.30), and
nonspecific colitis (K52.9). The Alphabetic Index main term for K62.3 is Prolapse, subterm rectum.
Rectal polyps are coded by accessing Alphabetic Index main term Polyps, subterm rectum
(nonadenomatous). Code K57.30 is referenced under the Alphabetic Index main term
Diverticulosis, subterm large intestine. To find K52.9, nonspecific colitis, access main term Colitis.
CPT Assistant states that “Coding for the services should be based on the technique employed to
resect the tissue sample(s). Some polyps are removed in pieces if a single application of the
technique (biopsy forceps, cautery biopsy, or snare) is inadequate. Codes 45380, 45384, and
45385 define different techniques and can be used only once for a single colonoscopy procedure
regardless of whether the technique is employed on multiple polyps or multiple times on a single
polyp” (2004, July). Refer also to CPT Assistant (2004, Jan.; 1996, Jan.). The correct code for the
cold biopsy in this scenario is 45380.
5.18. K40.90, 49505-RT
Rationale: The diagnosis is unilateral inguinal hernia (K40.90), the terms “direct” and “indirect” do
not affect the coding of this diagnosis which is found at the main term Hernia, subterm inguinal. To
assign the CPT code for the hernia repair, the coder needs to identify the age of the patient, the
type of hernia, whether initial or recurrent, associated clinical features of the hernia (reducible vs.
incarcerated or strangulated) and the approach whether open or laparoscopic. In CPT, it is not
correct to code the implantation of the mesh (49568) except for incisional or ventral hernia repairs.
Assign HCPCS Level II modifier -RT to indicate the right inguinal hernia.

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5.19. K80.00, 47563, 74300

Rationale: There is a combination diagnosis code that describes the cholecystitis and
cholelithiasis—K80.00. The Alphabetic Index main term is Calculus, calculi, subterm gallbladder,
with cholecystitis, acute. The cholelithiasis is described as chronic not the cholecystitis. Code
47563 describes a laparoscopic cholecystectomy with cholangiography. Radiology code 74300
would be reported by the hospital for radiological supervision and interpretation.
5.20. a. 45384, 45342
Incorrect answer. Code 45384 describes biopsy using a hot biopsy forceps, not the cold
forceps mentioned here. In addition, code 45342 is used to report a sigmoidoscopic
ultrasound, not ultrasound with colonoscopy.
b. 45380, 45391
Incorrect answer. Code 45391 does not include the transmural biopsy that was performed via
the ultrasonic endoscope. Code 45392 is the correct code.
c. 45384, 45392
Incorrect answer. Code 45384 describes biopsy using a hot biopsy forceps, not the cold
forceps mentioned here.
d. 45380, 45392
Correct answer. Use index entry Colonoscopy, flexible, biopsy to assign CPT 45380 and entry
Colonoscopy, flexible, ultrasound for 45392.
5.21. J69.0, 44500, 74340
Rationale: The diagnosis is aspiration pneumonitis—J69.0—found in the Index at Aspiration,
subterm pneumonitis. The documentation confirms placement of the tube in the patient’s jejunum.
Therefore, code 44500 describes the placement of the long gastrointestinal tube. Radiology code
74340 would be assigned for the fluoroscopic guidance used to place the tube.
5.22. T18.190A, 43194
Rationale: The diagnosis is foreign body in the esophagus, causing tracheal compression—
T18.190A—found in the Index at Foreign body with subterms esophagus, causing, tracheal
compression, specified type, NEC. The seventh character A is assigned to indicate initial
encounter. CPT code 43194 describes the rigid transoral esophagoscopy with removal of a
foreign body. The documentation indicates that only the esophagus was evaluated.
5.23. 45380, 45385, 43239
Rationale: The EGD with biopsy of the duodenum is coded with 43239. There were two procedures
performed during the colonoscopy. Code 45380 describes the biopsy of the additional polyps and code
45385 indicates the snare polypectomy of different polyps. Some payers may require that modifier -59
be added to code 45380. Modifier -59 is used to show that biopsies were taken from polyps other than
the ones that were removed. If the same lesion is biopsied and then removed, only the removal code is
used.
5.24. K43.9, 49652
Rationale: The diagnosis is ventral hernia—K43.9. The herniorrhaphy is coded with 49652, which
describes the laparoscopic repair. The code description specifies that it includes mesh insertion
when performed; therefore, an additional code is not assigned. There is also an instructional note
below 49652, which directs not to code 49652 in conjunction with 44180 (laparoscopic lysis of
adhesions), 49568 (mesh implantation).

Endocrine, Nutritional, and Metabolic Diseases

and Immunity Disorders
5.25. ICD-10-CM Reason for Visit Code(s): R10.32

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ICD-10-CM Code(s): E73.9, N94.6

Rationale: The reason for visit is the left lower quadrant abdominal pain. In this case, lactose
intolerance is confirmed. It would be inappropriate to code right lower quadrant abdominal pain as
the primary diagnosis because two sources of pain are documented—lactose intolerance and
menstrual cramps.
5.26. a. 60200
Incorrect answer. The patient has a thyroglossal duct cyst, not a thyroid cyst. CPT code
60281 is specific to a recurrent cyst of this location.
b. 60210
Incorrect answer. The patient has a thyroglossal duct cyst that is excised. The thyroid is not
excised in this case. CPT code 60281 is specific to the excision of a recurrent cyst of this
location.
c. 60280
Incorrect answer. Documentation states that the thyroglossal duct cyst is recurrent. As the
cyst is recurrent, the coder must assign CPT code 60281 for the excision of a recurrent
thyroglossal cyst.
d. 60281
Correct answer. CPT code 60281 is accessed using index entry Cyst, thyroglossal duct,
excision.
5.27. C82.99, 60100, 76942
Rationale:
The Alphabetic Index main term is Lymphoma, subterm follicular. The coder completes the code
using the Tabular List. The thyroid is an extranodal organ.
This is not a fine-needle aspiration. A large hollow-core needle is inserted percutaneously. Code
60100 is correct. Radiology code 76942 is assigned for the ultrasound guidance.

Disorders of the Genitourinary System

5.28. a. N39.3, N81.11, N81.4, 57284, 51840
Incorrect answer. The underlying cause of the incontinence is the vaginal prolapse and
cystocele. The primary diagnosis is N81.11 followed by N39.3 for the stress incontinence.
Diagnosis code N81.4 is not needed because it represents a uterovaginal prolapsed not
documented. See CPT Assistant (2010, June) regarding the procedure. Additional codes
such as 51840 and 51841 should not be reported separately when performed with a
paravaginal defect repair.
b. N39.3, 57284-50
Incorrect answer. The diagnosis code N81.11 should be reported first to reflect the incomplete
vaginal prolapse and the resulting cystocele, contributing to the stress incontinence. CPT
code 57284 does not describe a unilateral procedure so modifier -50 is not applicable.
c. N81.4, 57240
Incorrect answer. N81.4 describes a uterovaginal prolapsed that is not documented. The
correct diagnosis code is N81.11. A secondary code for the stress urinary incontinence is
needed (N39.3). Paravaginal defect repair is reported with CPT code 57284. The
documentation does not support assignment of code 57240 for anterior colporrhaphy.
d. N81.11, N39.3, 57284
Correct answer. The underlying cause of the incontinence is the vaginal prolapse and
cystocele. The primary diagnosis is N81.11 followed by N39.3 for the stress incontinence.
The Alphabetic Index main term Prolapse, prolapsed, with subterm vagina states to see

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Cystocele. The main term is now Cystocele with subterms female, midline. For the second
diagnosis, the Alphabetic Index main term is Incontinence with subterm stress (female). CPT
code 57284 is accessed using index entry Repair, paravaginal defect.
5.29. a. N39.45, N39.3, 53445, 51715, C1815, L8606
Correct answer. The correct diagnosis codes represent continuous incontinence (N39.45) and
stress incontinence (N39.3). For the first code, the Alphabetic Index main term is
Incontinence, subterm urine, continuous. For the second code, the main term is Incontinence,
subterm urine, stress (female) (male). CPT code 53445 is accessed using index entry
Urethra, sphincter, reconstruction. CPT code 51715 is accessed using index entry Urethra,
endoscopy, injection of implant material. HCPCS level II are assigned using C1815 for the
implantable urinary sphincter prosthesis and L8606 for the synthetic injectable bulking agent.
b. N39.498, 51715, C1815, L8606
Incorrect answer. The correct diagnosis codes represent continuous incontinence (N39.45)
and stress incontinence (N39.3). Additional procedure code 53445 is required to show the
incision of the perineum, with the placement of the artificial sphincter. The HCPCS Level II
codes are correct.
c. N39.45, 53440, C1815, L8606
Incorrect answer. Code N39.3 is also necessary to complete the stress incontinence. Code
53440 describes a sling operation. The HCPCS Level II codes are correct.
d. N39.45, N39.3, 53445, C1815, L8606
Incorrect answer. The diagnosis codes are correct. Code 51715 is also necessary to report.
The HCPCS Level II codes are correct.
5.30. a. R33.9, Z87.440, 51701
Incorrect answer. The diagnoses are correct. Coding Clinic for HCPCS, 2nd Quarter, 2009
and Third Quarter, 2007 directs the coder that code P9612 is the correct code for collection of
a urine specimen using a straight catheter. Code 51701 is to be used for the collection of
residual urine.
b. R33.9, 51702, P9612
Incorrect answer. Code 51702 is used to describe the insertion of a temporary indwelling
(Foley) catheter. Documentation does not support that an indwelling catheter was placed. In
addition, the patient has a known history of urinary tract infections, which should be reported
with diagnosis code Z87.440.
c. R33.9, Z87.440, P9612
Correct answer. The primary diagnosis is urinary retention (R33.9), found at Retention, urine
in the Index. The second code is for recurrent urinary tract infections which is found at the
main term History with subterms personal (of) infection, urinary (recurrent) (tract)—Z87.440.
Coding Clinic for HCPCS, 2nd Quarter, 2009 and 3rd Quarter, 2007 directs the coder that
code P9612 is the correct code for collection of a urine specimen using a straight catheter.
d. N39.0, 51701
Incorrect answer. The patient does not have a confirmed urinary tract infection, so code N39.0
should not be reported. Urinary retention and the history of urinary tract infections are coded
as R33.9 and Z87.440. Coding Clinic for HCPCS, 2nd Quarter, 2009 and 3rd Quarter, 2007
directs the coder that code P9612 is the correct code for collection of a urine specimen using
a straight catheter. Code 51701 is to be used for the collection of residual urine.
5.31. a. N40.1, R33.8, 53852
Correct answer. The primary diagnosis code is benign prostatic hyperplasia (N40.1), which is
found in the Alphabetic Index at the main term Hyperplasia, subterm prostate, with lower
urinary tract symptoms. A use additional code note is present at N40.1 directing to assign

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additional codes for associated symptoms, so a secondary code is assigned for the urinary
retention (R33.8). The Alphabetic Index main term is Retention, subterm urinary, specified.
CPT code 53852 is accessed using Index entry Prostate, destruction, thermotherapy,
radiofrequency.
b. N40.0, 52601
Incorrect answer. The documentation indicates the patient has benign prostatic hyperplasia with
urinary retention. Urinary retention is a lower urinary tract symptom. The correct diagnosis codes
are N40.1 and R33.8. When thermotherapy is used, code 53852 is reported. Code 52601 is
reported only for electrosurgical resection.
c. D29.1, 53852
Incorrect answer. The documentation indicates the patient has benign prostatic hyperplasia
(N40.0) rather than an adenoma of the prostate. A code is needed for the urinary retention
diagnosis, also. The procedure code is correct.
d. N40.3, R33.8, 53850
Incorrect answer. Benign prostatic hyperplasia with lower urinary tract symptoms is coded to
N40.1. Code R33.8 is correct for the urinary retention. Code 53850 is for microwave
thermotherapy. In this procedure radiofrequency was used, which is reported with 53852.
5.32. ICD-10-CM Reason for Visit Code(s): N50.8
ICD-10-CM and CPT Code(s): N44.00, 55899
Rationale: The reason for visit code is N50.8 as both testicular pain and scrotal swelling direct to
this code. The Alphabetic Index main term is Pain, testis and main term Swelling, subterm
scrotum. The primary diagnosis is N44.00 for the testicular torsion. The Alphabetic Index main
term is Torsion with subterm testis, testicle.
There is no specific CPT code describing the process of manual detortion of a testicle, so unlisted
code 55899 is assigned.
5.33. ICD-10-CM Reason for Visit Code(s): R50.9, R10.84
ICD-10-CM and CPT Code(s): R50.9, R10.84, F03.90, F05, Z87.440, 81000
Rationale: The reason for visit codes are R50.9 and R10.84 for the fever and abdominal pain.
The primary diagnosis is R50.9 and secondary diagnosis is R10.84 as no further diagnosis was
established after study for these symptoms of fever and abdominal pain. It is appropriate to add all
diagnoses that affect current patient management. In this case, the fact that the patient has senile
dementia with delirium does impact the care. These conditions are reported with codes F03.90
and F05. The Alphabetic Index main term is Dementia, subterms, senile, with acute confusional
state. An instructional note is present at F05 to code first the underlying physiological condition. In
this case the senile dementia is the underlying physical condition associated with the dementia.
An Excludes2 note is present at F03 indicating that this code may be assigned in addition to F05.
Excludes2 notes indicate that the condition excluded is not part of the condition represented by
the code and the patient may have both conditions at the same time. It is acceptable to use both
the code and excluded code together when documented.
A urinary tract infection was not established, so it is not coded. It may be useful to also report the
history of UTI with code Z87.440 to establish medical necessity for the urinalysis. The Alphabetic
Index main term is History, subterm personal, urinary tract infection.
CPT 81000 is assigned for the nonautomated urinalysis with microscopy.
5.34. E10.21, E10.22, N18.6, 36821
Rationale: Diagnosis codes for both the diabetic nephropathy and diabetic chronic kidney disease
are assigned (E10.21, E10.22). The Alphabetic Index main term is Diabetes, diabetic, with
subterms Type 1, nephropathy. The Alphabetic Index main term is Diabetes, diabetic with subterm
Type 1, with, chronic kidney disease. An instructional note is present at E10.22 to use additional

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code to identify the stage of chronic kidney disease (N18.6). In the Alphabetic Index, the main
term is Disease with subterms renal, end-stage (failure). According to guideline 1.C.4.a, it is
appropriate to assign as many codes as needed to identify all associated diabetic conditions
present (CMS 2016a).
CPT code 36821 is found using the index entry, Anastamosis, arteriovenous fistula, direct.
5.35. N73.6, 58660
Rationale: The diagnosis is tubo-ovarian adhesions (N73.6). Alphabetic Index main term is
Adhesions, subterm tubo-ovarian.
CPT code 58660 is found using index entry Adhesions, pelvic lysis. The lysis was accomplished
via laparoscopic approach. Do not assign a separate code for the exploratory laparoscopy
because it is included in 58660.
5.36. C67.4, C67.0, 52235
Rationale: Codes for each site should be assigned for multiple neoplasms of the same site that
are not contiguous (CMS 2016a, 1.c.2.). Refer to the Neoplasm table and identify subterms,
bladder, trigone and bladder, wall, posterior. Select the Malignant Primary column for both sites. A
code for gross hematuria is not assigned as hematuria is integral to the bladder cancer.
CPT code 52235 is found using index entry, Cystourethroscopy, with fulguration, tumor. This code
is only assigned once because the code description specifies tumor(s).
5.37. C64.1, 50592-RT, 77013
Rationale: The diagnosis is kidney carcinoma which is found in the Neoplasm table at the subterm
kidney. Select the Malignant Primary column to find code C64.1. CPT Code 50592 is found using
index entry Ablation, radiofrequency, renal tumor. Modifier -RT is appended to indicate this was
performed on the right side. The code description states “ablation, one or more renal tumors… ”
so it is not appropriate to report it more than once for multiple tumor ablations. Code 50250
reports an open procedure and 50542 a laparoscopic with tumor ablation, so neither is correct to
report a percutaneous procedure. An additional code, 77013, for the CT guidance is also
assigned. This code is accessed using index entry CT Scan, guidance, parenchymal tissue
ablation.

Infectious Diseases
5.38. ICD-10-CM Reason for Visit Code(s): R51, R50.9, R53.81 or R19.7
ICD-10-CM Code(s): A98.4
Rationale: The coder may select any three admitting symptoms as the reason for visit codes:
headache, fever, profound malaise, and bloody diarrhea. The Alphabetic Index main term is
Headache. Other main terms include Fever; Malaise; and Diarrhea.
The primary diagnosis is coded with A98.4. The Alphabetic Index main term is Ebola virus
disease. Symptoms are not reported separately as they are integral to the Ebola virus disease.
5.39. ICD-10-CM Reason for Visit Code(s): R23.8, L29.1, L29.8
ICD-10-CM Code(s): B86
Rationale: There are three codes that may be assigned as the reason for visit. The Alphabetic
Index main term is Eruption, subterm vesicular. For the pruritus, the main term is Pruritus, subterm
scrotum. The itching on the penis, buttocks, and groin is coded as Pruritus, specified NEC.
The primary diagnosis is found by reviewing main term Infestation, subterm Sarcoptes scabiei.
5.40. ICD-10-CM Reason for Visit Code(s): R19.7
ICD-10-CM Code(s): A04.1
Rationale: The reason for visit code is R19.7, which is found under main term Diarrhea. The
primary diagnosis is A04.1. The Alphabetic Index main term is Enteritis (acute) with subterms

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infectious, due to, Escherichia coli, enterotoxigenic. The diarrhea is not coded separately as this is
integral to the enteritis.
5.41. ICD-10-CM Reason for Visit Code(s): R76.11
ICD-10-CM Code(s): R76.11, F31.32
Rationale: The reason for visit is coded with R76.11 for the latent tuberculosis. The Alphabetic
Index main term is Tuberculosis, subterm latent.
The primary diagnosis is R76.11. Latent TB means that the patient has had a positive TB test but
has no active disease. INH is given prophylactically to keep the patient from converting to active
disease later in life. The bipolar disease is coded because this disease process affects the
patient’s ability to continue taking medication as prescribed. The bipolar disorder is found in
Alphabetic Index under main term Disorder, subterm bipolar (I), current episode, depressed,
without psychotic features, moderate.

Disorders of the Skin and Subcutaneous Tissue

5.42. C44.311, L82.1, 11642, 11441, 15260
The lesion on the right nasal tip was a basal cell carcinoma. Carcinoma (malignant), basal cell
(pigmented), (see also Neoplasm, skin, malignant), ICD-10-CM Table of Neoplasms, nose, nasal,
skin, basal cell carcinoma. Select the C44.311 code from the Malignant Primary column. The
cheek lesion was a seborrheic keratosis, which is benign. In the Alphabetic Index, the main term
Keratosis is referenced with subterm seborrheic.
After removal of the nasal tip lesion a full thickness skin graft was performed (15260). This code is
based on the size of the graft. Code 11642 is used to describe the excision of the malignant lesion
of the nose as the greatest clinical diameter of the lesion and associated margins was 1.4 cm.
Code 11441 is used to describe the excision of the benign lesion of the cheek as the greatest
clinical diameter of the lesion and associated margins required for complete excision was 1.0 cm.
5.43. a. C44.072, 14001
Incorrect answer. Code C44.072 describes an unspecified malignant neoplasm of the skin.
There is a more specific code available for melanoma of the thigh. The procedure code is
correct.
b. C43.72, 14001
Correct answer. The Alphabetic Index main term is Melanoma with subterms skin, thigh. A
review of the Tabular List is required to assign the fifth character “2” indicating the left leg.
CPT code 14001 describes the advancement flap closure of the calf. The defect size is
calculated by multiplying the width and length of the area excised to find the total square
2
centimeters (4.3 cm × 2.5 cm = 10.75 cm ). The excision of the malignant lesion is not
separately reportable.
c. C43.72, 14001, 11606
Incorrect answer. The diagnosis code is correct for the melanoma of the thigh. CPT code
14001 captures both the excision and repair by adjacent tissue transfer portions of the
procedure. The excision of malignant lesion (11606) is not separately reportable.
d. Z12.83, 14000
Incorrect answer. The patient presents with a known diagnosis of malignant melanoma.
Definitive treatment is carried out rather than a screening procedure. The primary diagnosis is
the malignant melanoma, C43.72. The defect size for the adjacent tissue transfer is 10.75 sq
cm (4.3 × 2.5). CPT code 14000 is for defects 10 sq cm or less.
5.44. a. C44.319, 15240, 11646
Incorrect answer. Code 11646 is incorrect because the size of the lesion was only 3.2 cm.
Code 11646 describes a lesion over 4.0 cm. The size of graft was 10 sq cm.

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b. C44.310, 15240, 15004

Incorrect answer. The diagnosis code is incorrect because the site of the carcinoma is
specified as the cheek. CPT code 15004 is reported for the surgical preparation or creation of
a recipient site by excision of open wounds, burn eschar, or scar; therefore, it is not accurate
to report this code for the malignant lesion excision. Report code 11644 for the 3.2-cm
malignant lesion.
c. C44.319, 15275, 15004, 11644
Incorrect answer. The diagnosis code is correct. CPT code 15275 for the graft is for an
allograft. This uses a homograft from healthy/cadaver skin from another person. When the
patient’s own tissue is used as a full thickness graft, code 15240 is reported for this size of
graft. CPT code 15004 is to be reported for the surgical preparation or creation of a recipient
site by excision of open wounds, burn eschar, or scar; therefore, it is not accurate to report
this code for the malignant lesion excision. Rather code 11644 is to be used for the excision
of malignant lesion.
d. C44.319, 15240, 11644
Correct answer. Reviewing the Table of Neoplasms, under cheek, external, basal cell
carcinoma, results in code C44.319. CPT code 15240 is found with index entry, Skin graft and
flap, free skin graft, full thickness. CPT code 11644 is found with index entry, Excision, skin
lesion, malignant. Instructional notes direct that an additional code for the reconstructive
closure may be reported separately.
5.45. ICD-10-CM Reason for Visit Code(s): L60.0
ICD-10-CM and CPT Code(s): L60.0, D51.0, G11.1, I51.9, 11750-TA
Rationale: The reason for visit and primary diagnosis is ingrown toenail. The Alphabetic Index
main term is Ingrowing with subterm nail (finger) (toe). Patient also has pernicious anemia, found
at main term Anemia with subterm pernicious. Code G11.1 is located at main term Ataxia with
subterm Friedreich’s. The final code is found at main term Disease with subterm heart.
The digital block is included in the procedure and therefore not coded separately. Code 11750 is
reported because the nail matrix is destroyed to achieve permanent removal, even though the
physician describes the procedure as a wedge resection. Code 11765 is not used because the
nail and the matrix are both removed, not just the skin of the nail fold. HCPCS level II modifier -TA
is appended to 11750 to indicate the left great toe as the site of the procedure.
5.46. B07.9, 17110
Rationale: For code B07.9, the Alphabetic Index main term is wart (viral). The code 17110
includes cryosurgery and curettement of up to 14 lesions, so no other code is assigned.
5.47. ICD-10-CM Reason for Visit Code(s): S61.412A, S51.812A, S81.811A
ICD-10-CM and CPT Code(s): S81.811A, S61.412A, S51.812A, W25.XXXA, Y92.018, Y93.H9,
Y99.8, 12031, 12002
Rationale: For the laceration diagnoses, the Alphabetic Index main term is Laceration with
subterms hand, forearm, leg (lower). The seventh character “A” is assigned to indicate initial
encounter for these three codes. The leg laceration is listed first since it required a repair of
deeper tissue and it corresponds with the first-listed procedure code. The main term in the Index
to External Causes is Contact with, subterms with, glass. The seventh character “A” is assigned to
indicate initial encounter. The main term in the Index to External Causes is Activity with subterms
maintenance, exterior building. The main term in the Index to External Causes is Place of
occurrence with subterms residence, house, single family, specified NEC. In the Index to External
Causes the main term is External Cause Status with subterm specified NEC.
The intermediate repair (layered) of the leg is coded using 12031. The lacerations repaired with
simple repair are added together to total 5 cm as all anatomic sites are listed in code 12002.

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5.48. L91.0, T20.07XS, 15004, 15005, 15277, 15278

Rationale: The keloid is found under main term Keloid. The Alphabetic Index main term for code
T20.07XS is Burn, neck. The degree is not specifically stated so code T20.07 is used. A review of
the Tabular List allows the coder to complete the code. The extension “S” is used to indicate there
is a sequelae. The residual condition of the sequela is sequenced first followed by the sequelae
code (CMS 2016a, 1.B.10.).
The excision of the scar prior to placement of the Integra is surgical preparation. Both 15004 and
2
15005 must be assigned as the total area excised was 160 sq cm (20 cm × 8 cm = 160 cm ).
Integra is an acellular dermal replacement that does not require a concurrent epidermal cover.
Both 15277 and 15278 are assigned as 160 sq cm was covered with the Integra.
5.49. 19081-LT, 19082-LT, 19083-LT
Rationale: For the biopsies with stereotactic guidance, code 19081 is assigned for the first lesion
and code 19082 is assigned for the second. An additional code is assigned for the biopsy using
ultrasound guidance—19083. The -LT modifier should be used on each of these codes to indicate
the left breast.
5.50. L89.153, L89.329, 11043
Rationale: The Alphabetic Index main term is Ulcer, subterm pressure, stage 3, sacral region. The
Alphabetic Index entry for the buttock is Ulcer, pressure, buttock. The coder completes the codes
using the Tabular List. The stage of the buttock ulcer is not specified.
The CPT index entry is Debridement, muscle. Review the codes to select the appropriate code
based on depth and size of the debridement.

Behavioral Health Conditions

5.51. a. F60.0, 90853
Incorrect answer. The diagnosis code is incorrect, there is a more specific code available. The
procedure code is correct.
b. F60.2, 90785, 90853
Incorrect answer. The diagnosis code is correct; however, the documentation does not
support individual psychophysiological therapy in conjunction with group therapy encounter.
c. F60.2, 90853
Correct answer. For the diagnosis, the Alphabetic Index main term is Disorder with subterms
personality, psychopathic. CPT Code 90853 is found using index entry Psychotherapy, group
other than multifamily.
d. F60.5, 90847
Incorrect answer. The diagnosis code is incorrect. The service was for a group, not an
individual, and there is no documentation of the patient’s family being present.
5.52. F40.01, 90849
Rationale: For the diagnosis code, the Alphabetic Index main term is Agoraphobia, subterm with
panic disorder.
Code 90849 describes multiple-family group psychotherapy. Refer to CPT index entry
Psychotherapy, multifamily. The length of the session is not defined in the code.
5.53. ICD-10-CM Reason for Visit Code(s): S61.512A, S61.511A
ICD-10-CM and CPT Code(s): S61.512A, S61.511A, F32.2, X78.8XXA, Y92.012, 12002
Rationale: For the lacerations, the Alphabetic Index main term is Laceration with subterms wrist,
left and wrist, right. The seventh character “A” is added to indicate initial encounter. For the
depression diagnosis, the Alphabetic Index main term is Depression with subterms severe, single
episode. In the Index to External Causes, the main term is Suicide, suicidal (attempted) (by) with

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subterms cutting or piercing instrument, specified NEC. The fourth character “A” is added to
indicate initial encounter. In the Index to External Causes, the main term is Place of occurrence
with subterms residence, house, single family, bathroom.
The laceration repairs were both simple suture. CPT instructions direct that when multiple wounds
are repaired add the lengths of those in the same classification, which for this case is the
extremities.
5.54. ICD-10-CM Reason for Visit Code(s): R40.20
ICD-10-CM and CPT Code(s): T42.4X2A, T43.012A, T51.0X2A, R40.20, I46.9, F32.9, Y92.032,
43753, 92950
Rationale: The reason for visit code is R40.20 as the patient was brought to the ER in an
unconscious state. The Alphabetic Index main term is Unconscious, which provides a cross
reference note to see Coma.
The Table of Drugs and Chemicals is used to code the two drugs and the alcohol. The column for
“Poisoning, Intentional, Self-Harm” is used as this is a suicide. The Tabular List is used to
complete codes and seventh character “A” is used for initial encounter. The patient’s
unconsciousness (R40.20) is a manifestation of the poisoning so it is reported as a secondary
code. To code the cardiac arrest, the main term is Arrest, subterm cardiac. To code depression,
the main term is Depression. The Index to External Cause code, main term, Place of occurrence,
subterm, apartment, which provides the cross reference—see Place of Occurrence, residence,
apartment, bedroom.
Report procedure codes for gastric lavage and CPR. CPT code 43753 is found with index entry
Lavage, stomach and CPT 92950 is found under index entry Resuscitation, cardiopulmonary.

Disorders of the Musculoskeletal System

and Connective Tissue
5.55. D17.24, 27327
A lipoma is a benign tumor. The Alphabetic Index main term is Lipoma, subterm legs (skin)
(subcutaneous). The coder completes the code using the Tabular List.
The operative report indicates that the lipoma was removed from the subcutaneous layer of the
thigh. It is not appropriate to assign an excision code from the integumentary system when the
lipoma is in the deep subcutaneous tissue (CPT Assistant, April 2010). The CPT code is accessed
using index entry Excision, tumor, leg, upper. CPT provides guidelines as the beginning of the
musculoskeletal system chapter that indicate that code selection is based on the location and size
of tumor-including margins required for the excision for tumors that are confined to the
subcutaneous tissue below the skin but above the deep fascia.
5.56. a. 27500-LT, 99148
Incorrect answer. Manipulation was required to reduce the fracture. Therefore, CPT code
27502 is the most appropriate to describe the service. Conscious sedation was provided by
the same physician with a qualified observer present for one hour five minutes, which is
reported with 99143 and add on code 99145 with two units.
b. 27502-LT, 99143, 99145 × 2
Correct answer. CPT 27502-LT describes closed treatment of a femoral shaft fracture with
manipulation. Conscious sedation was provided by the same physician with a qualified
observer present for one hour five minutes, which is reported with 99143 and add on code
99145 with two units.

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c. 27506-LT, 99143 × 2
Incorrect answer. CPT code 27502 is the most appropriate to describe the service. Conscious
sedation was provided by the same physician with a qualified observer present for one hour
five minutes, which is reported with 99143 and add on code 99145 with two units.
d. 27506-LT
Incorrect answer. CPT code 27502-LT is the most appropriate to describe the service.
Additional codes for the conscious sedation provided by the orthopedic surgeon may be
reported in addition to the surgical procedure.
5.57. a. S42.451B, 24577, 29065
Incorrect answer. The seventh character “B” appended to code S42.451 represents initial
treatment for an open fracture, which is not described here. Fractures not indicated as open
or closed are coded to closed. (CMS 2016a, 1.C.19.c).
The CPT code 24577 describes closed reduction of a humeral fracture, rather than the open
reduction and internal fixation procedure documented. CPT 29065 should not be assigned
with a fracture care code because casting is included in the initial fracture service per CPT
guidelines. The HCPCS Level II modifier -RT (right) is added to show laterality.
b. S42.451A, 24579, 29065
Incorrect answer. The diagnosis code and CPT code 24579 are correct. However, CPT code
24579 is missing the HCPCS Level II modifier of -RT (right) to designate laterality. CPT code
29065 should not be assigned with a fracture care code because casting is included in the
initial fracture service per CPT guidelines.
c. S42.451A, 24579-RT
Correct answer. The lateral condyle of the elbow is a site on the distal humerus. The
Alphabetic Index main term is Fracture, subterm humerus, lower end, lateral condyle. The
coder completes the code using the Tabular List to assign the sixth character 1 for right side
and seventh character A for initial encounter for closed fracture.
The CPT code is accessed using index entry Fracture, humerus, condyle, open treatment.
The HCPCS Level II modifier of -RT (right) is added to show laterality.
d. S42.451B, 24579-RT
Incorrect answer. The seventh character “B” appended to code S42.451 represents initial
treatment for an open fracture, which is not described here. Fractures not indicated as open
or closed are coded to closed. (CMS 2016a, 1.C.19.c). The procedure code is correct.

5.58. ICD-10-CM Reason for Visit Code(s): S01.411A

ICD-10-CM and CPT Code(s): S01.411A, S02.2XXA, W21.03XA, Y92.320, Y93.64, Y99.8, 21320,
12011-59
Rationale: For the cheek laceration, the Alphabetic Index main term is Laceration with subterm
cheek (external). The Tabular List is reviewed to assign the sixth character for laterality and the
seventh character indicating initial encounter. For the nasal fracture, in the Alphabetic Index, the
main term is Fracture with subterm nasal (bone[s]). Fractures not indicated as open or closed are
coded to closed (CMS 2016a, 1.C.19.c). In addition, the ER physician only stabilized the fracture
with a splint and tape. The seventh character “A” is assigned to indicate closed fracture, initial
encounter. In the Index to External Causes, the main term is Struck (accidentally) by, with
subterms ball (hit) (thrown), baseball. The seventh character “A” is assigned to indicate initial
encounter. In the Index to External Causes, the main term is Place of occurrence with subterms
sports area, athletic, field, baseball. In the Index to External Causes, the main term is Activity with
subterm baseball. In the Index to External Causes, the main term is External cause status, leisure
activity.
The ER provided fracture care of stabilization, splinting, and taping. This is frequently the only
care needed for a nondisplaced nasal fracture. CPT code 21320 is accessed using index entry

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Fracture, nasal bone, closed treatment. The physician did repair the superficial laceration of the
cheek. This code is accessed using index entry Repair, skin, wound, simple. A -59 modifier is
appended to 12011to identify the laceration repair is a distinct procedural service that is
separately identifiable from the closed treatment of the nasal fracture.
5.59. S62.630B, W31.82XA, Y92.63, Y93.89, Y99.0, 26765-F1
Rationale: The Alphabetic Index main term is Fracture, subterm finger, index, distal phalanx. The
Tabular List is referenced to assign sixth character “0” for displaced right index finger and seventh
character “B” for initial encounter of open fracture. Using the Index to External Causes, the coder
accesses Contact, subterm with, machine, machinery, commercial (W31.82). The place of
occurrence code is found under Place of occurrence, subterm factory. The External Status Code
(found under External Cause Status) is Y99.0, civilian activity for income or pay. Activity code is
Activity, specified NEC.
CPT code 26765 is accessed using index entry Finger, bone, fracture, distal, open treatment. The
CPT code would be assigned for each finger, and in this case there is no documentation that
multiple fingers are involved; therefore, one code is assigned with the HCPCS Level II modifier
-F1, to identify the left index finger was treated.
5.60. M20.12, 28292-TA
Rationale: To find the diagnosis code, the Alphabetic Index main term is Hallux, subterm valgus.
The Tabular List is reviewed to assign fifth character “2” representing the left foot. The bunion
repair is documented as a Keller repair resulting in code 28292. See index entry Keller procedure.
Add the HCPCS Level II modifier of -TA (left foot, great toe) to report laterality.
5.61. a. Osteochondral autograft
Incorrect answer. An osteochondral autograft involves harvesting tissue from the patient
himself or herself. When the graft comes from a cadaver, it is an osteochondral allograft.
b. Osteochondral allograft
Correct answer.
c. Autologous chondrocyte implantation
Incorrect answer. This procedure involves harvesting cells from the patient, growing them to
maturity in a laboratory setting, and reinjecting them. When a full osteochondral graft is
obtained from a cadaver, it is an osteochondral allograft.
d. Anterior cruciate ligament repair
Incorrect answer. When an osteochondral graft is obtained from a cadaver, it is an
osteochondral allograft. A ligament repair may involve cadaveric ligament, but not
osteochondral tissue.
5.62. a. M22.41, M25.861, 29873-RT, 29877-RT-59
Correct answer. For the chondromalacia diagnosis, the Alphabetic Index main term is
Chondromalacia with subterm patella. The Tabular List is referenced to assign fifth character
“1” for right knee. For the tight lateral retinaculum the main term is Disorder, subterm joint,
specified type NEC, knee. The Tabular List is referenced to assign sixth character “1” for right
knee.
CPT codes 29873 and 29877 are indexed using the entry Arthroscopy, surgical, knee. In a
Medicare OPPS case, HCPCS Level II code G0289 would be used in lieu of CPT code
29877-RT-59, since chondroplasty was performed in separate compartments as per the
source document.
b. M22.41, M25.561, 27425-RT
Incorrect answer. Diagnosis codes M22.41 and M25.861 are correct. CPT code 27425 is used
to report an open retinacular release, rather than the retinacular release via arthroscopy
described in the source document.

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c. M22.41, 29877-RT
Incorrect answer. Diagnosis code M25.861 should also be assigned for the tight lateral
retinaculum. The source document indicates a lateral retinacular release of the right knee was
performed in addition to the chondroplasty performed.
d. M22.41, M25.861, 29999-RT, 29877-RT
Incorrect answer. Diagnosis codes M22.41 and M25.861 are correct. CPT code 29999 is used
only when an unlisted arthroscopic procedure is performed. In this case, CPT code 29873
identifies arthroscopic retinacular release as described in the source document.
5.63. M72.0, 26123-F2, 26125-F3
Rationale: The Alphabetic Index main term is Contraction, subterm Dupuytren’s.
The CPT index entry Dupuytren’s contracture provides a subterm option for a fasciotomy, which
leads to potential codes 26040–26045. In this scenario, a fasciectomy was performed. Refer to
index entry Fasciectomy, palm for code range 26121–26125. CPT code 26123-F2 is assigned for
the fasciectomy with release of the left middle finger and add on code 26125-F3 is assigned for
the release of the left ring finger.
5.64. Z47.2, 20680
Rationale: The patient is being seen to remove previously placed internal fixation devices.
Therefore Z47.2, Encounter removal of internal fixation device, is used to describe the reason for
encounter. The Alphabetic Index main term is Encounter with subterms removal (of), internal
fixation device. Fracture codes are not used as the fracture is completely healed.
The correct CPT code is 20680, which is used to describe the removal of “deep” implants. Code
20670 would be used for superficial implants.

Neoplasms
5.65. a. Z51.0, 77412
Incorrect answer. The malignancy must be reported (C14.0 and Z77.0), as secondary codes
to Z51.0, Encounter for antineoplastic radiotherapy (CMS 2015a, 1.C.2.e.2). The procedure
code is correct.
b. C14.0, 77407
Incorrect answer. The encounter for radiation therapy, Z51.0 should be the first-listed code. In
addition to the primary malignancy code, the lymph node metastasis should also be reported
because this is also treated by radiation (C77.0) (CMS 2016a, 1.C.2.e.2). The correct
radiation treatment CPT code is 77412 because three treatment areas are involved and
custom blocking was employed.
c. Z51.0, C14.0, C77.0, 77412
Correct answer. For the radiation therapy diagnosis, the Alphabetic Index main term is
Admission, subterm radiation therapy (antineoplastic). To find the Neoplasm codes, use the
Neoplasm Table under Pharynx, wall (lateral) (posterior), Malignant Primary, and Lymph,
gland, cervical, Malignant Secondary (CMS 2016a, 1.C.2.e.2).
CPT code 77412 is accessed using index entry Radiation Therapy, treatment delivery, which
directs to codes 77401, 77402, 77407, 77412. The code range is reviewed and 77412 is
selected based upon the three separate areas treated and custom blocking was used.
d. C14.0, C77.0, 77402
Incorrect answer. Assign Z51.0, Encounter for antineoplastic radiotherapy as the first listed
code followed by secondary codes for the malignancy (CMS 2016a, 1.C.2.e.2). The CPT code
is not appropriate for three separate treatment areas and custom blocking; code 77412 is
assigned.

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5.66. a. C34.32, 31629

Correct answer. For the diagnosis, the Alphabetic Index main term is Carcinoma, with
subterm oat cell. There is a note directing the coder to refer to the Neoplasm Table, specific
site (lung), Malignant Primary column. The coder would refer to the site of lung, lower lobe.
The Tabular List is referenced to assign fifth character “2” for left.
CPT code 31629 is accessed using index entry Bronchoscopy, biopsy. Review the range of
codes provided to select 31629. The biopsy was accomplished via needle aspiration
technique. Note that the code description specifies that fluoroscopic guidance is included
when performed.
b. C34.92, 31629, 77002
Incorrect answer. Documentation specifies that the lung mass is in the left lower lobe of the
lung. Code C34.32 is specific to the left lower lobe.
Fluoroscopic guidance is included in all endoscopic biopsy codes in the range of 31622–
31646 and is not assigned as an additional code.
c. C34.32, 31625
Incorrect answer. The procedure code is incorrect for a transbronchial aspiration biopsy of
lung tissue. Code 31629 is assigned.
d. D38.1, 31629, 77002
Incorrect answer. The carcinoma was not specified as a neoplasm of uncertain behavior as
the pathology revealed it was an oat cell carcinoma. Using the Alphabetic index, the main
term Carcinoma, subterm oat cell, the coder is directed to the Neoplasm Table, specific site
(lung, lower lobe), Malignant Primary column. Fluoroscopic guidance is not reported
separately in the endoscopic biopsy code range of 31622–31646. This code is also not
specific to an intrathoracic needle biopsy.
5.67. a. C50.411, N60.12, 19120-RT, 19125-LT, 19281-LT
Correct answer. To find the primary diagnosis code using the Neoplasm Table, the coder
goes to breast, upper-outer, and completes code using the Tabular List. The second
diagnosis code is found by using the Alphabetic Index main term Fibrocystic, subterm
disease, breast, the coder is directed to Mastopathy, cystic.
CPT 19120-RT is accessed using index entry Breast, excision, tumor as the entire lesion was
removed. CPT 19125-LT is accessed using index entry Breast, excision, lesion, by needle
localization. An additional code is necessary to identify the placement of the radiologic marker
under mammographic guidance (19281-LT). HCPCS Level II modifiers are used to show that
the lesions were not in the same breast and different techniques with separate incisions were
employed.
b. N63, N60.12, 19120-50
Incorrect answer. The definitive diagnosis after study is the breast cancer rather than the
breast lump. C50.411 is assigned as the primary diagnosis. A bilateral modifier -50 applies
only to identical procedures on paired organs. The breasts are paired organs, but the
procedures involved here are not the same. HCPCS Level II modifier -RT identifies the 19120
procedure on the right breast, while the -LT modifier is appended to CPT codes 19125 and
19281 to show that procedure occurred on the left breast.
c. C50.411, N60.12, 19120-50, 19125-50, 19281-50
Incorrect answer. Appropriate use of the bilateral modifier has it appended to only one CPT
code with identical procedures performed on paired organs. Although the breasts may have
bilateral procedures using modifier -50, it is only assigned to one code, which communicates
to Medicare that 150 percent of the allowed amount should be provided in reimbursement for
the case. The correct way to code the procedures is by use of the -RT and -LT Level II

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HCPCS codes to show that different breasts were involved. Codes 19120 and 19125 would
be mutually exclusive otherwise.
d. C50.411, N60.12, 19120, 19125-59, 19281
Incorrect answer. The fibrocystic disease was not stated to be fibroadenosis. N60.12
describes the fibrocystic disease. The use of modifier -59 is not appropriate for this case
because HCPCS Level II modifiers -RT and -LT would describe the services more concisely.
5.68. C18.7, D37.5, 45384, 45380-59
Rationale: To find the colon cancer code, go to the Neoplasm Table, the subterms are intestine,
large, colon, sigmoid. Select the code from the Malignant, Primary column. Villous adenoma
(polyps) is a neoplasm of uncertain behavior. These codes are only appropriately reported when
specified as such by a pathologist. For the villous adenoma, go to the main term Adenoma with
subterm villous. There is a note referring the coder to the Neoplasm Table by site and Uncertain
Behavior column.
Two separate procedures were performed in two distinct locations, so two codes are required.
The excision of the polyps by hot biopsy forceps is coded with one code as the code description
includes polyp(s) (45384). The biopsy of the sigmoid colon is assigned a code because it is a
separate lesion (45380-59). Modifier -59 designates that the two procedures are not
components of one another, but distinct.
5.69. ICD-10-CM, CPT, and HCPCS Code(s): Z51.11, C91.00, 96409, J9070 with 2 units
Rationale: Code Z51.11 is assigned as the first listed code as the admission is solely for the
administration of chemotherapy (CMS 2016a, 1.C.2.e.2). The Alphabetic Index main term is
Encounter, subterm chemotherapy for neoplasm. The Alphabetic Index main term is Leukemia,
leukemic, subterm acute lymphoblastic.
CPT code 96409 is accessed using index entry Chemotherapy, intravenous, push. An intravenous
push is defined as (a) an injection in which the individual who administers the drug is continuously
present to administer the injection or (b) an infusion of 15 minutes or less.
Typically the J code is assigned by the chargemaster. Report J9070 with a “2” in the claim units
field to specify 200 mg.

Disorders of the Nervous System and Sense Organs

5.70. T85.09XA, G91.2, Y83.1, 62252
Rationale: Malfunction of the CSF shunt is coded as T85.09XA. The Alphabetic Index main term is
Complication, subterms ventricular shunt, mechanical, obstruction. The Tabular is reviewed to
assign seventh character “A” for initial encounter. Another main term is Hydrocephalus with
subterm normal pressure. External cause code Y83.1 may also be assigned. The External Cause
Index main term is Complication of or following, implant, artificial, internal device. Headache is not
coded, as this is a symptom of the hydrocephalus.
Reprogramming of a programmable shunt is coded as 62252. The CPT index entry is
Reprogramming, shunt, cerebrospinal.
5.71. a. G12.21, 92265-50, 95861
Incorrect answer. A bilateral modifier is not appropriate for the eye muscle EMG because the
code description states “one or both eyes.”
b. G12.29, 95868, 95861
Incorrect answer. The diagnosis code is incorrect because this is the code for primary lateral
sclerosis. ALS is coded G12.21. The CPT code for the EMG of the eye muscles is 92265 and for
the legs (two extremities) is 95861. No modifier is needed for reporting these procedures together
because they are for separate sites.

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c. G12.21, 95861, 92265

Correct answer. Amyotrophic lateral sclerosis is a synonym for Lou Gehrig’s disease. The
Alphabetic Index main term is Sclerosis, sclerotic, subterm amyotrophic (lateral).
Access the CPT codes using index entry Electromyography, needle, extremities and
Electromyography, needle, ocular.
d. G12.20, 95861
Incorrect answer. The diagnosis code is not specific to ALS. The correct CPT codes are 95861 for
the bilateral extremity testing and 92265 for the eye muscle testing.
5.72. a. E10.349, 67040-50
Correct answer. For the diagnosis, the Alphabetic Index main term is Diabetes with subterms
type I, with, retinopathy, nonproliferative, severe. The abbreviation “OU” is a Latin
abbreviation meaning oculus uterque or both eyes. The Tabular List is reviewed to assign
sixth character “3” representing bilateral eyes.
CPT code 67040 is accessed using index entry Vitrectomy, photocoagulation. Modifier -50 is
appended to identify that this procedure was performed bilaterally.
b. H35.00, 67040-50
Incorrect answer. When diabetic complications are present, the combination code that
includes the type of diabetes, the affected body system, and associated complication is
assigned. Code E10.349 captures the severe nonproliferative diabetic retinopathy as the
reason for service in this case.
c. E11.349, 67039-LT-RT
Incorrect answer. The diabetes is specified as type I rather than type II. The CPT code is for a
procedure limited to a small area, such as one or two areas (focal), rather than the increased
amount of laser energy required to treat all four quadrants. Correct modifier assignment when
both sides are treated is -50.
d. E10.329, 67105, 67145
Incorrect answer. The diabetic retinopathy is specified as severe nonproliferative, which is
assigned to code E10.349.
The CPT coding is incorrect in this answer. Code 67040 includes the vitrectomy with
panretinal laser treatment. Code 67105 is for repair of retinal detachment and 67145 is for
prophylaxis of retinal detachment via photocoagulation. These procedures would not occur
together.
5.73. H25.13, 66984-LT
Rationale: For the diagnosis, the Alphabetic Index main term is Cataract, nuclear, sclerosis, which
directs users to entry Cataract, senile, nuclear. The Tabular List is referenced to assign fifth
character “3” representing bilateral eyes.
The CPT code 66984 describes an extracapsular cataract removal. The insertion of the intraocular
lens is included in the code. There is no documentation that this was a complex procedure.
HCPCS level II modifier -LT is assigned to represent laterality.
5.74. ICD-10-CM Reason for Visit Code(s): G40.919
ICD-10-CM and CPT Code(s): G40.311, 95819
Rationale: For the reason for visit ICD-10-CM assignment, the Alphabetic Index main term is
Disorder, seizure, intractable. For the primary diagnosis code, the Alphabetic Index main term is
Epilepsy, epileptic, epilepsia with subterms generalized, idiopathic, intractable. Select the code
outlining the epilepsy with status epilepticus.
The procedure code may be assigned by the chargemaster or may be assigned by the coder.
CPT code 95819 is indexed using entry Electroencephalopathy, standard.

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Exercise Answer Key CCW: Practice Exercises for Skill Development With Online Answers 535

5.75. a. 66710-LT
Incorrect answer. This code describes a procedure not involving the use of the ophthalmic
endoscope. Code 66711 is the correct code.
b. 66711-LT
Correct answer. CPT code 66711 is found using index entry Ciliary body, destruction,
cyclophotocoagulation.
c. 66720-LT
Incorrect answer. This code describes destruction of the ciliary body by cryotherapy. Code
66711 is the correct code.
d. 66700-LT
Incorrect answer. This code describes destruction of the ciliary body by diathermy. Code
66711 is the correct code.
5.76. a. H44.002, 67036-LT, 66030-59-LT
Correct answer. For the diagnosis, the Alphabetic Index main term is Endophthalmitis. When
reviewing subcategory H44.00, the code for the left eye is listed as H44.002.
The patient underwent a pars plana vitrectomy with injection of medications for
endophthalmitis. The vitrectomy is coded with 67036-LT using index entry Vitrectomy, pars
plana approach. An additional code for the injection may also be assigned with 66030 even
though is designated as a separate procedure. The injection of antibiotics for the
endophthalmitis is not an integral part of the vitrectomy. Modifier -59 is appended to 66030 to
identify it as a distinct procedural service from the vitrectomy.
b. H44.19, 67036-LT, 66030-59-LT
Incorrect answer. The source documentation does not provide specificity of the type of
endophthalmitis the patient had. The procedure codes are correct.
c. H44.002, 67036-RT
Incorrect answer. The diagnosis code is correct. The additional code for the injection is
needed to completely identify the procedure performed. The procedure was performed on the
left eye; therefore, the correct modifier is -LT.
d. T81.4XXA, H44.002, 67036-LT, 66030-LT
Incorrect answer. Diagnosis code T81.4XXA is coded when a postoperative infection is
documented by the physician. The source document indicates the patient is status post a
procedure; however, it does not link the current infection as a complication of that procedure.
Also, modifier -59 is appended to code 66030 to identify it as a distinct procedural service
from the vitrectomy.

Newborn/Congenital Disorders
5.77. a. Q12.0, P00.2, 66984-50
Incorrect answer. Category P00 is used to report maternal conditions that affect the fetus or
newborn. This was likely reported during the birth episode but is not a reason for health
services at this time (evaluation and management are directed at the congenital cataract).
Documentation supports the left eye and not bilateral; therefore, the correct HCPCS Level II
modifier is -LT.
b. H26.012, 66984-LT
Incorrect answer. H26.012 describes an infantile and juvenile cortical, lamellar or zonular
cataract. The Excludes1 note present at category H26 excludes this code with Q12.0 for
congenital cataract. The documentation specifies this is a congenital cataract; therefore, only
Q12.0 is assigned. The procedure code is correct.

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Exercise Answer Key CCW: Practice Exercises for Skill Development With Online Answers 536

c. Z38.00, P35.0, Q12.0

Incorrect answer. This is a subsequent episode of care for a seven-month-old, so Z38.00 is
inappropriate. The documentation does not specify that the patient is under current treatment
for congenital rubella (P35.0). CPT code 66984-LT should be reported for the procedure.
d. Q12.0, 66984-LT
Correct answer. For the diagnosis, the Alphabetic Index main term is Cataract, subterm
congenital. CPT code 66984 is accessed using index entry Phacoemulsification, removal.
HCPCS Level II modifier -LT is appended to this code to indicate the procedure occurred on
the left side.
5.78. a. Q69.0, 11200
Correct answer. For code Q69.0, the Alphabetic Index main term is Accessory with subterm
fingers. CPT code 11200 is indexed via entry Removal, skin tag. The note present at the
header indicates that the removal includes ligature strangulations. Additional reassurance that
this is the correct code can be found when referencing other potential codes such as 26587,
which provides an instructional note that states, “For excision of polydactylous digit, soft
tissue only, use 11200.”
b. Q69.0, 28344-RT
Incorrect answer. CPT code 28344 describes the reconstruction of polydactylous toes. This
procedure involved ligation of accessory fingers.
c. Q69.2, 28899
Incorrect answer. The diagnosis specifies the accessory digits are of the fingers rather than
the toes. The unlisted code 28899 is required only if the procedure involved more than soft
tissue removal. In a two-week-old child, this likely is a very small lesion to remove. Code
11200 is used to report this service.
d. Q69.0, 26587
Incorrect answer. The procedure code listed is for procedures involving reconstruction of
tissue and bone for extra digits found on the hand. Because there is no bone in this case,
code 11200 is adequate to report the service. An instructional note is present directing the
coder to use 11200 for excision of polydactylous digit, soft tissue only.
5.79. Q54.9, 54304
Rationale: Hypospadias is a congenital condition reported with code Q54.9. The CPT code 54304
is the correct procedure to report because it is a first-stage procedure requiring transposition of
the prepuce. This code is accessed using main term Hypospadias, repair, first stage.
5.80. P83.5, K40.20, 49500-50
Rationale: For code P83.5, the Alphabetic Index main term is Hydrocele with subterm congenital.
For code K40.20, the main term is Hernia with subterms inguinal, bilateral.
CPT code 49500 is accessed using main term Hernia repair, inguinal, infant, child under 5 years.
Modifier -50 is appended to denote this procedure was performed on both sides. A separate code
for the hydrocelectomy is not necessary as 49500 includes hernia repairs with or without
hydrocelectomy.

Pediatric Conditions
5.81. ICD-10-CM Reason for Visit Code(s): Q36.9
ICD-10-CM and CPT Code(s): Q36.9, 40720
Rationale: For code Q36.9, the Alphabetic Index main term is Cleft, subterm lip. CPT code 40720
is accessed using main term Cleft lip, repair, secondary. The documentation specifies that this is a
secondary correction of the cleft lip.

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Exercise Answer Key CCW: Practice Exercises for Skill Development With Online Answers 537

5.82. a. J35.02, J35.01, 42825, 42830

Incorrect answer. The diagnosis codes are incorrect; there is a combination code available for
the chronic adenoiditis and tonsillitis. A combination code should be used for the combination
of the tonsillectomy and the adenoidectomy.
b. J35.02, J35.01, 42820, 42820
Incorrect answer. The diagnosis codes are incorrect; there is a combination code available for
the chronic adenoiditis and tonsillitis. Code 42820 is used for a bilateral T&A.
c. J35.03, 42821
Incorrect answer. The diagnosis code is correct. The procedure codes for a T&A are age-
dependent. This code would be used if the patient is 12 years of age or older. In this case the
patient is 6 years old.
d. J35.03, 42820
Correct answer. There is a combination code for the chronic adenoiditis and tonsillitis that is
found in the Index at the main term Adenoiditis (chronic), subterm with tonsillitis. The
procedure code 42820 is accessed using index entry Tonsils, excision with adenoids.

Emergency Room Service

5.83. ICD-10-CM, CPT, and HCPCS Level II Codes: J45.901, 94640, 94640-76, J7611
Rationale: Cough is integral to asthma and therefore not coded separately. For the asthma code,
the Alphabetic Index main term is Asthma, subterm allergic extrinsic, with, exacerbation (acute).
The nebulizer treatments are coded as 94640 and 94640 with modifier -76 (non-pressurized
inhalation treatment for acute airway obstruction). There is an instructional note under 94640
directing to append modifier -76 for more than one inhalation treatment on the same date. Refer
also to CPT Assistant, April 2000, 11.
J7611 is reported for the 1 mg of Albuterol (concentrated). Note that the medication may be
reported as a pharmacy charge in the chargemaster.
5.84. ICD-10-CM Reason for Visit Code(s): S06.9X9A, R56.9
For the loss of consciousness, the Alphabetic Index main term is Loss, subterm consciousness,
traumatic, which directs the coder to see Injury, intracranial. The length of the loss of
consciousness is not stated upon arrival, therefore sixth character “9” is used to represent
unspecified duration. The seventh character “A” is assigned to indicate this is an initial encounter.
For the seizure, the Alphabetic Index main term is Seizure.
ICD-10-CM Code(s): S02.119A, S06.0X2A, R56.9, R40.242, S50.812A, R11.10, W09.2XXA,
Y92.830, Y93.39, Y99.8
For the skull fracture, the Alphabetic Index main term is Fracture, traumatic, subterm occiput,
which refers the coder to entry Fracture, traumatic, subterms, skull, base, occiput. The seventh
character “A” is assigned to indicate this is an initial encounter. The Alphabetic Index main term is
Concussion for code S06.0X2A. The Tabular List is reviewed to assign the appropriate sixth
character representing the duration of the loss of consciousness. The seventh character “A” is
assigned to indicate this is an initial encounter. The Alphabetic Index main term is Seizure for
code R56.9. For reporting the Glasgow coma scale, the Alphabetic Index is Glasgow coma scale,
subterms, total score, 9–12. The abrasion is coded by accessing the Alphabetic Index main term
Abrasion, subterm forearm. The vomiting is also coded by locating the main term Vomiting. The
Tabular List is consulted to complete the code.
Four external cause codes are assigned to indicate how the injury happened (fall), the place of
occurrence, activity, and status. For code W09.2XXA, the External Cause Index main term is Fall,
subterms playground equipment, jungle gym. The External Cause Index main term is Place of
occurrence, subterm park (public) for code Y92.830. The External Cause Index main term is

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Exercise Answer Key CCW: Practice Exercises for Skill Development With Online Answers 538

Activity, subterm climbing NEC for code Y93.39. And finally, the status code is found in the
External Cause Index at the main term External cause status, specified NEC.
5.85. ICD-10-CM Reason for Visit Code(s): R05, R50.9
ICD-10-CM Code(s): H10.33, J06.9
ICD-10-CM Rationale: The reason for visit was a cough and fever which are found in the
Alphabetic Index at the main terms Cough and Fever, unspecified. For the final diagnosis of
conjunctivitis, the Alphabetic Index main term is Conjunctivitis, acute. The coder completes the
code using the Tabular List to assign fifth character “3” representing bilateral eyes. For the upper
respiratory infection, the Alphabetic Index main term is Infection, subterm respiratory, upper NOS.

Conditions of Pregnancy, Childbirth, and the Puerperium

5.86. a. R73.09, Z33.1, 82951
Incorrect answer. Sucbategory R73.0 includes an Excludes1 note indicating that abnormal
glucose in pregnancy may not be assigned with R73.09. O99.810 is the correct code for the
abnormal glucose in pregnancy. Z33.1 represents an incidental pregnancy that is not
appropriate for this encounter. An additional diagnosis code is necessary to report the weeks
of gestation, Z3A.26. Laboratory codes are typically coded by the chargemaster.
b. O99.810, Z3A.26, 82951
Correct answer. For the first diagnosis code, the Alphabetic Index main term is Pregnancy
with subterms complicated by, abnormal, glucose (tolerance) NEC. The Tabular List is
consulted to assign the appropriate sixth character “0” representing that the abnormal glucose
is complicating the pregnancy. For code Z3A.26, the Alphabetic main term is Pregnancy,
subterms weeks of gestation, 26 weeks. CPT 82951 is accessed using index entry Glucose,
tolerance test. Laboratory codes are typically coded by the chargemaster.
c. O99.810, Z3A.26, 82950
Incorrect answer. The correct diagnosis codes are listed. CPT code 82951 is the appropriate
code for this test, which involves obtaining three separate specimens for testing the glucose
levels at one hour, two hours, and three hours after the patient drinks the glucose mixture.
Laboratory codes are typically coded by the chargemaster.
d. O24.419, 82951, 82952
Incorrect answer. The documentation does not specify the patient has gestational diabetes
but it is to be ruled out. The reason for the test is abnormal glucose, which is coded with
O99.810 for this encounter. An additional diagnosis code is necessary to report the weeks of
gestation, Z3A.26. Three specimens are included in code 82951. CPT code 82952 would only
be reported if additional tests, beyond three, were performed. Laboratory codes are typically
coded by the chargemaster.
5.87. a. O02.1, 58120
Incorrect answer. The abortion was specified as spontaneous incomplete rather than missed
abortion. A weeks of gestation code should be assigned also, Z3A.10. Code 58120 is
incorrect because this is the surgical completion of an incomplete abortion. The correct CPT
code is 59812.
b. O03.4, Z3A.10, 59812
Correct answer. For code O03.4, the Alphabetic Index main term is Abortion, subterm
incomplete. For code Z3A.10, the Alphabetic main term is Pregnancy, subterms weeks of
gestation, 10 weeks. CPT code 59812 is accessed using index entry Abortion, incomplete.

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Exercise Answer Key CCW: Practice Exercises for Skill Development With Online Answers 539

c. O03.4, Z3A.10, 58120

Incorrect answer. The diagnosis codes are correct. The CPT code 58120 is used for a
nonobstetric procedure. Because this procedure is done for treatment of an incomplete
spontaneous abortion, code 59812 is reported.
d. O03.9, 59812
Incorrect answer. Code O03.9 describes a complete spontaneous abortion. Documentation
indicates this was an incomplete spontaneous abortion. A weeks of gestation code should be
assigned also, Z3A.10. The procedure code is correct.
5.88. Z36, Z3A.16, 76805
Rationale: Because the purpose of the test is antenatal screening, code Z36 is reported as the
reason for the test. The Alphabetic Index main term is Encounter (for) with subterm antenatal
screening. It is incorrect to assign Z33.1, incidental pregnancy, in this case. For code Z3A.16, the
Alphabetic main term is Pregnancy, subterms weeks of gestation, 16 weeks. CPT code 76805 is
accessed using index entry Prenatal testing, ultrasound.
5.89. N97.1, 58340, 74740
Rationale: For the diagnosis, the Alphabetic Index main term is Infertility, subterm female,
associated with, fallopian tube disease or anomaly. Code 58340 is reported for the injection. This
code is accessed using index entry Hysterosalpingography, injection procedure. Code 74740 is
reported for the interpretation of the hysterosalpingogram, which is accessed using index entry
Hysterosalpingography.

Disorders of the Genitourinary System

5.90. a. N21.1, 52332, 50590
Incorrect answer. This diagnosis code describes a stone in the urethra, which is incorrect for
this case. The cystourethroscopy with stent insertion was done on a previous admission. Only
the ESWL was done at this time.
b. N20.0, 50590
Correct answer. The diagnosis for the kidney stone is found in the Index at the main term
Calculus, subterm kidney. The procedure code is accessed using index entry Lithotripsy,
kidney.
c. N20.0, 52353
Incorrect answer. The diagnosis is correct. The lithotripsy was not done via
cystourethroscopy.
d. N20.1, 50590, 52353
The stone is in the kidney, rather than the ureter. Code 52353 is not appropriate—a
cystourethroscopy was not done on this admission.
5.91. Z30.2, 55250
Rationale: The patient presents for contraceptive surgery. Z30.2 is used for admissions that are
for sterilization surgery. Refer to Alphabetic Index main term is Encounter, subterm sterilization to
locate this code. Code 55250 is used for the vasectomy that is accessed using main term
Vasectomy. This code includes any post-surgery semen analysis. A bilateral modifier is not
necessary as the code description specifies unilateral or bilateral.
5.92. N44.03, F71, E66.9, 54512-RT
Rationale: For code N44.03, the Alphabetic Index main term is Torsion with subterm appendix
testis. For code F71, the Alphabetic Index main term is Disability, subterms, intellectual, moderate.
The Alphabetic Index main term is Obesity for code E66.9.

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Exercise Answer Key CCW: Practice Exercises for Skill Development With Online Answers 540

An appendix testis is a small solid projection of tissue on the upper outer surface of the testis. It is
a remnant of the embryonic Mullerian duct. There is no code that specifically refers to the removal
of an appendix testis but code 54512 is used for extraparenchymal tissue removal that an
appendix testis is. This code is accessed using main term Excision, testis, lesion.

Disorders of the Respiratory System

5.93. a. J44.1, J45.42
Correct answer. For code J44.1, the Alphabetic Index main term is Disease, subterms
pulmonary, chronic obstructive, with exacerbation. An instructional note is present at J44
provides instructions to “code also type of asthma, if applicable (J45.42).” An Excludes2 note
appears under J45 for “asthma with chronic obstructive pulmonary disease.” A type 2
“excludes” note represents “not included here.” An Excludes2 note indicates that the condition
excluded is not part of the condition represented by the code, but a patient may have both
conditions at the same time. When an Excludes2 note appears under a code, it is acceptable
to use both the code and the excluded code together, when appropriate. The “code also” note
does not provide sequencing direction. For code J45.42, the Alphabetic Index main term is
Asthma, subterms moderate persistent, with status asthmaticus.
b. J44.1, J45.902
Incorrect answer. The type of asthma is specified as moderate persistent. The more specific
code J45.42 is assigned.
c. J44.0, J45.42
Incorrect answer. Documentation indicate the presence of an acute exacerbation. There is not
documentation of an acute lower respiratory infection such as acute bronchitis to assign
J44.0.
d. J44.1
Incorrect answer. An additional code for the asthma is needed, J45.42. An instructional note
is present at J44 directs to “code also type of asthma, if applicable (J45.42).” An Excludes2
note appears under J45 for “asthma with chronic obstructive pulmonary disease.” A type 2
“excludes” note represents “not included here.” An Excludes2 note indicates that the condition
excluded is not part of the condition represented by the code, but a patient may have both
conditions at the same time. When an Excludes2 note appears under a code, it is acceptable
to use both the code and the excluded code together, when appropriate. The “code also” note
does not provide sequencing direction.
5.94. C34.11, F17.210, 31625
Rationale: The site is specified as upper right lobe of bronchus. The hemoptysis and cough would
be integral to the carcinoma. For the adenocarcinoma, the Alphabetic Index main term is
Neoplasm with subterms bronchus, upper lobe. Assign the code from the Malignant Primary
column. Category C34 provides a use additional code note to identify tobacco dependence. The
Alphabetic Index entry main term Smoker directs to see Dependence, drug, nicotine. The type of
tobacco used is specified as cigarettes in the scenario.
CPT code 31625 is accessed using index entry Bronchoscopy, bronchus.
5.95. ICD-10-CM Reason for Visit Code(s): Z43.0
ICD-10-CM and CPT Code(s): Z43.0, 31820
Rationale: For the diagnosis code, the Alphabetic Index main term is Attention (to), subterm,
tracheostomy.
The documentation states that plastic repair was not required for the closure, so code 31820 is
assigned. CPT code 31820 is accessed using index entry Tracheostomy, surgical closure, without
plastic repair.

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Exercise Answer Key CCW: Practice Exercises for Skill Development With Online Answers 541

Trauma and Poisoning

5.96. a. T17.498A, Y93.02, Y92.831, Y99.8, 31577
Correct answer. For the primary diagnosis code, the Alphabetic Index main term is Foreign
body with subterms trachea, causing, injury NEC, specified type NEC. External cause codes
are assigned for the activity, place of occurrence and status. In the Index to External Causes,
the main term is Activity with subterm running In the Index to External Causes, the main term
is Place of occurrence with subterm amusement park. In the Index to External Causes, the
main term is External cause status, subterm, leisure activity.
CPT code 31577 is accessed using index entry Laryngoscopy, fiberoptic, foreign body.
b. T17.498D, Y93.02, Y92.831, Y99.8, 31511
Incorrect answer. The correct code for the foreign body aspiration is T17.498A. Seventh
character “A” represents initial encounter. Code 31511 is for an indirect laryngoscopy rather
than the fiberoptic type of scope indicated. Code 31577 is correct.
c. R09.89, Y93.02, Y92.831, Y99.8, E000.8, 31530
Incorrect answer. An operative laryngoscopy requires anesthetic support not available in the
ED. CPT code 31577 is the correct code for a fiberoptic scope with local anesthesia used.
Also, when choking occurs from a foreign body lodged in the airway, the foreign body should
be coded rather than the symptom code for choking sensation.
d. T17.398A, Y93.02, Y92.831, Y99.8, 31577
Incorrect answer. Code T17.498A is specific to the trachea, while code T17.398A is for a
foreign body in the larynx. The procedure code is correct.
5.97. ICD-10-CM, CPT, and HCPCS Level II Code(s): T46.1X2A, 43753, 96365, 96366, 96375, J1610 ×
20, J7060
Rationale: The Drug and Chemical Table is used to locate the drug Verapamil. The column
Poisoning, Intentional, Self-harm is used. CPT code 43753 is found with index entry Lavage,
stomach. Based upon the CPT hierarchy, the infusion of Glucagon HCl is the primary service
(96365 and 96366). Although the IV push was performed first, it is secondary to an infusion
service in the hierarchy and is reported with the add-on code 96375. The Glucagon HCl is J1610
for 20 units (10 mg push and 5 mg per hour over 2 hours) and D5W is J7060.
5.98. T22.212D, T22.211D, X10.2XXD, 16025
Rationale: For the burn codes, the Alphabetic Index main term is Burn, subterms, forearm, left,
second degree and Burn, subterms forearm, right second degree. The Index to External Causes
main term Contact, subterms with, hot, fats. The seventh character “D” is assigned to indicate this
is a subsequent encounter as the burn is still under treatment. The external cause code is to be
reported for each encounter for which the burn is treated. An aftercare code from category Z48 is
not assigned as they are not to be used for after care of injuries (CMS 2016a, I.C.21.c.7).
The CPT code is accessed using index entry Dressings, burns. The size of the dressing changes
was specified as medium in the documentation.

5.99. C34.90, J91.0, 32555, 32555-76

Rationale: For the lung cancer, the Alphabetic Index main term is found in the Neoplasm Table
under Lung. The Alphabetic Index main term is Effusion, subterm pleura, malignant for code
J91.0. There is an instructional note present at J91.0 directing to code first the underlying
neoplasm.
The thoracentesis was repeated in the same day by the same physician. The CPT code is
accessed using index entry Thoracentesis, with imaging guidance. Both thoracentesis procedures
utilized imaging guidance therefore 32555 is assigned twice. Modifier -76 is reported on the
second procedure to indicate a repeat procedure by the same surgeon on the same day.

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Exercise Answer Key CCW: Practice Exercises for Skill Development With Online Answers 542

5.100. ICD-10-CM Reason for Visit Code(s): S61.411A, S51.811A, S71.112A

ICD-10-CM and CPT Code(s): S61.411A, S51.811A, S71.112A, W01.118A, Y92.73, Y93.02,
Y99.8, 12004, 12042
Rationale: When the sites of the open wounds are known, do not assign a code for multiple. Code
the sites individually. The Alphabetic Index main term is Laceration, subterms, hand, right. The
Alphabetic Index main term is Laceration, subterm forearm, right. The Alphabetic Index main term
is Laceration, subterms, thigh. The Tabular List is consulted to assign the appropriate seventh
character “A” for initial encounter. In the Index to External Causes, the main term is Fall, falling
with subterms due to, slipping, with subsequent striking against object, specified NEC. In the
Index to External Causes, the main term is Place of occurrence with subterm farm, field. In the
Index to External Causes, the main term is Activity with subterm running. In the Index to External
Causes, the main term is External Cause Status with subterm specified NEC.
The lengths of all three wounds are not added together. Only the lengths of wounds that are in the
same repair category and anatomic site are added together. In this case, the forearm and thigh
are both simple repairs, while the hand is an intermediate repair, which is separately reported. The
intermediate repair is listed as the first procedure since it is the more resource-intensive
procedure. Modifiers -LT and -RT are not used on skin repair codes.
5.101. a. T36.8X2A, T78.3XXA, R06.00, Y92.009
Incorrect answer. There is no evidence in the source document of an overdose of the
medication; therefore, an ICD-10-CM code for poisoning is inappropriate.
b. T78.3XXA, R06.00, L27.0, T50.995A, Y92.009
Incorrect answer. Code T50.995A is for the adverse effect of a specified drug not elsewhere
classified. Although there is not an entry for the brand name Bactrim in the Table of Drugs
and Chemicals, the generic ingredients are listed. Bactrim is made of two antibiotics,
sulfamethoxazole and trimethoprim.
c. T78.3XXA, R06.00, L27.0, T36.8X5A, Y92.009
Correct answer. The code for angioedema is found in the Alphabetic Index under main term
Angioedema, with the seventh character of “A” for initial encounter. The Alphabetic Index
main term is Distress, subterm respiratory. The Alphabetic Index main term is Rash, subterm
drug. The Table of Drugs and Chemicals is used to select the adverse effect code for Bactrim.
There is no entry for Bactrim, but Bactrim is made of two antibiotics, sulfamethoxazole and
trimethoprim. There is an entry in the table for this combination. The code is selected from
Adverse Effect. The Tabular List is reviewed to assign seventh character “A” indicating initial
encounter. The nature of the adverse effect is sequenced first followed by an appropriate
code for the adverse effect of the drug (CMS 2016a, 1.C.19.e.5.a.). The External Cause Index
main term is Place of occurrence, subterms residence, home.
d. T78.3XXA, R06.00, L27.0, T37.0X5A, Y92.009
Incorrect answer. The incorrect diagnosis code it T37.0X5A. Bactrim is an antibiotic that
contains a combination of sulfamethoxazole and trimethoprim. There is an entry in the Table of
Drugs and Chemicals for this combination (T36.8X5A).
5.102. S62.621B, S66.321A, S63.631A, W31.2XXA, Y92.015, Y93.H9, Y99.8, 26418-F1, 26540-F1,
11012
Rationale: The Alphabetic Index main term is Fracture, traumatic with subterms finger, index,
medial phalanx (displaced). The Tabular List is consulted to assign sixth character “1”
representing the left side and seventh character “B” representing open fracture, initial encounter.
The Alphabetic Index main term is Injury, subterms, muscle, finger, index, extensor, hand,
laceration. The Alphabetic index main term is Laceration, subterm ligament, which directs to see
Sprain. At the main term Sprain, subterms include finger, interphalangeal, index. The Tabular List
is reviewed to assign sixth and seventh characters. In the Index to External Causes, the main term
is Contact (accidental) with subterms with, circular saw. The Tabular List is reviewed to assign

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Exercise Answer Key CCW: Practice Exercises for Skill Development With Online Answers 543

seventh character “A” indicating initial encounter. In the Index to External Causes, the main term
is Activity with subterms maintenance, property. In the Index to External Causes, the main term is
Place of occurrence with subterms residence, houses, single family, garage. In the Index to
External Causes, the main term is External Cause Status with subterm specified NEC.
The source document reveals the patient had a compound fracture that was debrided down to the
bone with extensor tendon and collateral ligament repair. To access the CPT procedure codes,
the following index entries are used: Repair, finger, tendon, extensor; Ligament, collateral, repair,
interphalangeal joint; and Debridement, bone, with open fracture and/or dislocation. Modifier -F1
representing the index finger is appended to 26418 and 26540.

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