Review each case study and assign the correct CPT code and modifier (if applicable) to each. Some exercises may have more than one code and/or more than one modifier.
Review each case study and assign the correct CPT code and modifier (if applicable) to each. Some exercises may have more than one code and/or more than one modifier.
Pay close attention to who you are coding/reporting for—the physician or the facility. Most of these are physician coding, but some may require you to also identify what the facility would code/report. Remember, outpatient facilities (hospitals) are limited to the approved list of modifiers (located on the back of CPT’s front cover or in Appendix A of CPT).
Document your correct answers in the space provided below each exercise. Do not assign diagnosis codes!
Upon completion, enter your answers/codes into the electronic assignment in Blackboard. Keep in mind:
The assignment will not tell you how many codes to report—you need to decide. If more than one code for each question/provider, you will need to enter more than one code per question.
The assignment will not tell you if a modifier is required or not—you need to decide.
A bilateral endoscopic nasal polypectomy.
Surgeon (Physician) would report:
Insertion of permanent cardiac pacemaker with transvenous atrial & ventricular electrodes. Physician A performs the surgical creation of the pocket for the pulse generator. Physician B inserts the pacemaker.
Physician A Reports:
Physician B Reports
Patient undergoes a split thickness skin graft of his leg after the surgeon removes a large malignant melanoma of the leg. Melanoma is 8cm and the surgeon took .5cm margins on each side. The skin graft was 10 sq cm.
Surgeon (Physician) would report:
Code each different scenario for the same procedure. Procedure performed is:
Office procedure. Physician owns equipment, performs procedure & reads & interprets results of the pyelogram.
A cystourethroscopy with retrograde pyelography
Physician Reports:
Office procedure. Physician owns equipment, performs procedure & outside radiologist reads and interprets the results of the pyelogram.
Physician Reports:
Radiologist Reports:
Outpatient hospital procedure. Physician performs procedure at hospital and reads & interprets results of the pyelogram.
Physician Reports:
Hospital (facility) Reports:
Outpatient hospital procedure. Physician performs procedure at hospital. Independent radiologist reads and interprets the results of the pyelogram. Hospital does not bill for radiologist.
Physician Reports:
Radiologist Reports:
Hospital (facility) Reports:
Bilateral femur x-rays; 2 views on each side. Physician owns equipment and reads/interprets results of x-rays. (Coding Tip: Remember 50 modifier is not used with Radiology CPT codes.)
Physician would report:
Patient is in the hospital as an outpatient for a percutaneous liver biopsy. After the patient was prepped for surgery and after administration of anesthesia (not by the surgeon), the patient developed atrial fibrillation and the procedure was terminated.
Physician would report:
Hospital (facility) would report:
Laminectomy (hemilaminectomy) with excision of herniated disc, L2-L3. Code the services for a physician assisting the surgeon with the procedure.
Assistant Surgeon would report:
Liver transplant is performed by a surgical team consisting of four physicians. How would each physician code (report) for their services?
Physician #1 would report:
Physician #2 would report:
Physician #3 would report:
Physician #4 would report:
A patient underwent percutaneous placement of a gastrostomy tube under fluoroscopic guidance in the outpatient hospital setting. The patient was taken to the recovery room and 20 minutes later the patient began hemorrhaging and was returned to the operating room for replacement of the gastrostomy tube under fluoroscopic guidance at the same site.
Hospital (facility) would report:
A physician performed a thoracentesis for a patient with pleural effusion. Later that same day the
patient’s lungs filled up again and another thoracentesis was performed by the same physician.
Physician would report:
A 32-year-old female patient presents to her physician’s office for a routine yearly gynecological exam. She was seen 13 months ago by the same physician for an exam. During the exam, the physician identifies a palpable, solitary lump in her left breast. The physician considers this finding significant enough to require additional work-up and the performance of the key components of a problem-oriented evaluation & management service.
History=Problem Focused
Exam=Problem Focused
Medical Decision Making=Straightforward.
Physician would report:
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