Respiratory system
1. Julie, a 28-year-old ESRD patient was seen by Dr. Jeri in an outpatient hospital facility for treatment of
an obstructed hemodialysis AV graft. Dr. Jeri provided moderate conscious sedation to Julie for
percutaneous transluminal balloon angioplasty of the venous portion of the graft. This procedure lasted
45 minutes. Julie had an excellent result and was released to home after recovery from the treatment.
Dr. Jeri performed the professional radiological supervision and interpretation with this procedure.
What code(s) capture this service?
a. 35476, 75978-26
b. 35460, 75962-26
c. 36476, 92982, 75978-26
d. 36476, 99144, 99145, 75878-26
2. What code would you report for a cervical approach of a mediastinotomy with exploration, drainage,
removal of foreign body, or biopsy?
a. 39010
b. 39000
c. 39200
d. 39400
3. Roger had a rhinoplasty to correct damage caused by a broken nose. One year later he had a
secondary rhinoplasty with major revisions. At the end of the second surgery the incisions were closed
with a single layer technique. How would you report the second procedure?
a. 30450
b. 30450-78
c. 30420, 12014
d. 30430, 12014-59
4. A surgeon started with a diagnostic thoracoscopy. During the same surgical session she completed a
surgical thoracoscopy to control a hemorrhage. How would you report this procedure?
a. 32601
b. 32601, 32654-59
c. 32500
d. 32654
5. Dr. Sacra performed a CABG surgery on Fred five months ago. Today, Dr. Sacra completed another
coronary artery bypass using three venous grafts with harvesting of a femoropopliteal vein segment.
How would Dr. Sacra report her work for the current surgery?
a. 33512, 33530-51, 35572-51
b. 33535, 35500-51, 33519
c. 33512, 33530, 35572
d. 33535, 33519, 33530-51, 35500
6. What do the primary codes 33880 and 33881 include?
a. Placement of all distal extensions, if required in the distal thoracic aorta
b. Placement of all proximal extensions in the thoracic aorta
c. Repair of extensions in the thoracic aorta
d. Repositioning of all leads and extensions in the thoracic aorta
7. Mrs. Reyes had a temporary ventricular pacemaker placed at the start of a procedure. This temporary
system was used as support during the procedure only. How would you report the temporary system?
a. 33210
b. 33211
c. 33207
d. 33210, 33207-51, 33235-51
8. Mr. Azeri, a 68-year-old patient, has a dual-chamber pacemaker. The leads in this system were
recalled. The leads were extracted via transvenous technique, the generator was left in place, and new
leads were inserted via transvenous technique. How would you report this procedure?
a. 33214, 33215-51, 33208-51, 33218-51
b. 33215, 33210-51, 33216-51
c. 33208, 33235-51, 33217-51
d. 33235, 33217-51
9. A 35-year-old female patient with a venous catheter requires a blood sample for hematology testing.
The sample is collected via her PICC catheter. How would you report this procedure?
a. 36415
b. 36592
c. 36591
d. 37799
10. A patient underwent a secondary percutaneous transluminal thrombectomy for retrieval of a short
segment of embolus evident during another percutaneous intervention procedure. How would you
report this secondary procedure?
a. 37184, 37186
b. 37186 in addition to the primary procedure
c. 37185, 76000
d. 37187
11. The patient is a 67 -year-old gentleman with metastatic colon cancer recently operated on for a
brain metastasis, now for placement of an Infuse-A-Port for continued chemotherapy. The left
subclavian vein was located with a needle and a guide wire placed. This was confirmed to be in the
proper position fluoroscopically. A transverse incision was made just inferior to this and a subcutaneous
pocket created just inferior to this. After tunneling, the introducer was placed over the guide wire and
the power port line was placed with the introducer and the introducer was peeled away. The tip was
placed in the appropriate position under fluoroscopic guidance and the catheter trimmed to the
appropriate length and secured to the power port device. The locking mechanism was fully engaged.
The port was placed in the subcutaneous pocket and everything sat very nicely fluoroscopically. It was
secured to the underlying soft tissue with 2-0 silk stitch. What code should be used for this procedure?
A. 36556, 77001-26
C. 36561, 77001-26
B. 36558
D. 36571
12. A CT scan identified moderate-sized right pleural effusion in a 50-year-old male. This was estimated
to be 800 cc in size and had an appearance of fluid on the CT Scan. A surgical puncture using an
aspirating needle punctured through the chest tissues and entered the pleural cavity. Fluid was
aspirated, draining the effusion under ultrasound guidance using 1% lidocaine as local anesthetic. What
procedure code should be used?
A. 32421, 76942-26
C. 32420, 76942-26
B. 32422, 77002-26
D. 32400, 77012-26
13. The patient is a 59-year-old white male who underwent carotid endarterectomy for symptomatic left
carotid stenosis a year ago. A carotid CT angiogram showed a recurrent 90% left internal carotid artery
stenosis extending into the common carotid artery. He is taken to the operating room for re-do left
carotid endarterectomy. The left neck was prepped and the previous incision was carefully reopened.
Using sharp dissection, the common carotid artery and its branches were dissected free. The patient was
systematically heparinized and after a few minutes clamps applied to the common carotid artery and its
branches. A longitudinal arteriotomy was carried out with findings of extensive layering of intimal
hyperplasia with no evidence of recurrent atherosclerosis. A silastic balloon-tip shunt was inserted first
proximally and then distally, with restoration of flow. Several layers of intima were removed and the
endarterectomized surfaces irrigated with heparinized saline. An oval Dacron patch was then sewn into
place with running 6-0 Prolene. Which CPT code should be used?
A. 35301
B. 35301, 35390
C. 35302
D. 35311, 35390
14. A catheter is placed in the left common femoral artery in retrograde fashion which was directed into
the right iliac system advancing it to the external iliac. Dye was injected and a select right lower
extremity angiogram was performed which revealed patency of the common femoral and profunda
femoris. The catheter was then manipulated into the femoral artery in which a select lower extremity
angiogram was performed which revealed occlusion from the popliteal to the peroneal artery. What are
the procedure codes that describe this procedure?
A. 36217, 75736-26, 75774-26
B. 36247, 75716-26
C. 36217, 75658-26
D. 36247,75710-26
15. 79-year-old male with symptomatic bradycardia and syncope is taken to the Operating Suite where
an insertion of a DDD pacemaker will be performed. A left subclavian venipuncture was carried out. A
guide wire was passed through the needle, and the needle was withdrawn. A second subclavian
venipuncture was performed, a second guide wire was passed and the second needle was withdrawn.
An oblique incision in the deltopectoral area incorporating the wire exit sites. A subcutaneous pocket
was created with the cautery on the pectoralis fascia. An introducer dilator was passed over the first
wire and the wire and dilator were withdrawn. A ventricular lead was passed through the introducer,
and the introducer was broken away in the routine fashion. A second introducer dilator was passed over
the second guide wire and the wire and dilator were withdrawn. An atrial lead was passed through the
introducer and the introducer was broken away in the routine fashion. Each of the leads were sutured
down to the chest wall with two 2-0 silk sutures each, connected the leads to the generator, curled the
leads, and the generator was placed in the pocket. We assured hemostasis. We assured good position
with the fluoroscopy. What code should be used for this procedure?
A. 33208, 71090-26
B. 33212
C. 33226
D. 33235, 71090-26
16. PREOPERATIVE DIAGNOSIS: Left breast carcinoma. POSTOPERATIVE DIAGNOSIS: Left breast
carcinoma. NAME OF PROCEDURE: Left lumpectomy and sentinel node biopsy. DESCRIPTION OF
PROCEDURE: The patient is a 65-year female admitted with a diagnosis of left breast carcinoma. Risks
and benefits of the procedure had been discussed preoperatively including risks of bleeding, infection,
deformity in the breast, chronic pain, numbness, chronic lymph edema associated with the lymph node
biopsy as well as other possible complications. The patient agreed to proceed. Because the wire was
located in the upper outer quadrant of the breast over the lesion and the length of the wire was 10 cm,
it was felt that it would be best to approach the node biopsy as well as the lumpectomy through the
same incision in the upper outer quadrant of the left breast. Incision was made with a 15-blade through
skin and subcutaneous. Homeostasis achieved with Bovie electrocautery. Flaps were formed in the usual
manner. A wire was brought out through the incision. We then circumferentially removed all the tissue
around the wire down to the tip. We marked the specimen with a long lateral stitch, short superior
stitch, 2 lateral clips, and 1 superior clip. We were able to identify a hot node in the axilla and at least 2
lymph nodes that were blue-dyed within the sentinel nodes. We did perform lymphoscintigraphy and
injected 2 cc of methylene blue dye in the periareolar area preoperatively and massaged the breast for 5
minutes. The lymph nodes were excised and a biopsy was performed on the axillary node. At this point,
we copiously irrigated the area to assure good homeostasis. We placed clips throughout the entire
cavity. We then closed the deep dermal tissue with interrupted 3-0 Vicryl sutures and then closed the
skin with a fine 5-0 nylon. The patient tolerated the procedure well. Sponge count was correct. Blood
loss was minimal. The patient was sent to the recovery room in stable condition. What are the codes for
these procedures?
A. 19120, 38530-51-LT
B. 19301, 38525-52-51-LT, 38792-51-LT
C. 19302, 38520-51-LT
D. 19120, 38510-51-LT, 38792-51-LT
17. The patient is a fifty-eight-year-old white male, one month status post pneumonectomy. He had a
post pneumonectomy empyema treated with a tunneled cuffed pleural catheter which has been
draining the cavity for one month with clear drainage. He has had no evidence of a block or pleural
fistula. Therefore a planned return to surgery results in the removal of the catheter. The correct CPT
code is:
A. 32440-78
B. 32035-58
C. 32036-79
D. 32552-58
18. This 67 year-old man presented with a history of progressive shortness of breath, mostly related to
exercise. He has had a diagnosis of a secundum atrioseptal defect for several years, and has had atrial
fibrillation intermittently over this period of time. He was in atrial fibrillation when he came to the
operating room, and with the patient cannulated and on bypass, The right atrium was then opened. A
large 3 x 5 cm defect was noted at fossa ovalis, and this also included a second hole in the same general
area. Both of these holes were closed with a single pericardial patch. What CPT and ICD-9 codes should
be reported?
A. 33675, 745.4
B. 33647, 786.05, 745.5
C. 33645, 745.69, 786.05
D. 33641, 745.5
19. The femoral artery is punctured with a needle and a catheter is threaded over a guidewire which is
fed through the artery into the aorta and selectively placed into the right and the left common carotid.
An angiogram was performed bilaterally showing minimal tumor blush but no other pathology
identified. What CPT code describes this service?
A. 36216-RT, 36215-59-LT, 75671-26
B. 36216-59-LT, 75676-26
C. 36216-RT, 36215-59-LT, 75680-26
D. 36217-RT, 36216-59-LT, 75662-26
20. The patient is a 51 year old gentleman who has end-stage renal disease. He was in the OR yesterday
for a revision of his AV graft. The next day the patient had complications of the graft failing. The patient
was back to the operating room where an open thrombectomy was performed on both sides getting
good back bleeding, good inflow. An arteriogram was shot. There was a small amount of what looked
like pseudo-intima in the distal anastomosis of the venous tract that was causing a flow defect which
was taken out with a Fogarty catheter. A Conquest balloon was ballooned up again with a 6 millimeter
and a 7 millimeter. An arteriogram was reshot in both directions. The arterial anastomosis looked fine as
did the venous anastomosis. Select the appropriate codes for this visit:
A. 36831-76, 35460-51-76, 75978-26
B. 36831, 35460-51, 75978-26
C. 36831-78, 75791-26, 35460-78, 75978-26
D. 36831-58, 35460-51-58, 75978-26
21. The patient is a 77 year-old white female who has been having right temporal pain and headaches
with some visual changes and has a sed rate of 51. She is scheduled for a temporal artery biopsy to rule
out temporal arteritis. A Doppler probe was used to isolate the temporal artery and using a marking pen
the path of the artery was drawn. Lidocaine 1% was used to infiltrate the skin, and using a 15 blade
scalpel the skin was opened in the preauricular area and dissected down to the subcutaneous tissue
where the temporal artery was identified in its bed. It was a medium size artery and we dissected it out
for a length of approximately 4 cm with some branches. The ends were ligated with 4-0 Vicryl, and the
artery was removed from its bed and sent to Pathology as specimen. What code should be used for this
procedure?
A. 37609
B. 37605
C. 36625
D. 37799
22. 50-year-old female has recurrent lymphoma in the axilla. Ultrasound was used to localize the lymph
node in question for needle guidance. An 11 blade scalpel was used to perform a small dermatotomy.
An 18 x 10 cm Biopence needle was advanced through the dermatotomy to the periphery of the lymph
node. A total of 4 biopsy specimens were obtained. Two specimens were placed an RPMI and 2 were
placed in formalin and sent to laboratory. The correct CPT code is:
A. 10022
B. 38500, 77002-26
C. 38505, 76942-26
D. 38525, 76942-26
23. Procedure: Dual chamber pacemaker defibrillator implantation. Indications: A 67-year-old white
gentleman who has significant underlying ischemic cardiomyopathy with EF of 25 percent, prior infarcts,
remote history of syncope and at high risk for malignant ventricular arrhythmias. He has had a recent T
wave alternans test which was clearly abnormal. He has had episodes of resting bradycardia also noted.
He also meets Madit II criteria for ICD implantation. Description of Procedure: After informed consent
had been obtained, the patient was brought to the outpatient hospital lab in the fasting state. The left
anterior chest was prepped and draped in a sterile fashion. Intravenous sedation and local anesthetic
were given. After local anesthetic, a 5 cm incision was made at the left deltopectoral groove. With blunt
dissection and cautery, this was carried down through the prepectoralis fascia. The cephalic vein was
identified and ligated distally. Through the venotomy, a subclavian venogram was performed to provide
a roadmap. The atrial and ventricular leads were then advanced into the vessel to the level of the right
atrium under fluoroscopic guidance. The ventricular lead was maneuvered to the right ventricular
outflow tract and then through the RV apex where it was actively fixed. Good sensing and pacing
thresholds were demonstrated. The lead was anchored to the pre-pectoralis fascia with interrupted 2-0
Tycron sutures. 10 volt pacing did not result in diaphragmatic capture. The atrial lead was maneuvered
to the anterolateral right atrial wall where it was actively fixed. Good sensing and pacing thresholds
were demonstrated. The lead was anchored to the pre-pectoralis fascia with interrupted 2-0 Tycron
sutures. 10 volt pacing did not result in diaphragmatic capture. A subcutaneous pocket was created with
good hemostasis achieved. The pocket was subsequently irrigated with solution of Bacitracin. The
generator was connected to the lead and then placed in the pocket with no tension on the lead. The
deep fascial layer was closed with interrupted 2-0 Vicryl suture. The subcutaneous closure was made
with running 3-0 Vicryl suture. Subcuticular closure was made with running 4-0 Vicryl suture. Steri-strips
were applied. Ventricular fibrillation was induced with a T wave shock. This was successfully sensed and
terminated with a 15 joule shock to sinus rhythm. High voltage impedence was 39 ohms. Dry dressing
was placed over the wound. The patient returned to the floor in stable condition without apparent
complications. Which of the following codes accurately describes the basic procedure summarized in
this report?
A. 33207, 71090
B. 33208, 71090-26
C. 33240, 33208, 71090
D. 33249, 71090-26
24. A patient is brought from an MVA to the ER with multiple fractured ribs, labored breathing, and
complaints of chest pain and palpitations. In the ER the thoracic surgeon performs a tube thoracostomy
with some relief of the patient’s most severe symptoms. Several tests are run and radiographs taken.
What is the correct code?
A. 32100
B. 32421
C. 32422
D. 32551
25. A sinus endoscopy with tissue removal from the sphenoid sinus was performed. The correct CPT®
code is:
A. 31287
B. 31288
C. 31235
D. 31050
26. This 25-year-old male presents with deviated nasal septum. After intubation, a left hemitransfixion
incision was made with elevation of the mucoperichondrium. Cartilage from the bony septum was
detached and the nasoseptum was realigned and removed in a piecemeal fashion from the obstructed
perpendicular plate of the ethmoid. Thereafter, 4-0 chronic was used to approximate mucous
membranes. Next, submucous resection of the middle and inferior turbinates was handled in the usual
fashion by removing the anterior third of the bony turbinate and lateral mucosal followed by bipolar
cauterization of the posterior enlarged tip of the inferior turbinate as well as outfracturing. A small
amount of silver nitrate cautery was used to achieve hemostasis. A dressing consisted of a fold of Telfa
with a ventilating tube for nasal airway on each side achieved good hemostasis, patient went to
recovery in good condition. What is the correct code for this procedure?
A. 30520
B. 30420
C. 30620
D. 30450
27. At the patient’s bedside in the hospital, a PICC line is inserted. Using Xylocaine local anesthesia,
aseptic technique and ultrasound guidance, a 21 gauge needle was used to aspirate the right cephalic
vein of a 72-year-old patient. When blood was obtained, a 0.018 inch platinum tip guidewire was
advanced to the central venous circulation. A 6 French dual lumen PICC was introduced through a 6
French peel-away sheath to the SVA RA junction and after removal of the sheath, the catheter was
attached to the skin with a STAT-LOCK device and flushed with 500 units of Heparin in each lumen. A
sterile dressing was applied and the patient was discharged in improved condition. Code the
procedure(s).
A. 36565
B. 36556, 76942-26
C. 36561, 76942-26
D. 36569, 76942-26
28. The patient had been hoarse for a month. His surgeon scheduled a direct laryngoscopy with injection
of his vocal cords. During the surgery it became necessary to use an operating microscope. How should
these services be reported?
A. 31571
B. 31561
C. 31571, 69990
D. 31545
29. A 62-year old female with three-vessel disease and supraventricular tachycardia, which has been
refractory to other management. She previously had pacemaker placement and stenting of the coronary
artery stenosis, which has failed to solve the problem. She will undergo CABG with autologous
saphenous vein and a modified MAZE procedure to treat the tachycardia. The risks and benefits have
been discussed and the patient wishes to proceed. She is brought to the cardiac OR and placed supine
on the OR table. She is prepped and draped and adequate endotracheal anesthesia is assured. A median
sternotomy incision is made and cardiopulmonary bypass is initiated. The endoscope is used to harvest
an adequate length of saphenous vein from her left leg. This is uneventful and bleeding is easily
controlled. The vein graft is prepared and cut to the appropriate lengths for anatomosis. Three bypasses
are performed, one to the LAD, one to the circumflex and another distally on the circumflex. A modified
maze procedure was then performed and the patient was weaned from bypass. Once the heart was
once again beating on its own again, we attempted to induce an arrhythmia and this could not be done.
At this point, the sternum was closed with wires and the skin reapproximated with staples. The patient
tolerated the procedure without difficulty and was taken to the PACU. Choose the procedure code(s) for
this service.
A. 33519, 33508, 33254-51
B. 33512, 33508, 33999-51
C. 33512, 33508, 33254-51
D. 33512, 33508-51, 33254-51
30. The patient is a three-year-old boy who attempted to swallow a half-dollar. The boy’s mother
immediately brought the child to the ED, which was only a short distance from the house, and the
thoracic team was called emergently. The patient was in acute respiratory distress when we arrived in
the ED. A temporary tracheostomy was accomplished, allowing oxygen exchange. X-ray revealed the
coin to be deeply wedged in the trachea. Several attempts were made to remove the coin in the ED with
the use of forceps, without success. The patient was given a mild sedative and taken to the OR where a
scope was used to successfully remove the coin. The trach was discontinued. The patient was admitted
for overnight observation and discharged the next day in satisfactory condition.
A. 31530, 31603-51, 934.0
B. 31635, 31603-59, 934.0, E912, E849.0
C. 31603, 31530-59, 934.0, E912, E849.0
D. 31635, 934.0
31. The patient had trouble breathing for three days. Her urgent care physician referred her to an ENT
physician. The ENT performed a diagnostic maxillary sinusoscopy. How should the sinusoscopy be
reported?
A. 31237
B. 31256
C. 31233
D. 31256-LT
32. Diagnosis: Right lung mass Indications: Patient with a mass in the right lung mass identified on
routine X-ray presents for bronchoscopy and biopsy. Procedure: The patient was brought to the
endoscopy suite and the mouth and throat were anesthetized. The bronchoscope was inserted and
advanced through the larynx to the bronchus. The left side was examined first and no abnormalities
were appreciated. The bronchoscope was then introduced into the right bronchus. Using fluoroscopic
guidance, the tip of the bronchoscope was maneuvered into the area of the mass. A closed biopsy
forceps was passed through the channel in the bronchoscope and then through the bronchial wall. A
tissue sample was obtained. There were no other abnormalities appreciated in the right side and the
bronchoscope was removed. The specimen was labeled and sent to pathology for testing. The patient
tolerated the procedure well. Pathology indicates that the mass is cancer. What are the procedure and
diagnosis codes?
A. 31628, 786.6
B. 31628, 162.9
C. 31628, 31622-51, 162.9
D. 31625, 786.6
20. Dr. Walters performed a subsequent thoracentesis of the pleural cavity for aspiration with needle
fluoroscopic guidance. Which codes should Dr. Walters report for his professional services?
a. 32422, 77012-26
b. 32421, 77002-26
c. 32421, 77012-26
d. 32421-26, 77002-TC
33. Alicia is 20 months old and suffering from chronic inflammation of the trachea, which is causing
difficulty in breathing. Dr. Marion inserted a planned incisional tracheal tube for Alicia. This procedure
was completed under general endotracheal anesthesia. The patient tolerated the procedure well and
was returned to the recovery room in stable condition. How should Dr. Marion report this procedure?
a. 31610
b. 31601
c. 31830
d. 31615
34. Dr. Manning, a thoracic surgeon, was asked to consult with Nancy, a 66-year-old female with
atherosclerotic heart disease. The patient, who requested the visit, is well known to Dr. Manning, who
performed thoracic surgery on her two years ago. She was seen in his office Monday morning for a
consultative visit with mild complaints of fatigue and shortness of breath. Dr. Manning dictated a
comprehensive history, comprehensive examination, and high-complexity decision-making. During this
consultation, Dr. Manning made the decision to reoperate on Nancy. He sent a written report back to
her cardiologist, Dr. Shaw, regarding the need for another surgery to take place the following day.
Monday evening, Nancy was admitted to the hospital to start the prep for the planned bypass surgery
Tuesday morning. Tuesday’s operative report
Preoperative diagnosis: Atherosclerotic heart disease
Postoperative diagnosis: Same
Anesthesia: General
Procedure: The patient was brought to the operating room and placed in the supine position. With the
patient under general intubation anesthesia, the anterior chest, abdomen, and legs were prepped and
draped in the usual fashion. Review of a postoperative angiography showed severe, recurrent, twovessel disease with normal ventricular function.
A segment of the femoropopliteal artery was harvested using endoscopic vein-harvesting technique and
prepared for grafting. The patient was heparinized and placed on cardiopulmonary bypass. The patient
was cooled as necessary for the remainder of the procedure and an aortic cross-clamp was placed. The
harvested vein was anastomosed to the aorta and brought down to the circumflex and anastomosed
into place. An artery was anastomosed to the left subclavian artery and brought down to the left
anterior descending and anastomosed into place. The aortic cross-clamp was removed after 55 minutes
with spontaneous cardioversion to a normal sinus rhythm. The patient was warmed and weaned from
the bypass without difficulties after 104 minutes. The patient achieved homeostasis. The chest was
drained and closed in layers in the usual fashion. The leg was closed in the usual fashion. Sterile
dressings were applied and the patient returned to intensive care recovery in satisfactory condition.
How should Dr. Manning report his services for Monday and Tuesday in this case?
a. Monday: 99255-57; Tuesday: 33511, 33517, 35600
b. Monday: 99215-57; Tuesday: 33533, 33517-51, 35572-80, 33530-51
c. Monday: 99255-57; Tuesday: 33533, 33510, 33572, 33530
d. Monday: 99215-57; Tuesday: 33533, 33517, 35572, 33530
35. A patient had a temporary transvenous pacemaker system inserted with electrodes placed in the
right atrial and ventricular chambers. How should you report this service?
a. 33211
b. 33208
c. 33213, 33208-51
d. 33211, 33208-51
36. Marvin, a 51-year-old patient, required a conversion of a single-chamber pacemaker system to a
dual-chamber system. The previously placed electrode was removed transvenously. The skin pocket was
opened and the pulse generator removed. The skin pocket was then relocated and a dual system was
placed with transvenous electrodes in both the right atrial and ventricular chambers. The system was
tested and the new skin pocket was then closed. The patient tolerated the procedure well. How should
you report these services?
a. 33208, 33234-51, 33233-51, 33222 -51, 33214-51
b. 33208, 33214-51, 33223-51
c. 33208, 33234-51, 33233-51, 33222-51
d. 33214, 33222-51
37. A patient required a battery change for a single-chamber pacing cardioverter-defibrillator system.
The battery was taken out in a subcutaneous fashion and a new battery placed. The cardioverterdefibrillator was then reattached to the electrodes, which were intact and tested, and the skin pocket
was then closed. How should these services be reported?
a. 33244, 33241-51, 33240
b. 33241, 33240-51
c. 33236, 33202-51, 33206-51
d. 33241, 33240-51, 33233-51
38. Dr. Lim completed an external ECG with 48-hour continuous rhythm testing during which analysis
was performed for Mr. Brown. The report was reviewed and interpretation completed for evaluation of
change to the pacemaker system. The report conclusion stated predominant rhythm of atrial fibrillation
with non controlled left ventricular rate. Dr. Lim scheduled Mr. Brown for placement of a biventricular
pacemaker, which will be connected to his current pacemaker system. How should Dr. Lim report her
services for the cardiovascular monitoring?
a. 33224
b. 33244, 93224-59
c. 93224
d. 33208, 33225-51, 93225-59
39. A patient had an endarterectomy during the same surgical session for a repair to a coronary
arteriovenous chamber fistula. The fistula repair did not require cardiopulmonary bypass to complete
the procedure. How should these services be reported?
a. 33572, 33501
b. 33500, 33572-59
c. 33501
d. 33507, 33501-59
40. A patient suffering from chronic inflammation of the maxillary sinus underwent a surgical
endoscopic transnasal balloon dilation procedure to restore normal sinus function. During this
procedure, maxillary antrostomy with removal of tissue was completed. How should you report these
procedures?
a. 31295
b. 31267, 31295-59
c. 31295, 31256-59, 31267-59
d. 31297
41. A patient underwent a recurrent destruction of the laryngeal nerve for therapeutic purposes. How
would you report this procedure?
a. 31595
b. 31599
c. 31595, 64681-59
d. 64614, 31599-59
ANSWERS
1. “a” You can find the code 35476 in the index of the CPT Professional Edition under Angioplasty,
Venous, Percutaneous. See the parenthetical note under code 34576 regarding the correct radiology
code. This procedure includes moderate conscious sedation. The modifier -26 represents the
professional services for the radiology code.
2. “b” Code 39000 is a cervical approach, code 39010 reports a transthoracic approach.
3. “a” This is a secondary rhinoplasty with major revision. The closure is bundled with the surgical
procedure. Modifier -78 isn’t required because the second service was not performed within the
postoperative period. Generally, the maximum postoperative period is no more than 90 days.
4. “d” A surgical thorascopy always includes a diagnostic thorascopy. You can find this note in the CPT
Professional Edition under the Endoscopy heading.
5. “c” The code 33530 and 35572 are add-on codes and should not have modifier -51 appended. Review
modifier -51 in Appendix A of the CPT Professional Edition for this note.
6. “a” You can find this statement under the heading of Endovascular Repair of Descending Thoracic
Aorta in the CPT Professional Edition. Read the guidelines carefully and you will see the primary codes
listed with this statement.
7. “a” The code 33210 reports a temporary transvenous single chamber pacemaker. There is not enough
information in the question to code for the placement of the permanent system.
8. “d” When coding for this procedure, it is necessary to code for the removal (33235) and then
replacement of the leads (33217). Modifier -51 indicates multiple procedures in the same anatomic site.
9. “b” The code 36592 describes this procedure. You can find this answer in the index of the CPT
Professional Edition under Collection and Processing, Specimen, Venous Catheter.
10. “b” The code 37186 is an add-on code and would be reported in addition to the primary procedure.
The guidelines preceding this procedure clearly state, do not report 37184–37185 with code 37186.
11. C Patient is having an Infuse-A-Port put in his chest to receive chemotherapy. The subclavian vein
(central venous) is being tunneled for the access device, eliminating multiple choices A and D. The
patient had a subcutaneous pocket created to insert the power port, eliminating multiple choice answer
B. Code 77001 reports fluoroscopic guidance for a central venous access device. Modifier -26 denotes
the professional service.
12. A There was removal of fluid from the pleural cavity, eliminating multiple choice answer C. No
biopsies were taken, eliminating multiple choice answer D. The procedure was performed under
ultrasound guidance, eliminating multiple choice answer B.
13. B The procedure involved removing plaque and the vessel lining from the carotid artery through a
neck incision, eliminating multiple choice answers C and D. This was a re-operation (35390), as the
original surgery was performed a year ago.
14. D A first order selective catheter placement in the brachiocephalic system was not performed,
eliminating multiple choice answer A. Bilateral angiography of the lower extremities was not performed,
eliminating multiple choice answer B. A third order selective catheter placement in the brachiocephalic
arterial system was not performed, eliminating multiple choice C. Arterial access was the left common
femoral artery. The final selective catheter placement on the right was third order 36247 (femoral
artery). Angiography for the right extremity is 75710. An additional angiography was performed to
complete the extremity angiography; therefore, 75774 is not reported.
15. A The patient is having an insertion of a pace maker, eliminating multiple choice answers C and D. A
subcutaneous pocket was created for the pacemaker generator and the leads connected to the
generator were placed in the atrium and ventricle leading you to multiple choice answer A.
16. B Patient was having a lumpectomy, eliminating multiple choice answers A and D. An injection of
blue dye was performed in the periareola area and two lymph nodes were removed along with an
axillary “hot node”, eliminating multiple choice C. Only one incision was made to accommodate the
removal of the breast lesion and the axillary lymph nodes. Modifier -52 is appended to 38525 because a
separate incision was not performed for the axillary lymph nodes. Note that 19302 which describes a
lumpectomy includes axillary lymphadenectomy. In this procedure lymph nodes between the pectoralis
major and the pectoralis minor and nodes in the axilla are removed which was not the case.
17. D You can start narrowing your choices by the modifiers. Appendix A in the CPT manual lists the
numeric modifiers. The key phrase to choose the correct modifier is “planned return”, which is found in
the descriptive for modifier 58.
18. D The patient had a secundum atrial septal (atrioseptal) defect, eliminating multiple choice answers
A and C. The surgery was only performed on the atrial septum, eliminating multiple choice answer B.
According to ICD-9 guidelines: “Codes that describe symptoms and signs, as opposed to diagnoses, are
acceptable for reporting purposes when a related definitive diagnosis has not been established
(confirmed) by the provider. Signs and symptoms that are associated routinely with a disease process
should not be coded assigned as additional codes, unless otherwise instructed by the classification.”
Shortness of breath (786.05) is a symptom of an atrium secundum defect and would not be coded.
19. C Angiography was of the common carotids, eliminating multiple choice answers A and B and C. The
angiogram was performed bilaterally in the right and left cervical carotid. Access to the right common
carotid is second order 36216 while the access on the left is first order brachiocephalic 36215. Modifier 59 is required to show two separate brachiocephalic families coming off the aorta.
20. C Modifiers need to be appended to all the procedures since the patient had to return to surgery
within the postoperative period, eliminating multiple choice answer B. Appendix A lists the modifiers
needed to append to the procedure codes. The patient did not have a planned return to surgery,
eliminating multiple choice answer D. Nor did the patient have a repeat procedure on the same day of
service, eliminating multiple choice answer A. The patient had to return to the operating room to have a
thrombectomy and balloon angioplasty of the venous anastomosis due to the AV graft failing which is a
complication that followed the initial procedure
21. A .The key term for this scenario is “temporal artery biopsy”, which is found in the code descriptive
for multiple choice answer A.
22. C. A needle was used to obtain the biopsies, eliminating multiple choice answers B and D. An
aspiration (drawing fluid out) was not performed, eliminating multiple choice answer A. Imaging
guidance (ultrasound) was performed, correctly reporting 76942 from the parenthetical note.
23. D. Defibrillator is the first hint in finding this procedure code. The only codes that have “defibrillator”
in their code description are 33240 and 33249. Code 33249 is the correct code since electrical leads
were inserted for a dual chamber pacemaker defibrillator in connecting it to a generator. Code 71090 is
coded to report the fluoroscopic guidance to place the leads. Since this procedure was performed in an
outpatient hospital lab, modifier 26 is appended to report the professional component.
24. D. For this procedure the thoracic surgeon is performing a thoracostomy, which is the puncturing of
the chest between the ribs to remove fluid and/or air from the chest cavity. This eliminates the codes
that have thoracentesis, which a needle is used to puncture the chest. The final clue is “tube”
thoracostomy which leads to the code 32551.
25. B. A surgical endoscopy is being performed since there is a removal of tissue from the sphenoid
sinus. No biopsies were performed or just a look-see (diagnostic endoscopy) for that area of the sinus.
26. A. The multiple choice answers are between a rhinoplasty and septoplasty for which you will need to
know the difference. Rhinoplasties are performed on patients that are having cosmetic surgery,
restorative, or reconstruction on the nose. This patient is coming in to correct a deviated septum, which
falls under a septoplasty which is removing a portion of the deviated septum and straightening the
septum to correct airway obstruction. You eliminate multiple choice answers B and D. C is incorrect
since the patient is not coming in for a dermatoplasty, which is surgical replacement of destroyed skin.
27. D. With these codes you need to know what type of catheter was inserted in this patient, which was
a PICC line. This eliminates multiple choice answers A, B, and C. The ultrasound guidance is reported
with 76942. Modifier 26 is appended to indicate the professional component was performed.
28. A. This is a direct laryngoscopy with “injection into vocal cords,” which eliminates multiple choice
codes B and D. You would not code 69990, Operating Microscope, since 31571 has operating
microscope already in its code descriptive.
29. C. This scenario is on a patient having a coronary artery bypass graft (CABG) involving three venous
grafts, which eliminates multiple choice answer A. Code 33508 is an add-on code, which does not need a
modifier 51 appended to the procedure, eliminating multiple choice answer D. 33254 is the correct code
since a modified maze was performed on the patient.
30. C. This three year old had a “tracheostomy” done due to acute respiratory distress. This eliminates
choices B and D where a bronchoscopy is performed. Then a laryngoscope was used to remove the coin,
coded 31530. To assign the ICD-9-CM code for the swallowed coin, in the index, look up Foreign
Body/trachea. Code 934.0 falls under the injury codes, which indicates that E codes would need to be
coded to provide the cause of injury and be used as an additional code for more detailed analysis. In
Section 3 of the alphabetic index (right after the Drug Table); look up Foreign body/air passage/with
asphyxia, obstruction, suffocation. You are referred to code E912. The next E code is to show the place
of occurrence of the injury. In Section 3, look up, Accident/occurring (at) (in)/home (private)
(residential), you are referred to E849.0. Verify all codes in the tabular section for accuracy.
31. C. The key term to narrow down your choices is “diagnostic” maxillary sinusoscopy, which is found in
the code description of 31233.
32. B. To narrow down your choices, you can start with coding the diagnosis first. The patient is having
the procedure done due to a lung mass. A specimen was sent to pathology and came back indicating
that the lung mass is cancerous. In the ICD-9-CM index, look up in the Neoplasm Table
lung/malignant/primary column. You are referred to code 162.9, eliminating multiple choice answers A
and D. You would not code 31622 since this is a separate procedure. A diagnostic procedure is not coded
if performed at the same session as a surgical procedure in the same area. A surgical procedure (biopsy)
was performed with the bronchoscopy.
33. b. This tracheostomy was a planned procedure for a 20-month-old patient. The anesthesia code
would not be reported for the operating physician.
34. d. The patient requested the consult in this question; therefore, evaluation and management consult
codes are not reported. Modifier -57 is applied to the evaluation and management code because the
decision for surgery was made during this visit. The bypass surgery in this question is a combination
procedure using one artery and one vein; therefore, the combination (add-on) code is reported in
addition to the arterial grafting code. The venous grafting codes are reported when only veins are used
in a procedure. The add-on code for reoperation would be reported since the primary procedure (or first
operation) was more than one month prior to the subsequent bypass surgery. Additionally, the add-on
code for harvesting the femoropopliteal vein would be reported. The use of modifier -51 would not be
appropriately appended to add-on codes per the Appendix A of the CPT® Professional Edition.
35. a. This question deals with the placement of a dual temporary pacemaker; therefore, codes for
permanent pacemaker systems would not be reported.
36. d. This is an upgrade from a single to dual pacemaker system. Code 33214 includes removal of the
old system, testing, and insertion of the new system. In this question, a revision of the skin pocket would
be reported separately.
37. b. According to the CPT® Professional Edition subcategory guidelines with pacemaker and
pacingcardioverter-defibrillator, when the “battery” of one of these systems is replaced, it is actually the
pulse generator that is changed.
38. c. This question focuses on the cardiovascular monitor testing. The placement of the biventricular
pacemaker is scheduled, but not stated as completed; coding for services not completed would be
incorrect.
39. c. This repair includes an endarterectomy or angioplasty when completed with the basic procedure.
This note can be found in the CPT® Professional Edition under the “Coronary artery anomalies”
subheading.
40. a. This procedure is represented with a new code for 2011. Review of the parenthetical notes with
this code in the CPT® Professional Edition will assist with correct conjunctive coding.
41. a. One way to find this procedure in the index of the CPT® Professional Edition is under the main
term “Nerves,” “Destruction,” then “Laryngeal Recurrent.”