Musculoskeletal system 20000
1. Sally suffered a burst fracture to her lumbar spine during a skiing accident. Dr. Phyllis
performed a partial corpectomy to L2 by a transperitoneal approach followed by anterior
arthrodesis of L1-L3. She also positioned anterior instrumentation and placed a structural
allograft to L1-L3. How would Dr. Phyllis report this procedure?
a. 63090, 22558-51, 22585, 22845, 20931
b. 63085, 22533, 22585-51, 22808-59
c. 22612 x 2, 22808, 22840-51, 20931
d. 22558, 22858-51, 22845-51, 20931-59
2. A patient suffered a fracture of the femur head. He had an open treatment of the femoral
head with a replacement using a Medicon alloy femoral head and methyl methacrylate cement.
How would you report this procedure?
a. 27236
b. 27235
c. 27238
d. 27275, 27236-59
3. What modifier should you report when the same physician provided a re-reduction of a
fracture?
a. 76
b. 59
c. 77
d. 54
4. A patient suffered a penetrating knife wound to his back. A surgeon performed wound
exploration with enlargement of the site, debridement, and removal of gravel from the site.
The surgeon decided a laparotomy procedure was not necessary at this time. How would you
report this procedure?
a. This procedure is bundled with the laparotomy
b. 49000, 97602-51, 20100-59
c. 49000, 20102-59
d. 20102
5. While playing at home, Riley dislocated his patella, when he fell from a tree. The surgeon
documented an open dislocation. Riley underwent a closed treatment under anesthesia. How
would you report the treatment and diagnoses?
a. 27420, 836.3
b. 27562, 836.4, E884.9, E849.0
c. 27840, 27562-51, 836.3, E884.9
d. 27562, 836.4
6. Sarah presented to her primary care physician with pain and swelling in the right elbow. After
careful examination he referred her to an orthopedic surgeon for a second opinion. Dr. Femur
diagnosed Sarah with acute osteomyelitis of the olecranon process and recommended surgery.
Sarah agreed to the surgery and underwent a sequestrectomy, through a posterior incision,
with a loose repair over drains ending the procedure. Dr. Femur sent a written report back to
Sarah’s primary care physician along with the operative report. How would you report the
procedure?
a. 99244-57, 24138-RT
b. 99214, 99244-57
c. 24138-RT
d. 99214, 23172-59
7. How should you report a deep biopsy of soft tissue of the thigh or knee area?
a. 27323
b. 27324
c. 20206
d. 27328
8. Mike had a bicycle accident and suffered deep hematomas in both knees. He underwent a
bilateral incision and drainage. How would you report the procedure?
a. 27301-50
b. 10040
c. 27303
d. 27301-59
9. A patient had a unilateral percutaneous intradiscal electrothermal annuloplasty on L3-L5 with
fluoroscopic guidance for needle placement. How would you report this professional service
procedure?
a. 22526, 22527
b. 22526, 22527, 77002-26
c. 22899, 77002-51
d. 22526, 22527, 77003-26
10. What modifier is exempt from the following codes:20974, 61107, 93602, 95900, 94610?
a. RT and LT
b. 63
c. 59
d. 51
11. 52 year old female has a mass growing on her right flank for several years. It has finally gotten
significantly larger and is beginning to bother her. She is brought to the Operating Room for definitive
excision. An incision was made directly overlying the mass. The mass was down into the subcutaneous
tissue and the surgeon encountered a well encapsulated lipoma approximately 4 centimeters. This was
excised primarily bluntly with a few attachments divided with electrocautery. What CPT should be
reported?
A. 21932, 214.9
B. 21935, 214.1
C. 21931, 214.1
D. 21925, 789.39
12. PREOPERATIVE DIAGNOSIS: Right scaphoid fracture. TYPE OF PROCEDURE: Open reduction and
internal fixation of right scaphoid fracture. DESCRIPTION OF PROCEDURE: The patient was brought to
the operating room, anesthesia having been administered. The right upper extremity was prepped and
draped in a sterile manner. The limb was elevated, exsanguinated, and a pneumatic arm tourniquet was
elevated. An incision was made over the dorsal radial aspect of the right wrist. Skin flaps were elevated.
Cutaneous nerve branches were identified and very gently retracted. The interval between the second
and third dorsal compartment tendons was identified and entered. The respective tendons were
retracted. A dorsal capsulotomy incision was made, and the fracture was visualized. There did not
appear to be any type of significant defect at the fracture site. A 0.045 Kirschner wire was then used as a
guidewire, extending from the proximal pole of the scaphoid distalward. The guidewire was positioned
appropriately and then measured. A 25-mm Acutrak drill bit was drilled to 25 mm. A 22.5-mm screw was
selected and inserted and rigid internal fixation was accomplished in this fashion. This was visualized
under the OEC imaging device in multiple projections. The wound was irrigated and closed in layers.
Sterile dressings were then applied. The patient tolerated the procedure well and left the operating
room in stable condition. What code should be used for this procedure?
A. 25628-RT
B. 25624-RT
C. 25645-RT
D. 25651-RT
13. An infant with genu valgum is brought to the operating room to have a bilateral medial distal femur
hemiepiphysiodesis done. On each knee, the C-arm was used to localize the growth plate. With the
growth plate localized, an incision was made medially on both sides. This was taken down to the fascia,
which was opened. The periosteum was not opened. The Orthofix figure-of-eight plate was placed and
checked with x-ray. We then irrigated and closed the medial fascia with 0 Vicryl suture. The skin was
closed with 2-0 Vicryl and 3-0 Monocryl. What procedure code should be used?
A. 27470-50
B. 27475-50
C. 27477-50
D. 27485-50
14. 42 year old male has a frozen left shoulder. An arthroscope was inserted in the posterior portal in
the glenohumeral joint. The articular cartilage was normal except for some minimal grade III-IV changes,
about 5% of the humerus just adjacent to the rotator cuff insertion of the supraspinatus. The biceps was
inflamed, not torn at all. The superior labrum was not torn at all, the labrum was completely intact. The
rotator cuff was completely intact. An anterior portal was established high in the rotator interval. The
rotator interval was very thick and contracted and this was released with electrocautery and the Bovie
including the superior glenohumeral ligament. After this was all released, the middle glenohumeral
ligament was released as well as the tendinous portion of the subscapularis. After this was all done with
a shaver and electrocautery, the arthroscope was placed anteriorly and the shaver and used to debride
some of the posterior capsule and the posterior capsule was released in its posterosuperior and then
posteroinferior aspect. After this was done, the arthroscope was then placed back posteriorly and used
to release the anteroinferior capsule down to 6’oclock. This was done with electrocautery. The
arthroscope was then placed anteriorly and used to release the posteroinferior capsule. The arthroscope
was then placed anteriorly and used to release the posteroinferior capsule. The arthroscope was then
placed back posteriorly and used to confirm that there was still one little strip of capsule around the
biceps superiorly and there was one little strip from 6-7 o’clock posteroinferiorly that was only partially
cut. The rest of the capsule was completely circumferentially released. What CPT code describes this
procedure?
A. 23450-LT
B. 23466-LT
C. 29805-LT, 29806-51-LT
D. 29825-LT
15. After adequate anesthesia was obtained the patient was turned prone in a kneeling position on the
spinal table. A lower midline lumbar incision was made and the soft tissues divided down to the spinous
processes. The soft tissues were stripped way from the lamina down to the facets and discectomies and
laminectomies were then carried out at L3-4, L4-5 and L5-S1. Interbody fusions were set up for the
lower three levels using the Danek allografts and augmented with structural autogenous bone from the
iliac crest. The posterior instrumentation of a 5.5 mm diameter titanium rod was then cut to the
appropriate length and bent to confirm to the normal lordotic curve. It was then slid immediately onto
the bone screws and at each level compression was carried out as each of the two bolts were tightened
so that the interbody fusions would be snug and as tight as possible. Select the appropriate CPT code(s)
for this visit?
A. 22612, 22614 x 2, 22842, 20938, 20930
B. 22533, 22534 x 2, 22842
C. 22630, 22632 x 2, 22842, 20938, 20930
D. 22554, 22632 x 2, 22842
16. PREOPERATIVE DIAGNOSIS: Displaced impacted Colles fracture, left distal radius and ulna.
POSTOPERATIVE DIAGNOSIS: Displaced impacted Colles fracture, left distal radius and ulna. OPERATIVE
PROCEDURE: Reduction with application external fixator, left wrist fracture FINDINGS: The patient is a
46-year-old right-hand-dominant female who fell off stairs 4 to 5 days ago sustaining an impacted distal
radius fracture with possible intraarticular component and an associated ulnar styloid fracture. Today in
surgery, fracture was reduced anatomically and an external fixator was applied. PROCEDURE: Under
satisfactory general anesthesia, the fracture was manipulated and C-arm images were checked. The left
upper extremity was prepped and draped in the usual sterile orthopedic fashion. Two small incisions
were made over the second metacarpal and after removing soft tissues including tendinous structures
out of the way, drawing was carried out and blunt-tipped pins were placed for the EBI external fixator.
The frame was next placed and the site for the proximal pins was chosen. Small incision was made.
Subcutaneous tissues were carried out of the way. The pin guide was placed and 2 holes were drilled
and blunt-tipped pins placed. Fixator was assembled. C-arm images were checked. Fracture reduction
appeared to be anatomic. Suturing was carried out where needed with 4-0 Vicryl interrupted
subcutaneous and 4-0 nylon interrupted sutures. Sterile dressings were applied. Vascular supply was
noted to be satisfactory. Final frame tightening was carried out. What CPT and ICD-9-CM codes should
be reported?
A. 25600-LT, 20692-51
B. 25605- LT, 20690-51
C. 25606-LT
D. 25607-LT
17. The patient is a 66-year-old female who presents with Dupuytren's disease in the right palm and ring
finger. This results in a contracture of the ring digit MP joint. She is having a subtotal palmar fasciectomy
for Dupuytren's disease right ring digit and palm. An extensile Brunner incision was then made beginning
in the proximal palm and extending to the ring finger PIP crease. This exposed a large pretendinous cord
arising from the palmar fascia extending distally over the flexor tendons of the ring finger. The fascial
attachments to the flexor tendon sheath were released. At the level of the metacarpophalangeal crease,
one band arose from the central pretendinous cord-one coursing toward the middle finger. The digital
nerve was identified, and this diseased fascia was also excised. What procedure code should be used?
A. 26123-RT, 26125
B. 26121-RT
C. 26035-RT
D. 26040-RT
18. This is a 32 year old female who presents today with sacroilitis. On the physical exam there was pain
on palpation of the left sacroiliac joint and imaging confirmation was done for the needle positioning.
Then 80 mg of Depo-Medrol and 1 mL of bupivacaine at 0.5% was injected into the left sacroiliac joint
with a 22 gauge needle. The patient was able to walk from the exam room without difficulty. Follow up
will be as needed. The correct CPT code is:
A. 20610, 77003-26
B. 20551
C. 27096-LT, 77003-26
D. 20555
19. PREOPERATIVE DIAGNOSIS: Medial meniscus tear, right knee POSTOPERATIVE DIAGNOSIS: Medial
meniscus tear, extensive synovitis with an impingement medial synovial plica, right knee TITLE OF
PROCEDURE: Diagnostic operative arthroscopy, partial medial meniscectomy and synovectomy, right
knee The patent was brought to the operating room, placed in the supine position after which he
underwent general anesthesia. The right knee was then prepped and draped in the usual sterile fashion.
The arthroscope was introduced through an anterolateral portal, interim portal created anteromedially.
The suprapatellar pouch was inspected. The findings on the patella and the femoral groove were as
noted above. An intra-articular shaver was introduced to debride the loose fibrillated articular cartilage
from the medial patellar facet. The hypertrophic synovial scarring between the patella and the femoral
groove was debrided. The hypertrophic impinging medial synovial plica was resected. The hypertrophic
synovial scarring overlying the intercondylar notch and lateral compartment was debrided. The medial
compartment was inspected. An upbiting basket was introduced to transect the base of the
degenerative posterior horn flap tear. This was removed with a grasper. The meniscus was then further
contoured and balanced with an intra-articular shaver, reprobed and found to be stable. The cruciate
ligaments were probed, palpated and found to be intact. The lateral compartment was then inspected.
The lateral meniscus was probed and found to be intact. The loose fibrillated articular cartilage along the
lateral tibial plateau was debrided with the intra-articular shaver. The knee joint was then thoroughly
irrigated with the arthroscope. The arthroscope was then removed. Skin portals were closed with 3-0
nylon sutures. A sterile dressing was applied. The patient was then awakened and sent to the recovery
room in stable condition. What CPT and ICD-9-CM codes should be reported?
A. 29880-RT, 717.0, 727.00, 733.92, 717.7
B. 29881-RT, 717.1, 727.09, 733.92, 717.7
C. 29881-RT, 29822-59-RT, 717.2, 727.09, 733.92, 717.7
D. 29880-RT, 29822-59-RT, 717.2, 727.09, 733.92, 717.7
20. A 61 year-old gentleman with a history of a fall while intoxicated suffered a blow to the forehead
and imaging revealed a posteriorly displaced odontoid fracture. The patient was taken into the
Operating Room, and placed supine on the operating room table. Under mild sedation, the patient was
placed in Gardner-Wells tongs and gentle axial traction under fluoroscopy was performed to gently try
to reduce the fracture. It did reduce partially without any change in the neurologic examination. More
manipulation would be necessary and it was decided to intubate and use fiberoptic technique. The
anterior neck was prepped and draped and an incision was made in a skin crease overlying the C 4-C5
area. Using hand-held retractors, the ventral aspect of the spine was identified and the C2-C3 disk space
was identified using lateral fluoroscopy. Using some pressure upon the ventral aspect of the C2 body,
we were able to achieve a satisfactory reduction of the fracture. Under direct AP and lateral fluoroscopic
guidance, a Kirschner wire was advanced into the C2 body through the fracture line and into the
odontoid process. This was then drilled, and a 42 millimeter cannulated lag screw was advanced through
the C2 body into the odontoid process. What procedure code should be used?
A. 22505
B. 22305
C. 22315
D. 22318
21. Patient is having ongoing back and hip pain. The physician elects to perform a sacroiliac injection at
an ambulatory surgery center. After sterile prep, the patient is placed prone and under fluoroscopic
guidance; the needle is placed into the SI joint with a mixture of 20 mg of Celestone and Marcaine for
pain relief. Code the procedure(s).
A. 27096, 77003-26
B. 20610
C. 27096, 73542-26
D. 27096
22. Patient is seen in the hospital’s outpatient surgical area with a diagnosis of a displaced comminuted
fracture of the lateral condyle, right elbow. An ORIF procedure was performed, which included the
following techniques: An incision was made in the area of the lateral epicondyle. This was carried
through subcutaneous tissue, and the fracture site was easily exposed. Inspection revealed the fragment
to be rotated in two places about 90 degrees. It was possible to manually reduce this quite easily, and
the manipulation resulted in an almost anatomic reduction. This was fixed with two pins driven across
the humerus. The pins were cut off below skin level. The wound was closed with plain catgut
subcutaneously and 5-0 nylon for the skin. Dressings and a long arm cast were applied. Which are the
correct ICD-9-CM and CPT® codes assignment?
A. 24579, 29065-51, 812.52
B. 24577, 812.42
C. 24579, 812.42
D. 24575, 812.52
23. 35-year-old female patient presents with acute onset of severe pain since October. Her workup has
revealed evidence of disk herniation with loss of lordosis at the C5-C6. Intraoperative findings were
consistent with two large fragments of free disk fragments in the foramen at C5-C6 on the right side.
After general anesthesia, the patient was placed on the operative table in the supine position. All
pressure points were cushioned and a transverse skin incision was fashioned under fluoroscopic
guidance over the C5-C6 disc space. Dissection through the platysma eventually allowed for exposure of
the anterior entrance to the vertebral body of C5 and C6 and retractors were inserted to maintain
adequate exposure. The operating microscope was brought into the field. Caspar posts were placed and
slight distraction allowed exposure. A complete discectomy was performed at C5-C6 by using endplate
curets pituitary rongeurs and Kerrison rongeurs. The posterior longitudinal ligament was resected and
beneath the posterior longitudinal ligament, two significant sized disc fragments were noted in the
foramen at C5-C6. These were removed using pituitary and Decker instruments. The endplates were
then decorticated so that they were parallel to each other and a midline keel was performed on AP and
lateral fluoroscopy. A size #1 by 5 mm interbody Kineflex-C device was placed under fluoroscopic
guidance. Satisfied with the positioning of the device, the decision was made to close. What is the
correct code for this procedure?
A. 63075
B. 63081
C. 22856
D. 22554
24. A 17-year-old male presents to the emergency department after being involved in a car accident.
The patient’s primary physician calls the orthopedic surgeon to the emergency department. The
orthopedist diagnoses a sprained knee ligament. He places a long leg walking cast and instructs the
patient to return to his office for follow-up care. What are the procedure and diagnosis codes?
A. 29358, 844.8
B. 29355, 844.9
C. 27520-54, 844.0
D. 29345, 844.9
25. Patient complains of chronic/acute arm and shoulder pain following bilateral carpal tunnel surgery.
Patient is followed by pain management for over a year. Physician finally diagnoses patient with reflex
dystrophy syndrome (RSD). Physician performs six trigger point injections into four muscle groups. Code
the procedure(s).
A. 20552
B. 20610 x 6
C. 20552 x 5
D. 20553
26. A Grade I, high velocity open right femur shaft fracture was incurred when a 15-year-old female
pedestrian was hit by a car. She was taken to the operating room within four hours of her injury for
thorough irrigation and debridement, including excision of devitalized bone. The patient was then
reprepped, redraped, and repositioned. Intramedullary rodding was then carried out with proximal and
distal locking screws. What are the correct codes for this diagnosis and procedure?
A. 27506, 11044-51, 821.11
B. 27506, 11012-51, 821.11
C. 27507, 11012-51, 821.01
D. 27507, 11044-51, 821.10
27. This 45-year-old male presents to the operating room with a painful mass of the right upper arm.
General anesthesia was induced. Soft tissue dissection was carried down thru the proximal aspect of the
teres minor muscle. Upon further dissection a large mass was noted just distal of the IGHL(inferior
glenohumeral ligament), which appeared to be benign in nature. With blunt dissection and
electrocautery, the 4.5 cm mass was removed en bloc and sent to pathology. The wound was irrigated,
and repair of the teres minor with subcutaneous tissue was then closed with triple-0 Vicryl. Skin was
closed with double-0 Prolene in a subcuticular fashion. What is the correct CPT® code for this service?
A. 23076
B. 23066
C. 23075
D. 23030
28. Postoperative Diagnosis: 1. Impingement syndrome left shoulder. 2. AC synovitis left shoulder
Procedure: Arthroscopy with subacromial decompression and AC resection left shoulder. The patient
was placed supine on the operating table prepped and draped in usual sterile fashion. The scope was
introduced from a posterior portal and the joint was inspected. The rotator cuff looked in good
condition. The articular surfaces looked good. The bicep also was in good condition. We went
subacromially and there was a fair amount of bursal inflammation encountered. We did a thorough
bursectomy. A ligament chisel was used to take down the coracoacromial ligament. A high-speed bur
was used to do a subacromial decompression going from lateral to medial. We took off about 2 cm of
bone anteriorly. Next we opened the AC joint through an anterosuperior portal. We ground off about 10
mm of distal clavicle because there was a large subchondral cyst and we wanted to get this totally
ground out, which we did. Then the wounds were irrigated out, Nylon suture was placed in our portals.
The patient was placed in a bulky dressing and an arm sling and sent to the recovery room in stable
condition. Code the procedure.
A. 29826-LT, 29824-LT
B. 29825-RT, 29824-RT
C. 23120-LT, 23130-LT
D. 29826-LT, 29824-LT, 29825-LT
29. The patient presented for medial meniscal tear left knee. Arthroscopy with partial medial
menisectomy left knee and arthroscopic picking (drilling pick holes) of the lateral femoral condyle left
knee was performed. Code the procedure and diagnosis codes.
A. 29880-LT, 29879-LT, 836.0
B. 29881-LT, 29879-LT, 836.0
C. 29882-LT, 29885-LT, 836.1
D. 29881-RT, 29885-LT, 836.2
30. A 47-year-old patient was previously treated with external fixation for a Grade III left tibia fracture.
There is now nonunion of the left proximal tibia and he is admitted for open reduction of tibia with bone
grafting. Approximately 30 grams of cancellous bone was harvested from the iliac crest. The fracture site
was exposed and the area of nonunion was osteotomized, cleaned, and repositioned. Intrafragmentary
compression was applied and three screws and the harvested bone graft were packed into the fracture
site. What are the correct codes for this diagnosis and procedure?
A. 27724, 733.82, 905.4
B. 27722, 733.82
C. 27722, 733.81, 905.4
D. 27724, 733.82
31 . A patient reports a history of right groin pain, which is worse with sitting and rising from a sitting
position. Physical examination, x-rays, and CT scans confirm a cam lesion in the right femoral head-neck
region and noted as the cause for loss of rotation. Dr. Curtis completed an arthroscopy of the right hip
with debridement and a femoroplasty. How should Dr. Curtis report her procedure?
a. 29914-RT
b. 29862-RT, 29914-59
c. 29861-RT, 29862, 29914
d. 29860-RT, 29862-59, 29914-59
32 . Dr. Reese completed a deep transfer of the anterior tibial and flexor digitorum tendons. Which
code(s) should be used to report this procedure?
a. 27658 x 2
b. 27690, 27692-51
c. 27691, 27692
d. 27691, 27692 x 2
33. Which code(s) should you report for the following case?
Preoperative diagnosis: Procedures:
Left knee medial collateral ligament tear Exam under anesthesia
Anterior cruciate ligament tear Diagnostic arthroscopy of left knee
Possible meniscus tear Left knee arthroscopic repair of lateral meniscus
Postoperative diagnosis: Same
Tourniquet time: 2.5 hours
Procedure: The patient was taken to the operating room and positioned, and an epidural anesthetic was
placed. Once the anesthetic had taken effect, the patient’s left leg was examined under anesthesia and
noted to have increased valgus laxity with end point, a positive Lachman test, and positive pivot-shift
test. The patient was prepped and draped in the normal fashion, exsanguinated, and the tourniquet
applied to a 350 mmHg. The knee was then insufflated and irrigated with fluid. Using the arthroscopic
sheath, visualization of the knee joint began. Attention was turned to the lateral meniscus where the
tear was debrided. Using the arthroscope, the lateral meniscus was sutured with two mattress-type
sutures of non-absorbable 2-0 material. The sutures were then tied and visualized with arthroscopy to
reveal the meniscus to be in excellent shape and stable position. The 3.5-cm wound was thoroughly
irrigated and closed with intermediate subcutaneous sutures. A sterile compression dressing was
applied. The patient was placed in a TED hose and Watco brace, setting the brace between 40º and 60º
of free motion. He was then taken to the recovery room in stable condition. The instrument, sponge,
and needle counts were correct.
a. 29882, 29877-52, 29870-51
b. 29866, 29868
c. 29870, 29882, 12032
d. 29882
34 . Two weeks ago, Sam underwent an open repair of his lower femur due to a traumatic fracture
suffered while snow skiing. His leg is healing as expected, and no new treatment is required to the
femur. Today, he returns as planned for an application of a new long leg cast. The cast application is
completed by the same physician who performed the surgery. How should today’s services be reported?
a. 29345-58, V53.7, V54.16
b. 99024, V53.7, V54.16
c. 29345, 29700-59, 99024, V53.7, V54.29
d. 29345-76, 821.22, V53.7, V54.16
35. What type of soft tissue tumor resection is commonly used for malignant tumors or very aggressive
benign tumors?
a. Manipulative soft tissue resection
b. Radical soft tissue resection
c. Residual soft tissue resection
d. Manageable soft tissue resection
36 . A patient was stabbed in the right arm. A surgeon took the patient to an operating suite and
completed wound exploration. The surgeon widened the wound to achieve proper visualization and
completed subcutaneous debridement and ligation of minor subcutaneous blood vessels. No further
procedures were required for this wound exploration. The arm wound was closed and dressed in the
usual fashion. The patient tolerated the procedure well and was returned to the recovery room in good
condition. How would you report this procedure?
a. 20103, 11011-51
b. 20103
c. 20103, 11011-59
d. 11043, 12036-59, 20103-51
37. A patient underwent an anterior interbody arthrodesis with discectomy, osteophytectomy, fusion,
and decompression of nerve roots at level C3, C4, and C5. The fusion was explored and then stabilized
with application of anterior instrumentation placed from C3 to C5. Which codes would you use to report
this procedure?
a. 22551, 22585 x 2, 22845-51, 22830-59
b. 22554, 22585 x 2, 22845, 22830-51
c. 22600, 22614, 22842, 22830-59
d. 22551, 22552 x 2, 22845, 22830-51
38. Which code(s) would you report for an aspiration and injection of a ganglion cyst to the bone of the
left great toe?
a. 20600
b. 20612
c. 20615
d. 20600, 20612-59
39. A patient suffering from a nonhealing knee tendon underwent a platelet-rich plasma injection under
imaging guidance. How should you report this procedure?
a. 0232T
b. 20551
c. 20551, 77002
d. 0232T, 20551, 77002
40. Dr. Bender completed a therapeutic manipulation of the temporomandibular joint. An
anesthesiologist placed this healthy 54-year-old patient under general anesthesia and monitored the
patient during the procedure. The intraservice time was noted as one hour. The patient tolerated the
procedure well and was returned to the recovery room in good condition. How would Dr. Bender’s
services be reported?
a. 21073, 99144, 99145 x 2
b. 21480
c. 21073
d. 21480, 99149, 99150 x 2
ANSWERS
1. “a” The primary procedure is a partial corpectomy (you can find this in the CPT Professional Edition
index under corpectomy). An arthrodesis was done in addition to the definitive procedure; therefore
modifier -51 is necessary (you can find this in the subcategory guidelines under Arthrodesis). Do not
attach modifier -51 to add-on codes (see Appendix A for this definition). You would report the code for a
structural allograft.
2. “a” One way to find this answer is in the index of the CPT Professional Edition under Fracture, Femur,
Neck, Open Treatment. There is an illustration under the code 27236 for a prosthetic replacement.
3. “a” You can find this answer in the CPT Professional Edition in the main section guidelines for the
Musculoskeletal System.
4. “d” One way to find this answer is in the index of the CPT Professional Edition under Wound,
Exploration, Back.
5. “b” Refer to the index of the CPT Professional Edition under Dislocation, Patella closed treatment for a
code range. It is necessary to look up the code range and read the descriptions to select the correct
code. You can find the ICD-9-CM codes under Dislocation, patella, open. The E code Alphabetic listing is
in Volume 2, Section 3. Look up, Fall, (from off), tree; the second code, look up Accident, (occurring at
in), house.
6. “c” This question asks for you to report the procedure. There is not enough information to report the
evaluation and management code. You can find the procedure in the index of the CPT Professional
Edition under Sequestrectomy, Olecranon Process. The modifier -RT provides additional information.
7. “b” The code 20206 reports a needle biopsy of soft tissue. Use code 27324 to report a deep biopsy of
soft tissue of the thigh or knee area.
8. “a” Modifier -50 indicates a bilateral procedure. You can find this procedure in the index of the CPT
Professional Edition under Incision and Drainage, Hematoma, Knee.
9. “a” One way to find this answer is in the index of the CPT Professional Edition under Annuloplasty.”
This procedure was done to more than one level, which requires use of the add-on code 22527.
10. “d” You can find codes exempt from modifier -51 in Appendix E of the CPT Professional Edition. You
could also look up each code and locate the symbol that indicates modifier -51 exempt.
11. C The mass growing turned out to be a lipoma found in the subcutaneous tissue of the flank. In the
ICD-9-CM alphabetic index, look up Lipoma/subcutaneous tissue. You are referred to code 214.1,
eliminating multiple choice answers A and D. Since the 4 cm tumor was found in the subcutaneous
tissue code 21931 is the correct code to report.
12. A Patient had an open reduction, meaning an incision was made to get to the fracture, eliminating
multiple choice answer B. The fracture site was the scaphoid of the wrist (carpal), eliminating multiple
choices C and D.
13. D Your keywords in the scenario to narrow your choices down to code 27485 are: “genu valgum”
and “hemiepiphysiodesis”
14. D To start narrowing down your choices was the procedure an open procedure or performed with
an arthroscope? It was performed with an arthroscope, eliminating multiple choice answers A and B.
The diagnostic arthroscopy (29805) is a separate procedure, and according to CPT Surgery guidelines
“The codes designated as “separate procedure” should not be reported in addition to the code for the
total procedure or service of which it is considered an integral component”. Meaning code 29806
already includes the diagnostic arthroscopy code, so you would only report code 29806. Code 29806
represents suturing of the capsule (capsulorrhaphy); however, this was not the procedure performed.
The procedure performed was a lysis of adhesions for a frozen shoulder (29825) noted in multiple choice
answer D.
15. C To start narrowing the correct arthrodesis code to report, you first need to determine the
approach. The scenario tells us that the patient was placed in prone position (lying face down) and a
lumbar incision was made indicating a posterior approach, eliminating multiple choices B and D. The
next bit of information to look for is the technique that was used for the arthrodesis, which was the
interbody fusion technique guiding you to code 22630.
16. B In the beginning of the procedure note it documents, “the fracture was manipulated”, eliminating
multiple choice answer A. Was the fracture treatment opened or closed? There is no indication in the op
note that an incision was made for internal fixation, eliminating multiple choice answer D. The key
words to choose the correct code between B and C is “external fixator” where pins are connected to
bone and to an external fixator to help the fracture heal. The fixator was a uniplane system as only one
external fixator was applied in one plane (20690).
17. A The patient is having a fasciectomy, eliminating multiple choice answers C and D. The fasciectomy
was performed on the hand as noted in “the fascial attachments to the flexor tendon sheath were
released” and “subtotal palmar fasciectomy” The op note also mentions the middle finger where
diseased fascia was also excised.
18. C The injection of is being performed in a joint, eliminating multiple choice answers B and D. The
injection was performed on the sacroiliac joint with imaging confirmation eliminating multiple choice
answer A. Arthrography was not performed; therefore, fluoroscopic guidance is reported with 77003-26
as noted in the notes below 27096.
19.C For this op note scenario only the meniscus was performed on, eliminating multiple choice answers
A and D. There are two ways to choose the correct codes for this op note. One way, is procedure code
29875 is a separate procedure, according to CPT Surgery Guidelines: “The codes designated as “separate
procedure” should not be reported in addition to the code for the total procedure or service of which it
is considered an integral component.” A limited synovectomy (29875) was performed; however, it was
performed in the medial compartment of the knee along with the medial meniscectomy; therefore, is
not reported. Debridement was performed in the lateral and patellofemoral compartments; therefore, it
is reported with 29822. Modifier -59 is appended to show a different compartment from the
compartment for the meniscectomy. The diagnosis of chondromalacia (733.92) for the fibrillated
articular cartilage of the tibial plateau and patella (717.7) are report with the debridement. The other
way to choose the correct code for this procedure is by the diagnoses. The patient had a meniscus tear,
but the op note indicates a more specific area of the tear. It documents that, “An upbiting basket was
introduced to transect the base of the posterior horn flap tear”, indexed in the ICD-9-CM as
Tear/meniscus/medial/posterior horn/old.
20. D the procedure performed is the reduction of an odontoid fracture, by incising (open treatment)
the anterior neck (anterior approach) to reduce the fracture and placement of internal fixation
(Kirschner wire and lag screw). Gardner-Wells tongs (20660) were applied originally to try to reduce the
fracture with axial traction; however, this procedure is listed as a separate procedure and it should not
be reported during the same session for reduction of the fracture.
21. A 27096 is the correct code since a steroid injection (Celestone and Marcaine) is placed into the
sacroiliac (SI) joint. Code 77003 is coded since there is a parenthetical note under the code descriptive
that states: (For fluoroscopic guidance without formal arthrography, use 77003). Modifier 26 is
appended to the radiology code for the professional component, physician not owning the equipment.
22. C There is a diagnosis of a closed fracture of the lateral condyle. The fracture is closed since the
scenario does not mention a piece of bone has broken through the skin and is exposed. In the ICD-9-CM
manual, look up Fracture/humerus/condyle(s)/lateral (external). You are referred to code 812.42. You
have eliminated multiple choice answers A and D. The next step is to figure out if the fracture care is
opened or closed treatment. A hint is that the surgeon made “an incision” to get to fracture site. Code
24579 is the correct code since this was an open treatment due to the surgeon making an incision to get
to fracture site along with performing an internal fixation (two pins). Also ORIF means Open Reduction
and Internal Fixation which is also an indication an open approach is used to perform the surgery.
23. C The keyword in this op note is “disectomy,” which in this scenario is a removal of the herniated
disk in the cervical spine (neck). Eliminating multiple choice B. There is no documentation of the
vertebrae being fused together (arthrodesis), eliminating Multiple choice D. The scenario documents
end plates were decorticated to insert an artificial disk (Kineflex-C device) to replace the cervical disk
that was removed, guiding you to code 22856.
24. B. The key term is “long leg walking cast,” which is found in the code description of procedure code
29355. Code 29345 does have long leg cast in its description, but it does not include a walker type of a
long leg cast. This patient did not have a fracture, eliminating choice C; neither did the patient have a
long leg cast brace, eliminating choice A. The diagnosis is indexed in the ICD-9-CM manual under
Sprain/knee.
25. D. Trigger point is your key term in this scenario, eliminating choice B. Trigger points are coded by
the number of muscles that the injections are performed on, not by the number of trigger point
injections. The scenario tells you that six trigger points were injected into four muscle groups which lead
you to the procedure code 20553.
26. B. One way to start finding the correct answer is to look up the diagnosis in the ICD-9-CM manual. It
is indexed under Fracture/femur/shaft/open which refers you to code 821.11, eliminating codes C and
D. The only difference between choices A and B are the second procedure codes. Code 11012 is the
correct code since extensive debridement was performed all the way to the bone on an open fracture.
27. A. This patient is having a mass removed from the shoulder area, eliminating multiple choices B,
which is biopsy and D, which is incision and drainage of an abscess. The size of the mass that was excised
was 4.5 cm, which leads you to code 23076.
28. A. This surgery is being performed by arthroscopy, eliminating multiple choice answer C, which is an
open procedure code without using any type of scope. Our next clue is that a “subacromial
decompression” was performed, which leads you to code 29826. The scenario does not mention that
the physician lyses and resects adhesions, eliminating multiple choice answers B and D. 29824 is
performed when the physician opens the AC (acromioclavicular) joint to the anterosuperior portal
grounding of 10 mm of “distal clavicle” then totally grounding it out due to a cyst.
29. B. One way to narrow down the choices is to code for the diagnosis first, which is a medial meniscus
tear of the left knee. In the ICD-9-CM index, look up Tear/meniscus/medial; you are referred to code
836.0. You eliminated choices C and D. 29881 (medial OR lateral) is the correct procedure code, since
the menisectomy (removing torn fragments) was performed on the medial meniscus only.
30. A .The physician is repairing a nonunion tibia fracture (failure of two ends of a fracture to completely
heal). Next you need to find out what type of graft was used. Your hints are “bone grafting” and “iliac
crest,” which leads you to the code 27724, eliminating multiple choice codes B and C. The bone graft
was harvested from the iliac crest, and then the graft is placed at the fracture site of the tibia
compressing it for desired position and alignment and the screws were used to stabilize the fracture. In
the ICD-9-CM index, look up Fracture/nonunion referring you to code 733.82. The late effect code is also
appropriate in this case.
31. a. Code 29914 has two symbols listed to indicate this code is new and resequenced. Additionally,
theparenthetical note listed with this code provides information related to correct reporting of codes
used in conjunction.
32. c. One way to find the code range in the index of the CPT® Professional Edition is under the main
term. “Tendon,” “Transfer,” then “Leg, Lower.” Reporting the add-on code is required for the additional
tendon. According to the modifier -51 definition in the CPT® Professional Edition, this modifier should
not be appended to add-on codes.
33. d. This is a surgical arthroscopy procedure, which includes the diagnostic arthroscopy. You can find
the coding note related to diagnostic and surgical arthroscopies multiple times in the CPT® Professional
Edition. Specifically, this note can be found under the subcategory heading “Endoscopy/Arthroscopy”
with this code set. The wound closure is included with the procedure and should not be coded
separately.
34. a. The casting would be coded for the application of a new cast by the same physician who
completed the surgery. As stated in the question, this was a planned application; therefore, modifier -58
should be appended. The guidelines are listed under the subheading for application of casts and
strapping in the CPT® Professional Edition.
35. b. You can find the definition of a radical resection of soft tissue tumors in the CPT® Professional
Edition at the beginning of the section on the musculoskeletal system.
36. b. You can find this answer in the index of the CPT® Professional Edition under “Exploration,”
“Extremity,”then “Penetrating Wound.” The exploration of wound subcategory guidelines list the
procedures that are included or bundled. This was a wound exploration only; therefore, no other codes
would be reported, according to the subcategory guidelines.
37. d. Careful review of the approach and level of spinal surgery is important to determine the correct
code selection. Modifier -51 should not be appended to add-on codes for spinal instrumentation;
however, guidelines with spinal fusion exploration indicate modifier -51 should be appended to this
code when performed with a definitive procedure.
38. c. This question is specifically for a bone cyst. There is no mention of an arthrocentesis in this
question.
39.a. The parenthetical note under code 20551 indicates the use of a Category III code for this
procedure. According to CPT® Changes: An Insider’s View 2011, the imaging guidance, harvesting, and
preparation are included with the code and should not be reported separately.
40. c. This procedure was completed under general anesthesia, not moderate sedation. The codes for
moderate sedation should not be reported with this procedure as the description of the code includes
the words “general anesthesia.”