Click here for more sample CPC practice exam questions with Full Rationale Answers

Practice Exam

Click here for more sample CPC practice exam questions and answers with full rationale

Practice Exam

CPC Practice Exam and Study Guide Package

Practice Exam

What makes a good CPC Practice Exam? Questions and Answers with Full Rationale

CPC Exam Review Video

Laureen shows you her proprietary “Bubbling and Highlighting Technique”

Download your Free copy of my "Medical Coding From Home Ebook" at the top right corner of this page

Practice Exam

2018 CPC Practice Exam Answer Key 150 Questions With Full Rationale (HCPCS, ICD-9-CM, ICD-10, CPT Codes) Click here for more sample CPC practice exam questions with Full Rationale Answers

Practice Exam

Click here for more sample CPC practice exam questions and answers with full rationale

Financial Assistance for Businesses Suffering as a Result of COVID-19

The novel Coronavirus (COVID-19) has changed the way most of us are living. Offices have been moved to living rooms, restaurants and stores have been closed, events have been postponed, and conferences have gone digital. For many people, and most small business owners, COVID-19 is causing serious financial distress. As a result of COVID-19’s impact […]

The post Financial Assistance for Businesses Suffering as a Result of COVID-19 appeared first on AAPC Knowledge Center.

AAPC Knowledge Center

Assistance with Cath/Angiography

Can someone check my codes and if I’m incorrect let me know why/what I have incorrect or missed?

36224-50, 93460-26, 93567, 99152

Thank you!

PROCEDURES PERFORMED:
Combined right and left heart catheterization, left ventricular angiography,
aortic root angiography, selective right and left coronary angiography,
selective right carotid angiography, selective left carotid angiography,
selective left subclavian angiography, left internal mammary angiography,
selective left vertebral angiography, Fick cardiac outputs, monitored
anesthesia care for 57 minutes supervised by myself.

CLINICAL DATA:
83-year-old male, who recently diagnosed with prostate
cancer anticipating brachytherapy. He has already had external radiation.
His preoperative EKG suggests inferior wall infarct, asymptomatic with
no history of atherosclerotic heart disease. Physical exam, he has
evidence of carotid disease bilaterally. He had evidence of aortic
stenosis. An echocardiogram demonstrates normal LV function with moderate
aortic stenosis. A stress test is high-risk study demonstrating reversible
defects in the anterior wall, apex, septum, and inferior and inferior
lateral walls with a drop in ejection fraction of about 20 points with
pharmacologic stress. The procedure is performed from the right groin.
We used a monitoring Swan-Ganz for the right heart cath. The 6-French
diagnostic catheters were used for the remainder.

HEMODYNAMIC DATA:
The patient is in a sinus rhythm in the 60 to 65 beat per minute range.
The arterial pressure of 136/60, mean of 90. The LV pressure of 180
with an LVEDP.

COMMENTS:
The gradient across the aortic valve ranged from 50 to 60 during the
case. The mean right atrial pressure was 4. Kussmaul sign negative.
RV pressure of 30/6, PA pressure of 30/10 with a mean of 18. Pulmonary
capillary wedge pressure was 12. No significant V waves were noted.

The mean arterial saturation 93%, mean mixed venous saturation 72%.
Cardiac output was 5.3 L/minute with an index of 2.9 L/minute per meter
squared. The mean planimetered gradient was 47. The peak-to-peak gradient
was about 55. The flow was 295 mL/second, systolic ejection period
0.27 seconds per beat with a heart rate of 65. The aortic valve area
is about 0.9 cm2, calculated using the Fick method, 0.8 cm2 using the
Quick formula.

Left ventricular angiography is performed in a shallow RAO projection.
There is severe mitral annular calcification and severe calcifications
of all epicardial coronary arteries. The left ventricle is well opacified
with dye. There is evidence of mild LVH. Systolic function is well
preserved. There is hypokinesis of the inferior basal segment. Ejection
fraction is estimated in the 55% to 60% range. No significant mitral
regurgitation was seen.

The aortic root angiogram is performed in a LAO projection. The aortic
valve is a trileaflet structure. There is moderate restriction of valve
leaflet excursion of the right coronary leaflet. The left coronary
and noncoronary leaflets do not appear to be moving. The origin of
both right and left coronary arteries are noted to be severely calcified.
There was no aortic insufficiency. There was minimal post stenotic
aortic root dilatation.

CORONARY ANGIOGRAPHY:
Coronary angiography is performed in multiple projections.
A. The right coronary artery appears to been a dominant vessel in this
patient. There is an ostial total occlusion of the right coronary artery.
A second subtotal occlusion is noted about 10 mm from the ostium and
the vessel is totally occluded at the acute margin. The distal right
coronary artery appears graftable and fills via the septal arcade from
the left coronary system and also the circumflex.
B. The left main coronary artery arises from the left cusp, ends in
a trifurcation. The left main coronary artery has mild atherosclerotic
plaquing, but no significant obstructive disease.
C. The circumflex is a moderate, but nondominant vessel. There is an
ostial 90% stenosis followed by 75% stenosis. The circumflex basically
ends as a marginal branch, which is graftable.
D. The left anterior descending artery is a large wrap-around type LAD,
severely calcified, but well distributed in the left ventricular apex.
The origin of the LAD is patent. It immediately gives rise to a diagonal
branch/ramus branch, which has a 90% stenosis at its ostium. The vessel
is tortuous, but graftable. As the LAD continues to give rise to a
second diagonal branch, which has an 80% diameter stenosis, this vessel
is diffusely diseased. In the LAD proper, there was a severe calcific
lesion in the mid LAD of about 70% diameter stenosis. The distal LAD
is free of significant obstructive disease and appears graftable.

Carotid angiography: A selective right carotid angiogram is performed
in a single oblique view. The carotid bifurcation is patent. The right
external carotid artery is patent. There is a high-grade 70% stenosis
in the proximal right internal carotid artery with an atherosclerotic
ulcer just proximal to it appears to be mild thrombus in this area.
Selective views of the left carotid were performed. Visualization
was not as good as on the right. In the distal left common carotid
artery, there is a high-grade lesion of about 70%. The left external
carotid artery is patent. The right external carotid artery has an
ulcerated lesion approaching 90% diameter stenosis is a web type lesion.

Left internal mammary angiography is performed in a single AP projection.
The left internal mammary artery is somewhat small, but appears to
be adequate in length and diameter for use as an in-situ graft. Next,
the left vertebral artery appears to be a dominant artery, luminal irregularities
are noted, but it appears to be free of significant obstructive disease.
There was some ostial spasm.

IMPRESSIONS:
1. Normal right heart pressures.
2. Normal sinus rhythm.
3. Normal cardiac output.
4. Moderately severe aortic stenosis.
5. Well-preserved left ventricular function with inferior wall motion
abnormalities.
6. No significant mitral valve disease.
7. Severe calcific coronary artery disease with:
a. Chronic total occlusion in the right coronary artery at multiple
levels. Right coronary artery is dominant.
b. High-grade 90% ostial circumflex lesion.
c. High-grade ostial ramus/diagonal lesion at least 80% to 90%.
d. Severe disease in the left anterior descending artery at multiple levels.
e. Severe carotid disease on the left side with moderately severe
carotid disease on the right side.
8. Adequate LIMA vessel for use as an in-situ graft.

COMMENTS:
This 83-year-old male is anticipating brachytherapy. He has fairly well-preserved
LV function. Recommendations are for surgical consideration, graftable
vessels include the distal right coronary artery, LAD, major diagonal
branch, and circ marginal branch. The patient’s aortic stenosis is
severe, but not critical. He could be a candidate for a TAVR procedure
in the future if aortic valve replacement is not entertained at the
time of bypass surgery. This patient will need a CT angiogram of the
carotid arteries and will likely need a left carotid endarterectomy
prior to coronary artery bypass grafting surgery.

90051917MC

Medical Billing and Coding Forum

OP Note assistance

Hello all,

I’m in need of some assistance withe coding the below report. It has me a little confused due to the scope only went to the duodenum, but the report also states "Papillotome was used for cannulation and a cholangiogram was obtained and showed no filling defects". I’m thinking 43247 and not sure on the cannulation. :confused: Any assistance would be great!

PROCEDURE PERFORMED: Endoscopic Retrograde cholangiopancreatography with stent removal.

PREOPERATIVE DIAGNOSIS: Bile leak after laparoscopic cholecystectomy

POSTOPERATIVE DIAGNOSIS: Normal cholangiogram

PROCEDURE: Olympus sided viewing duodenoscope was inserted into the patient’s mouth and advanced down to the descending duodenum. The stent was noted to be protruding the ampulla. A snare was placed through the endoscope and the tip of the stent was grasped. The scope was withdrawn, and this pilled the stent up through the patient’s esophagus and out the patient’s mouth. The scope was then reintroduced back into the descending duodenum. Papillotome was used for cannulation and a cholangiogram was obtained and showed no filling defects. The common bile duct appeared normal in caliber. There was no evidence of any bile leak. The scope was removed and no immediate postprocedure complications.

Thanks in advance for any help!!

Medical Billing and Coding Forum

FMT (Fecal Microbiota Transplant) Assistance

All,

We are looking to start providing FMT and we are having discussions on the correct coding for these procedures. I’d love to find some contacts to discuss what procedure they using for the transplant and how they are coding it, as well as if they are being reimbursed. Our FI is Palmetto and they don’t cover these and our commercial payers want the G code, but our providers have been told by other providers they can use the diagnostic colonoscopy code instead. The cost of the transplant product has increased significantly in the last few months since we started looking at this process, so proper reimbursement is important. If anyone is willing to share their journey and experience, it would be greatly appreciated. Just message me.

Thanks!
Marianne

Medical Billing and Coding Forum

Newbie Needs Assistance

Hi All

I’m trying to assist a family member’s family medical practice. I’ve signed up for the CPB course thru AAPC that starts in November. In the meantime, I was wondering if someone could assist me with the below.

67 yo female presents to the office for labs. Wants the flu vaccine.

Billing for . . .
99214 office visit
90472 immunization admin
96372 therapeutic prophylactic injection
1033F tobacco non-smoker (I know this isn’t covered)
4035F Influenza immunization recommended (probably not covered)
3008F BMI (not covered)
I think the Fs are for reporting purposes from what I’ve found.

When I submit the above, I get the following . . .

Code 99214 is a component of code 90472 but a modifier is allowed on 99214
Code 99214 is a component of code 96372 but a modified is allowed on 99214
The procedure code 90472 is defined as an add-on code
The procedure code 90472 is invalid or requires a parent that is not on the claim

I’m unsure when to add modifiers like 25, 59, QW, etc. When I add 25 modifier to 99214 I get
The procedure code 90472 is defined as an add-on code.
The procedure code 90472 is invalid or requires a parent that is not on the claim.

Any assistance anyone could give would be greatly appreciated.
TIA

Medical Billing and Coding Forum

Ablation/EP Assistance

Can someone give me some guidance on this? I’ve only coded the simple av node ablations so this is new to me.

Thank you!

SURGEON:
HW, MD and DR. DH

REFERRING PHYSICIAN:

CLINICAL INDICATION:
The patient is a 78-year-old gentleman with severe cardiomyopathy and
Medtronic BiV-ICD. The patient was noted to have atrial flutter with
recurrent tachycardia and he did have one AV node ablation, but the
patient was noted to have possible recovery with heart rate up to 120s.
The patient also was noted to have heart rate in the 60s. Thus, the
patient came in for EP study with possible ablation redo for AV node.

DESCRIPTION OF PROCEDURE:
The patient was sedated by anesthesiologist using general anesthesia.
Dr. H and I did the procedure together. The patient was prepped
and draped in sterile fashion. Right femoral vein was accessed and 7.0
sheath was placed with ablation. We decided to use a bidirectional ThermoCool
ablation catheter. BiV-ICD was programmed to VVI-40. Dr. H and
I did a detailed mapping of AV node. So far, we have trouble finding
the AV node with his potential, but we did anatomical ablation for presumed
sites for the AV node. In retrospect, the patient could have idioventricular
rhythm and some of the tachycardia could be rate response of slow VT.
We did an anatomical ablation of AV node. Isuprel was started and so
far, the patient is to have heart rate in the 60s to 65 with isoproterenol,
there was no recovery of AV node, but we were not 100% certain. We tried
to attempt cardioversion, but atrial flutter was persistent. We tried
to do atrial pacing. So far, the cycle lines were ranging from 390 to
450 milliseconds. Initially, so we may able to terminate atrial flutter,
then checked through AV conduction, but with multiple attempts, the
patient has persistent atrial flutter ranging from 390 to 450 milliseconds.
I gained isoproterenol changes of cycle lines of the tachycardia. We
did attempt to do the ablation along the isthmus without changing the
cycle lines and then we concluded the study without further ablation.
Hemostasis was obtained by manual pressure. BiV-ICD was reprogrammed
to VVI-80.

CONCLUSION:
1. Attempted ablation redo for AV node, but in retrospect, the patient
could have complete heart block with idioventricular rhythm. We did
an anatomical ablation involving AV node.
2. Isuprel drug testing and the patient has persistent high-grade
complete heart block on isoproterenol.
3. BiV-ICD reprogramming to VVI-80.
4. Attempted cardioversion and atrial pacing, but atrial flutter persisted.
5. Detailed 2D mapping of AV node.

ESTIMATED BLOOD LOSS:
About 10 mL.

CONTRAST USED:
None.

PLAN:
The patient will be kept in ICU overnight and see how he does. At this
moment, we think the patient has complete heart block with idioventricular
rhythm with heart rate in the 60s. We will see how the patient does
with Bi-V pacing of 80.

Dr. H and I performed the procedure together.

Medical Billing and Coding Forum

EVAR Coding Assistance

I am new to EVAR coding and need confirmation that I am coding this report appropriately. My provider uses the term "extension" in his report, but I don’t think that it is truly an extension that I can code for as it does not appear that it is placed distal to the common iliac artery. I came up with CPT 34705-62 for this report. Please confirm.

Pre-Operative Diagnosis: Abdominal Aortic Aneurysm
*
Post-Operative Diagnosis: Successful Endovascular AAA Stent Graft Placement
*
Abdominal Aortogram, Bilateral Iliac Angiogram and AAA Stent Graft Placement
*
INDICATION FOR PROCEDURE:
Infrarenal abdominal aortic aneurysm more than 5 cm in diameter
*
Nature of procedure, including benefits, alternative and risks, e.g. bleeding, CVA, MI, renal failure, infection, emergency CABG and even death explained.
*
CO-SURGEON: Dr. XXXXX and Dr. XXXXX
*
CONTRAST:
* Intraprocedure medication information is unavailable because the case start and end events have not been set *
*
NAME OF PROCEDURE:
1. Insertion of bilateral arterial sheath and catheter placement via both femoral arteries.
2. Abdominal aortogram with bilateral selective iliac angiogram to facilitate stent graft placement.
3. Placement of a Cook Zenith AAA stent graft main body by flex flex body 30×111 mm device via the left groin.
4. Placement of a contralateral limb via the right groin using a Cook Zenith spiral limb extension 20×74 mm iliac limb.
5. Placement of a left iliac limb extension using a Cook Zenith spiral limb extension 11 X 74 mm iliac device.
6. Balloon angioplasty of all stent graft anastomosis site using a Coda balloon.
*
*
DESCRIPTION OF PROCEDURE:
After an informed consent, the patient was brought into the cath lab and prepped and draped in the usual fashion. General anesthesia was administered by anesthesiologist and the anesthesia record will be reported separately.
Bilateral femoral artery cutdown was performed by Dr. XXXXX. His cutdown report will also be dictated separately.
After bilateral arterial cutdown, bilateral 7-French sheath was placed under Seldinger technique under open condition without complication. Bilateral arterial catheterization was performed using a soft Glidewire and then exchanged out for 2 stiff Lunderquist guide wires. A 6-French Royal Flush pigtail catheter was advanced from the right groin into the abdominal aorta above the renal arteries. Suprarenal abdominal aortogram was performed to evaluate position of the renal artery so as to use it as a landmark for stent graft placement. The left renal artery appeared to be the lower vessel and was used as a landmark. Subsequently, a Cook Zenith main body 30×111 mm Tri-Flex flex body device was advanced from the left groin into the abdominal aorta at the junction of the left renal artery. Prior to that slow subsequent dilatation was done with 16, 18 and 20 mm dilator Slow deployment was performed where we were able to precisely place the stent graft below the left renal artery as well as to allow the contralateral limb to open up toward the anterior projection. Subsequently, we were able to exchange out for a soft wire and a Headhunter catheter to access the contralateral limb from the right side without difficulty. Confirming position of the wire into the main body from the contralateral limb using a pigtail catheter, we were able to measure the size and the length of the device that we need. After insuring that we were truly in the true lumen of the contralateral limb, we were able to deliver a 20×74 mm Zenith spiral limb extension contralateral limb device with at least 1 to 1-1/2 graft overlap distally without occlusion of the internal iliac artery. The right limb deployed slowly without complication.
After the rest of the main body limb was fully deployed on the left side, the pigtail catheter was exchanged out in the left side. Left iliac angiogram was subsequently performed where we were able to precisely locate and measure the size of the device we need for the right limb extension. After measuring the length, we were able to determine that a 11×74 mm Zeta spiral limb extension iliac limb distention was needed for the left-sided. Subsequently the 11×74 mm left iliac limb extension was advanced and deployed with 1 to 1-1/2 stent overlap into the main body and with good opposition of the distal side without occlusion of the internal iliac artery. After all stent grafts were deployed, at that point, we used a Coda balloon and inflate all attachment sites using the Coda balloon at low pressures. The ostium of bilateral iliac artery needed to be further dilated with 10×40 mm peripheral balloon Subsequently, angiography was performed which demonstrated excellent main body main AAA stent graft position without occlusion of the renal artery. There was no endoleak seen by the lumbar vessel, which is not significant. At that point, both cutdown sites were repaired by Dr. XXXX and Dr. XXXXX without complication. The patient was subsequently gradually recovered from anesthesia and was transferred to recovery room in stable condition.
*
FINAL IMPRESSION:
Successful placement of a Zenith AAA endograft with main body through the left side with bilateral iliac extension was performed without complication.
*
FINAL DIAGNOSES:
Successful abdominal aortic aneurysm sealed with endovascular graft with bilateral iliac limb extension
RECOMMENDATION:
Recommend routine post-aortic stent graft monitoring. Will followup CT with ultrasound in 3 months and yearly as indicated to rule out endoleak.

Medical Billing and Coding Forum

Impella/PCI Assistance

Could someone give me their thoughts on the codes for this? Thank you!

PROCEDURES:
1. Ultrasound guidance, vascular access of the right common femoral
artery, left common femoral artery, and right common femoral vein.
2. Distal aortogram.
3. Bilateral common iliac to common femoral artery angiogram.
4. 12-French Impella 2.5 insertion
5. Temporary pacemaker wire insertion.
6. Left heart catheterization.
7. Coronary angiography
8. CSI rotational atherectomy, mid circumflex artery.
9. Drug-eluting stent integrity resolute 3.5/12 mm mid circumflex artery.
10. Unsuccessful CTO opening of the mid RCA, chronic total occlusion.

11. 02HA3RZ Insertion of external heart assist, percutaneous approach.
12. 5A0221D Assistance with cardiac output usin, continuous.
13. 215 Other heart assist system implant

The risks and benefits of cardiac catheterization and PCI with Impella
support were discussed with the patient, wife, and son. They are agreeable
to the procedure. Consent was obtained.

Time-out was performed. The patient, procedure and physician were identified.

Ultrasound guidance was used to access the right common femoral artery,
right common femoral vein, and left common femoral artery. A 7-French
sheath was introduced to the right common femoral artery and a 6-French
sheath into the right common femoral vein. A 12-French sheath was introduced
into the left common femoral artery. Before the sheath was placed,
Preclose x2 was placed.

A 12-French Impella 2.5 was inserted into the left ventricle without difficulty.

Temporary pacer wire was placed through the right common femoral vein.

Before the Impella implantation, distal aortogram showed no abdominal
aortic aneurysm. Bilateral iliac angiogram showed no significant stenosis
in the right and left common iliac, and external iliac arteries. The
common femoral arteries bilaterally were also without significant disease.

Temporary pacer wire was placed into the right ventricular apex and acceptable
thresholds were obtained.

A 7-French FL4 guide catheter was used to engage the left main. The
ViperWire was advanced into the distal circumflex artery. A CSI 1.25
burr was used to make multiple passes at the 90% stenotic region. An
integrity resolute 3.5/12 mm stent was deployed in the mid segment.
The stent was post dilated with a noncompliant 3.5/12 mm to 12-14 atmospheres.
The previous 80% to 90% stenosis had 0% stenosis at final angiography.

Occlusion of the circumflex artery and injection into the left anterior
descending artery showed no significant ostial disease. Ostial waist
of approximately 20% to 30% is noted. Heavy calcification is noted
in the segment.

Our attention was directed to the right mid CTO. A 7-French JR4 catheter
was used to engage the ostium. Multiple wires including a Choice, run-through,
Fighter, Confianza wires were used, but not able to cross the CTO.
The procedure was subsequently terminated.

The Impella support was weaned. The sheath was removed and the Perclose
sutures were deployed without difficulty. A 6-French Angio-Seal was
used to close the left common femoral artery. Manual pressure was applied
for approximately 15-20 minutes. Good hemostasis was obtained.

The left common femoral artery was also closed with a Perclose. The
common femoral vein sheath was sutured in place and to be removed when
the ACT less than 150 seconds.

IMPRESSION:
1. Successful CSI, drug-eluting stent placement to the mid circumflex artery.
2. Unsuccessful opening of the mid RCA CTO.

The patient tolerated the procedure well and was transferred to the recovery
area in stable condition. The patient awoke without apparent neurologic
deficit.

Medical Billing and Coding Forum