CHAPTER 13, MEDICAL CODING,
EXAM QUESTIONS AND ANSWERS
A patient with severe adenomyosis has a vaginal hysterectomy with bilateral
salpingo-oophorectomy. After the uterus is removed it is weighed at 300 grams.
What is the CPT® code reported for this procedure? - Answer-58291
Response Feedback: Rationale: A vaginal hysterectomy code can be selected based
on the weight of the uterus and additional procedures included with the
hysterectomy. In the CPT® Index look for Hysterectomy/Vaginal/Removal
Tubes/Ovaries directing you to codes 58262, 58263, 58291, 58292, 58552, 58554. A
vaginal hysterectomy for a uterus greater than 250 grams is reported from code
range 58290-58294. Further selection of removal of tubes and ovaries defines code
58291.
A pregnant patient presents to labor and delivery with the baby in a breech
presentation. During the delivery the doctor attempts to turn the baby (version of the
breech presentation) while it is still in the uterus. The baby turns but then
immediately resumes his previous breech position. Can this service (the version of
the breech) be billed? If so, what is the code? - Answer-Yes, because the doctor did
the work, even though the outcome was unsuccessful. Report this procedure with
code 59412
Response Feedback:Rationale: The physician can bill for this service separately.
Look in the CPT® Index Version, Cephalic — see Cephalic Version. Look in the
CPT® Index for Cephalic Version/of Fetus/External and you are referred to 59412.
Verify in the numeric section.
A 32-year-old woman with a previous vertical incision for cesarean delivery presents
in spontaneous labor with the baby in cephalic presentation. She has had an
uneventful pregnancy and after laboring for 10 hours she delivers a single female
child with brief use of a vacuum extractor over an episiotomy that is repaired by the
delivering physician. There are no complications. What are the diagnosis codes for
this delivery? - Answer-O66.5, O34.212, Z3A.00, Z37.0
Response Feedback:Rationale: Rationale: You do not code a normal delivery, code
O80, because a vacuum extractor is used to deliver the baby. In the ICD-10-CM
Alphabetic Index look for Delivery/complicated/by/attempted vacuum extraction and
forceps referring you to code O66.5. ICD-10-CM guidelines, I.A.14., state the word
"and" should be interpreted as "and" or "or" when appearing in the title. The second
code reports the previous cesarean delivery. In the Alphabetic Index look for
Delivery/cesarean (for)/previous/cesarean delivery/classical (vertical) scar, guiding
you to code O34.212. Instructional note in the beginning of Chapter 15 indicates a
code from Z3A is reported with the pregnancy codes. Z3A.00 indicates unspecified
weeks. This is found in the Alphabetic Index by looking for Pregnancy/weeks of
gestation/not specified. Your last code to report is the outcome of the delivery. Look
in the Alphabetic Index for Outcome of delivery/single NEC/liveborn referring you to
code Z37.0. Verify all codes in the Tabular List.
A 27-year-old woman's regular obstetrician delivers her twins. The first is delivered
vaginally but the second is delivered by cesarean delivery. Both are delivered
, without complications. Patient will return in two weeks for a postpartum visit. What
is/are the CPT® code(s) reported for this service? - Answer-59510, 59409-51
Response Feedback:Rationale: Two codes are reported for this twin delivery to
indicate one delivery is cesarean and the other delivery is vaginal. First code the
global package with the cesarean delivery to capture the highest reimbursement. It is
listed in this order even though the vaginal delivery was performed first, followed by
the cesarean delivery. Look in the CPT® Index for Cesarean Delivery/Routine care
referring you to 59510. The caesarean delivery is coded first because the global
package includes the appropriate postsurgical follow up reimbursement. Look in the
CPT® Index for Vaginal Delivery/Delivery Only referring you to 59409. Appending
modifier 51 to this procedure indicates multiple procedures performed in the same
session. The global obstetrical package is reported when a physician from a solo
practice or the same physician group practice provides the global routine obstetric
care, which includes the antepartum care, delivery, and postpartum care. This
scenario informs us the delivery is performed by her obstetrician, meaning she has
been going to her obstetrician for check-ups during her pregnancy, before delivery
and will be returning for postpartum care. The Maternity Care and Delivery
guidelines list the services included in the global service.
A patient has ovarian cancer of both ovaries. She has removal of her ovaries with
peritoneal washings and assessment of the abdomen for any metastases, including
inspection of omentum, diaphragm and multiple biopsies. Lymph nodes in the pelvic
and peri-aortic areas were also biopsied. She has previously had a hysterectomy.
What are the CPT® and ICD-10-CM codes reported for this service? - Answer-.
58943, C56.3
Response Feedback:Rationale: Patient has ovarian cancer in which there was an
open approach for removal of her ovaries only (total bilateral oophorectomy) along
with biopsies performed on the peritoneal, pelvic and peri-aortic lymph nodes. Look
in the CPT® Index for Ovary/Excision/Total guiding you to codes 58940-58943.
58943 is correct and includes the oophorectomy for malignancy and the biopsies.
This is used for with or without salpingectomy and with or without omentectomy.To
report the diagnosis, ovarian cancer, look in the ICD-10-CM Table of Neoplasms for
Neoplasm, neoplastic/ovary/Malignant Primary column referring you to C56.-. In the
Tabular List a 4 th character is reported for laterality. Both ovaries are cancerous
reporting C56.3.
A woman with abdominal pain and bleeding has a diagnosis of multiple fibroid
tumors and undergoes laparoscopic resection without hysterectomy. After the
abdomen is entered and inspected it is found she has 5 separate intramural fibroid
tumors. The fibroid tumors are successfully removed, with a total weight of 300
grams. Pathology confirms leiomyoma (myomas or fibroids). What are the CPT® and
ICD-10-CM codes reported for this service? - Answer-58546, D25.1
Response Feedback:Rationale: Surgical laparoscopy is performed to remove the five
fibroid tumors weighing over 250 grams. Look in the CPT® Index for
Laparoscopy/Removal/Leiomyomata referring you to 58545, 58546. 58546 is correct
for 5 or more fibroid tumors. In the ICD-10-CM Alphabetic Index, look for
Leiomyoma/uterus/intramural referring you to code D25.1. Verify this code in the
Tabular List.
EXAM QUESTIONS AND ANSWERS
A patient with severe adenomyosis has a vaginal hysterectomy with bilateral
salpingo-oophorectomy. After the uterus is removed it is weighed at 300 grams.
What is the CPT® code reported for this procedure? - Answer-58291
Response Feedback: Rationale: A vaginal hysterectomy code can be selected based
on the weight of the uterus and additional procedures included with the
hysterectomy. In the CPT® Index look for Hysterectomy/Vaginal/Removal
Tubes/Ovaries directing you to codes 58262, 58263, 58291, 58292, 58552, 58554. A
vaginal hysterectomy for a uterus greater than 250 grams is reported from code
range 58290-58294. Further selection of removal of tubes and ovaries defines code
58291.
A pregnant patient presents to labor and delivery with the baby in a breech
presentation. During the delivery the doctor attempts to turn the baby (version of the
breech presentation) while it is still in the uterus. The baby turns but then
immediately resumes his previous breech position. Can this service (the version of
the breech) be billed? If so, what is the code? - Answer-Yes, because the doctor did
the work, even though the outcome was unsuccessful. Report this procedure with
code 59412
Response Feedback:Rationale: The physician can bill for this service separately.
Look in the CPT® Index Version, Cephalic — see Cephalic Version. Look in the
CPT® Index for Cephalic Version/of Fetus/External and you are referred to 59412.
Verify in the numeric section.
A 32-year-old woman with a previous vertical incision for cesarean delivery presents
in spontaneous labor with the baby in cephalic presentation. She has had an
uneventful pregnancy and after laboring for 10 hours she delivers a single female
child with brief use of a vacuum extractor over an episiotomy that is repaired by the
delivering physician. There are no complications. What are the diagnosis codes for
this delivery? - Answer-O66.5, O34.212, Z3A.00, Z37.0
Response Feedback:Rationale: Rationale: You do not code a normal delivery, code
O80, because a vacuum extractor is used to deliver the baby. In the ICD-10-CM
Alphabetic Index look for Delivery/complicated/by/attempted vacuum extraction and
forceps referring you to code O66.5. ICD-10-CM guidelines, I.A.14., state the word
"and" should be interpreted as "and" or "or" when appearing in the title. The second
code reports the previous cesarean delivery. In the Alphabetic Index look for
Delivery/cesarean (for)/previous/cesarean delivery/classical (vertical) scar, guiding
you to code O34.212. Instructional note in the beginning of Chapter 15 indicates a
code from Z3A is reported with the pregnancy codes. Z3A.00 indicates unspecified
weeks. This is found in the Alphabetic Index by looking for Pregnancy/weeks of
gestation/not specified. Your last code to report is the outcome of the delivery. Look
in the Alphabetic Index for Outcome of delivery/single NEC/liveborn referring you to
code Z37.0. Verify all codes in the Tabular List.
A 27-year-old woman's regular obstetrician delivers her twins. The first is delivered
vaginally but the second is delivered by cesarean delivery. Both are delivered
, without complications. Patient will return in two weeks for a postpartum visit. What
is/are the CPT® code(s) reported for this service? - Answer-59510, 59409-51
Response Feedback:Rationale: Two codes are reported for this twin delivery to
indicate one delivery is cesarean and the other delivery is vaginal. First code the
global package with the cesarean delivery to capture the highest reimbursement. It is
listed in this order even though the vaginal delivery was performed first, followed by
the cesarean delivery. Look in the CPT® Index for Cesarean Delivery/Routine care
referring you to 59510. The caesarean delivery is coded first because the global
package includes the appropriate postsurgical follow up reimbursement. Look in the
CPT® Index for Vaginal Delivery/Delivery Only referring you to 59409. Appending
modifier 51 to this procedure indicates multiple procedures performed in the same
session. The global obstetrical package is reported when a physician from a solo
practice or the same physician group practice provides the global routine obstetric
care, which includes the antepartum care, delivery, and postpartum care. This
scenario informs us the delivery is performed by her obstetrician, meaning she has
been going to her obstetrician for check-ups during her pregnancy, before delivery
and will be returning for postpartum care. The Maternity Care and Delivery
guidelines list the services included in the global service.
A patient has ovarian cancer of both ovaries. She has removal of her ovaries with
peritoneal washings and assessment of the abdomen for any metastases, including
inspection of omentum, diaphragm and multiple biopsies. Lymph nodes in the pelvic
and peri-aortic areas were also biopsied. She has previously had a hysterectomy.
What are the CPT® and ICD-10-CM codes reported for this service? - Answer-.
58943, C56.3
Response Feedback:Rationale: Patient has ovarian cancer in which there was an
open approach for removal of her ovaries only (total bilateral oophorectomy) along
with biopsies performed on the peritoneal, pelvic and peri-aortic lymph nodes. Look
in the CPT® Index for Ovary/Excision/Total guiding you to codes 58940-58943.
58943 is correct and includes the oophorectomy for malignancy and the biopsies.
This is used for with or without salpingectomy and with or without omentectomy.To
report the diagnosis, ovarian cancer, look in the ICD-10-CM Table of Neoplasms for
Neoplasm, neoplastic/ovary/Malignant Primary column referring you to C56.-. In the
Tabular List a 4 th character is reported for laterality. Both ovaries are cancerous
reporting C56.3.
A woman with abdominal pain and bleeding has a diagnosis of multiple fibroid
tumors and undergoes laparoscopic resection without hysterectomy. After the
abdomen is entered and inspected it is found she has 5 separate intramural fibroid
tumors. The fibroid tumors are successfully removed, with a total weight of 300
grams. Pathology confirms leiomyoma (myomas or fibroids). What are the CPT® and
ICD-10-CM codes reported for this service? - Answer-58546, D25.1
Response Feedback:Rationale: Surgical laparoscopy is performed to remove the five
fibroid tumors weighing over 250 grams. Look in the CPT® Index for
Laparoscopy/Removal/Leiomyomata referring you to 58545, 58546. 58546 is correct
for 5 or more fibroid tumors. In the ICD-10-CM Alphabetic Index, look for
Leiomyoma/uterus/intramural referring you to code D25.1. Verify this code in the
Tabular List.
