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CHAPTER 1: REIMBURSEMENT, HIPAA, AND COMPLIANCE

Theory 1. a. persons eligible for disability benefi ts from Social Security b. persons with permanent kidney failure requiring dialysis or transplant 2. CMS (Centers for Medicare and Medicaid Services) 3. Social Security Administration 4. deductibles, premiums, and coinsurance 5. 80% 6. Relative Value Unit 7. 12 8. November, December 9. OBRA 10. no 11. benefi ciaries 12. MACs or Medicare Administrative Contractors 13. Medicare Advantage 14. Health Insurance Portability and Accountability Act 15. Administrative Simplifi cation 16. Electronic Data 17. National Provider 18. unit 19. limiting 20. 125 21. Internet Only 22. gatekeeper 23. Staff 24. Individual Practice 25. Program, All-Inclusive

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CHAPTER 2: AN OVERVIEW OF ICD-10-CM

Theory 1. True 2. True 3. True 4. True 5. False 6. False 7. True 8. False 9. True 10. True

Practical 11. f 12. d 13. b 14. a 15. c 16. e 17. d 18. a 19. f 20. b 21. e 22. c

CHAPTER 3: ICD-10-CM OUTPATIENT CODING AND REPORTING GUIDELINES

Theory 1. False 2. True 3. False 4. False 5. True 6. False 7. False 8. True 9. False 10. False 11. True 12. True 13. True 14. False 15. False

Practical 16. Left upper quadrant abdominal pain, R10.12; end stage renal disease,

N18.6; dialysis status, Z99.2 17. Congestive heart failure, I50.9. The shortness of breath is a symptom of

congestive heart failure and is not reported. 18. Arteriosclerotic heart disease with unstable angina, I25.110. There

is a combination code for arteriosclerotic heart disease and unstable angina. Even though the question states the patient has a history of



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arteriosclerotic heart disease, it means that the patient currently has coronary artery disease as the condition does not go away.

19. Hypertension with end stage renal disease, I12.0; end stage renal dis-ease, N18.6. There is a combination code for hypertension with end stage renal disease. I12.0 assumes a causal relationship in this scenario. Under code I12.0 in the Tabular, a notation states “Use additional code to identify the stage of the chronic kidney disease (N18.5, N18.6).”

20. Chemotherapy for neoplasm, Z51.11; prostate cancer, C61. The admission for chemotherapy is always fi rst-listed, followed by the type of neoplasm.

21. Chronic obstructive pulmonary disease with acute lower respiratory infection, J44.0. A combination code includes COPD and the acute lower respiratory infection.

22. Inguinal hernia, K40.90; upper respiratory tract infection, J06.9; procedure scheduled but not performed due to contraindications, Z53.09. The Guidelines state to code the reason for the surgery fi rst. The fever is not reported as it is a symptom of the URI.

23. Exposure to tuberculosis, Z20.1 24. Chest pain with breathing, R07.1 25. Abnormal perfusion study, R94.39; cardiovascular disease, I25.10. The

purpose of the visit is the abnormal perfusion study; therefore, it is reported fi rst, followed by the cardiovascular disease.

26. Hallux valgus, M20.11; asthma with exacerbation, J45.901. The reason for the surgery is reported fi rst, followed by the asthma with exacerbation.

27. Contusion of the left cheek, S00.83xA; fi st fi ght, Y04.0xxA. External cause codes are never reported as a fi rst-listed diagnosis.

28. Fractured shaft of right femur, S72.301A; falling off horse being ridden; V80.010A, horseback riding, Y93.52. The external cause codes are never fi rst-listed codes. If the activity at the time of the event is known, it is reported after the external cause code.

29. Encounter for insulin pump titration, Z46.81 30. Supervision in second trimester of high risk pregnancy due to previous

ectopic pregnancy, O09.12. 31. Infant, liveborn, twin, born in hospital, Z38.30. 32. Encounter for change of nephrostomy tube, Z43.6. 33. Abrasion of left upper arm, S40.812A. 34. Either code could be fi rst-placed because both problems were addressed.

Hypertension, I10, or psoriasis, L40.9 35. COPD with acute bronchitis, J44.0; cigarette smoker, F17.210. If the

infectious organism is known, it would also be reported.

CHAPTER 4: USING ICD-10-CM

Theory 1. False 2. False 3. False 4. True 5. True 6. False 7. True 8. True 9. False 10. False 11. False 12. False 13. False



96

14. True 15. False 16. Chest pain, shortness of breath, nausea and/or vomiting, palpitations,

lightheadedness 17. Heartburn, acid regurgitation, belching, hoarseness in the morning,

refl ux, pain in chest, trouble swallowing, choking feeling, dry cough 18. Runny nose, itchy and/or watery eyes, sneezing, coughing 19. Swelling, pain, discoloration, disfi guration 20. Residual: Acute renal failure Cause: Viral encephalitis 21. Residual: Constrictive Pericarditis Cause: Tuberculosis infection 22. Residual: Hemiplegia/hemiparesis of right dominant side Cause: Cerebrovascular accident 4 months prior

Practical 23. J01.90 (Sinusitis, acute), J32.9 (Sinusitis [chronic]) 24. J03.90 (Tonsillitis [acute]), J35.01 (Tonsillitis, chronic) 25. J62.8 (Pneumoconiosis, dust, lime) 26. M51.9, G55 (Neuritis, due to, herniation, nucleus pulposus) 27. J14 (Pneumonia, due to, Hemophilus infl uenzae) 28. I20.0 (Angina, unstable) 29. I95.9 (Hypotension) 30. M83.3 (Osteomalacia, adult, due to, malnutrition) 31. K85.9 (Pancreatitis, acute), K86.1 (Pancreatitis, chronic) 32. M32.11 (Lupus, erythematosus, systemic, with, endocarditis) 33. E83.31, M90.80 (Rickets, vitamin-D-resistant) 34. G40.901 (Seizure, febrile, with status epilepticus) 35. K70.11 (Ascites, due to, hepatitis, alcoholic), E10.288 (Dependence,

alcohol, with, specifi ed disorder NEC)

CHAPTER 5: CHAPTER-SPECIFIC GUIDELINES (ICD-10-CM CHAPTERS 1-10)

Theory 1. True 2. True 3. True 4. True 5. False 6. True 7. True 8. True 9. True 10. False 11. True 12. True 13. True 14. True 15. True 16. True 17. False 18. False 19. True 20. True



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Practical 21. A41.9 (Sepsis [generalized]), R65.20 (Sepsis, severe), N17.9 (Failure,

renal, acute), J96.0 (Failure, respiration, respiratory, acute) 22. G30.0 (Disease, Alzheimer’s, early onset, with behavioral disturbance),

F02.81 (Dementia, with behavioral disturbance) 23. E86.0 (Dehydration), B19.10 (Hepatitis, B) 24. O98.713 (Pregnancy, complicated by, human immunodefi ciency

[HIV] disease), B20 (AIDS [related complex]), B59 (Pneumonia, in, pneumocystosis)

25. J85.2 (Abscess, lung), B95.6 (Infection, bacterial, as cause of disease classifi ed elsewhere, Staphylococcus aureus), Z16 (Infection, with, drug resistant organism)

26. Z11.4 (Screening, human immunodefi ciency virus [HIV] infection) 27. Z09 (Examination, follow-up [routine] [following], surgery), Z87.71

(History, hypospadias) 28. T45.1x5A (Table of Drugs and Chemicals, Substance, Antineoplastic

NEC, Adverse Effect), E86.0 (Dehydration), C25.9 (Neoplasm, pancreas, Malignant Primary)

29. C80.0 (Neoplasm, disseminated, Malignant Primary or Malignant Secondary), R18.0 (Ascites, malignant)

30. I11.0 (Hypertension, heart, with, heart failure [congestive]). I50.9 (Failure, heart, congestive)

31. L03.116 (Cellulitis, lower limb), E11.65 (Diabetes, type 2, with, hyperglycemia)

32. I21.3 (Infarct, myocardium, Q wave), I25.10 (Arteriosclerosis, coronary [artery]), Z95.0 (Status, pacemaker, cardiac)

33. O9A.111 (Pregnancy, complicated by, neoplasm, malignant), C50.912 (Neoplasm, breast, female, unspecifi ed site, Malignant Primary)

34. T80.29xA (Infection, due to or resulting from, infusion, injection, or transfusion), A41.9 (Sepsis [generalized]), D66 (Hemophilia)

35. C61 (Neoplasm, prostate, Malignant Primary), D63.0 (Anemia, in, neoplastic disease)

36. Z51.11 (Chemotherapy [session] [for], cancer), C22.8 (Neoplasm, liver, Malignant Primary)

37. K56.60 (Obstruction, intestine), I12.0 (Hypertension, kidney, with stage V chronic kidney disease), N18.5 (Disease, kidney, chronic, hypertensive, stage 5)

38. C77.3 (Neoplasm, lymph, lymphatic channel, gland, axilla, axillary, Malignant Secondary), C50.411 (Neoplasm, breast, female, upper-outer quadrant, Malignant Primary)

39. C79.31 (Neoplasm, brain NEC, Malignant Secondary), Z85.3 (History, personal [of], malignant neoplasm, breast), Z90.12 (Absence, breast(s) [acquired])

40. C67.9 (Neoplasm, bladder [urinary], Malignant Primary) 41. D45 (Polycythemia, vera) 42. G56.01 (Syndrome, carpal tunnel) 43. T85.614A (Complication, insulin pump, mechanical, breakdown),

T38.3x1A (Substance, Insulin NEC, Poisoning, Accidental [Unspecifi ed]), E10.641 (Diabetes, type I, with, hypoglycemia)

44. G31.83, F02.80 (Dementia, with, Lewy bodies) 45. C34.11(Neoplasm, lung, upper lobe, Malignant Primary) 46. F10.229 (Drunkenness, acute in alcoholism) 47. I21.3 (Infarct, myocardium [acute], Q wave) 48. T40.5x1A (Substance, Cocaine, Poisoning Accidental [Unintentional]),

F14.229 (Dependence, drug, cocaine, with intoxication), I46.9 (Arrest, cardiac)



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49. F23 (Schizophrenic), Z91.14 (Noncompliance, with, medication regimen NEC)

50. F14.23 (Dependence, drug, cocaine, with, withdrawal) 51. B05.1 (Meningitis, in [due to], measles) 52. E11.41 (Diabetes, type 2, with neuropathy), G57.91 (Mononeuropathy,

lower limb) 53. A52.15 (Polyneuropathy, in [due to], syphilis [late]), A52.77 (Syphilis,

joint [late]) 54. M00.20 (Arthritis, streptococcal NEC), B95.5 (Infection/Infected/infective,

bacterial, as cause of disease classifi ed elsewhere, Streptococcus) 55. G80.2 (Palsy, cerebral, hemiplegic, spastic) 56. H90.3 (Deafness, sensorineural, bilateral), G09 (Sequelae [of], meningitis,

bacterial) 57. H81.09 (Meniere’s disease, syndrome or vertigo) 58. I63.231 (Occlusion, artery, carotid, with, infarct) 59. I50.1 (Failure, ventricle, left), Z99.11 (Dependence, on, ventilator)

Reports 60. Report 90: C61 (Neoplasm, prostate [gland], Malignant Primary)


Theory 1. True 2. False 3. True 4. True 5. False 6. True 7. False 8. True 9. True 10. True

Practical 11. K03.2 (Erosion, dental [idiopathic] [occupational] [due to diet, drugs, or

vomiting]) 12. K11.3 (Abscess, salivary [duct] [gland]) 13. N83.6 (Hemorrhage, fallopian tube) 14. N41.11 (Prostatitis, chronic, with hematuria) 15. N76.4 (Cellulitis, genital organ NEC, female [external]) 16. M25.631 (Stiffness, joint NEC, wrist) 17. N47.2 (Paraphimosis [congenital]) 18. K12.2 (Abscess, submandibular [region] [space] [triangle]) 19. N91.1 (Amenorrhea, secondary) 20. M24.274 (Disorder, ligament, foot joint) 21. M79.81 (Hematoma, nontraumatic, soft tissue) 22. M53.3 (Lesion, sacroiliac [joint] [old]) 23. K51.412 (Polyp, polypus, colon, infl ammatory, with, intestinal

obstruction) 24. L91.0 (Scar, hypertrophic) 25. L97.112 (Ulcer, lower limb, thigh, right, with, exposed fat layer) 26. K11.22 (Sialoadenitis, acute, recurrent) 27. K40.41 (Hernia, inguinal [internal], with, gangrene, recurrent) 28. M86.131 (Osteomyelitis, acute, radius)



99

29. N03.1 (Nephritis, nephritic [focal], chronic, with, focal and segmental glomerular lesions)

30. N18.6 (Disease, diseased, end stage renal [ESRD]), Z99.2 (Status, dialysis [hemodialysis] [peritoneal])

31. L05.02 (Sinus, pilonidal [infected] [rectum], with abscess) 32. L21.0 (Cradle cap) 33. M60.162 (Myositis, interstitial, lower leg) 34. N93.9 (Bleeding, uterus, uterine, unrelated to menstrual cycle) 35. M32.13 (Lupus, erythematosus, systemic, with organ or system

involvement, lung) 36. M00.031 (Arthritis, staphylococcal, wrist), B95.6 (Staphylococcus,

aureus, as cause of disease classifi ed elsewhere) 37. M00.242 (Arthritis, streptococcal NEC, hand joint), B95.1 (Streptococcus,

group B, as cause of disease classifi ed elsewhere) 38. N80.1 (Endometriosis, ovary), N80.2 (Endometriosis, fallopian tube) 39. M60.221 (Granuloma, foreign body [in soft tissue], upper arm) 40. K35.2 (Appendicitis, acute, with, peritonitis, with perforation or rupture) 41. N61 (Abscess, areola [chronic]) 42. N75.0 (Cyst, Bartholin’s gland)

Reports 43. Report 91: M75.52 (Bursitis, shoulder) 44. Report 92: N20.0 (Calculus, kidney) 45. Report 93: T86.10 (Complication, transplant, kidney), N17.9 (Failure,

renal, acute)


Theory 1. True 2. False 3. True 4. False 5. True 6. False 7. True 8. True 9. False 10. True 11. False 12. True 13. True 14. True 15. True 16. secondary 17. anomaly 18. sign, symptom 19. abnormal 20. S 21. third degree 22. underdosing 23. 18 24. 15 25. severity



100

Practical 26. O04.5 (Abortion, induced, complicated by, endometritis) 27. S40.812A (Abrasion, arm [upper]) 28. R16.0 (Hepatomegaly) 29. T78.2xxA (Shock, anaphylactic) 30. R62.51 (Failure, gain weight [child over 28 days old]) 31. O08.0 (Peritonitis, following ectopic or molar pregnancy) 32. T40.1x1A (Table of Drugs and Chemicals, Substance, Heroin, Poisoning,

Accidental [unintentional]), F11.129 (Abuse, drug, opioid, with intoxication), I46.8 (Arrest, cardiac)

33. Q55.69 (Concealed penis) 34. T79.5xxD (Crush, syndrome [complication of trauma]) 35. O26.53 (Pregnancy, complicated by, hypotension) 36. P38.1 (Cellulitis, naval, newborn, with mild hemorrhage) 37. R13.0 (Aphagia) 38. R19.11 (Abnormal, bowel sounds, absent) 39. S93.402A (Sprain, ankle) 40. P28.4 (Newborn, apnea, obstructive) 41. T23.201D (Burn, hand[s], right, second degree) 42. S68.121A (Amputation, traumatic [complete] [partial], fi nger,

index) 43. R80.1 (Proteinuria, persistent) 44. T39.311A (Table of Drugs and Chemicals, Substance, Ibuprofen, Poisoning

Accidental [unintentional]) 45. S00.33xD (Contusion, nose) 46. Z38.01 (Infant[s], liveborn, born in hospital, by cesarean) 47. Q99.2 (Syndrome, fragile X) 48. P61.2 (Anemia, of prematurity) 49. O30.23 (Pregnancy, complicated by, multiple gestations, quadruplet) 50. R99 (Death) 51. T43.1x1A (Table of Drugs and Chemicals, Substance, Monoamine

Oxidase Inhibitor NEC, Poisoning Accidental [unintentional]), G25.1 (Tremor[s], drug induced)

52. R11.2 (Nausea, with vomiting) 53. S60.821A (Blister, wrist) 54. T47.1x5A (Table of Drugs and Chemicals, Substance, Omeprazole,

Adverse Effect), K29.01 (Gastritis, acute, with bleeding) 55. S42.001G (Fracture, clavicle) 56. R19.5 (Blood, in, feces, occult) 57. J80 (Distress, respiratory, adult), R53.83 (Fatigue) 58. R10.2 (Pain[s], vaginal)

Reports 59. Report 94: R06.00 (Dyspnea) 60. Report 95: M25.551 (Pain[s], joint, hip), R05 (Cough)

CHAPTER 8: AN OVERVIEW OF ICD-9-CM

Theory 1. f 2. g 3. a 4. i 5. h 6. l 7. j



101

8. e 9. d 10. k 11. b 12. c 13. a 14. b 15. f 16. b 17. c 18. d 19. a 20. e 21. g 22. c 23. d 24. False 25. True 26. False 27. True 28. False 29. reaction 30. fracture 31. obstruction 32. palsy 33. pregnancy 34. stenosis 35. respiration 36. meningitis 37. subcategory 38. subclassifi cation 39. category 40. subclassifi cation 41. subcategory 42. subclassifi cation 43. diagnosis code 44. diagnosis code 45. procedure code 46. procedure code 47. diagnosis code

Practical 48. 10. Diseases of the Genitourinary System (580-629) 49. Nephritis, Nephrotic Syndrome, and Nephrosis (580-589) 50. 580 Acute glomerulonephritis 51. 580.0 Acute glomerulonephritis with lesion of proliferative

glomerulonephritis 52. 580.81 Acute glomerulonephritis in diseases classifi ed elsewhere 53. Essential 54. Nonessential 55. Essential 56. Nonessential 57. Essential 58. No, 022.3 59. No, 770.0 60. No, 289.2 61. 002.0, 484.8 (in this order)



102

62. 556.9, 713.1 (in this order) 63. 075, 573.1 (in this order)

CHAPTER 9: ICD-9-CM OUTPATIENT CODING AND REPORTING GUIDELINES

Theory 1. True 2. True 3. False 4. False 5. False 6. True 7. False 8. True 9. True 10. True

Practical 11. V18.19 (History [of], family, gout) 12. V54.89 (Admission, for removal of, cast [plaster]) 13. V72.0 (Admission, for, vision examination) 14. V45.01 (Status (post), cardiac, device (in situ), pacemaker) 15. V73.4 (Screening (for), fever, yellow) 16. V76.51 (Screening (for), malignant neoplasm (of), intestine, colon) 17. V71.89 (Observation (for), suicide attempt, alleged) 18. V15.07 (History (personal) of, allergy to, latex) 19. V04.1 (Vaccination, prophylactic, smallpox) 20. V55.3 (Colostomy, fi tting or adjustment) 21. V77.6 (Screening (for), cystic fi brosis) 22. V77.99 (Screening (for), immunity) 23. V06.4 (Vaccination, rubella, with measles and mumps) 24. V02.4 (Diphtheria, carrier (suspected) of) 25. V59.3 (Donor, bone, marrow) 26. V01.5 (Exposure, to, rabies) 27. V55.3 (Attention to, colostomy) 28. V53.31 (Reprogramming, cardiac pacemaker)

CHAPTER 10: USING ICD-9-CM

Theory 1. False 2. True 3. False 4. True 5. True 6. False 7. False 8. False 9. False 10. True

Practical 11. (any two) urgency, burning pain, urinary retention or inability to fully

empty bladder, hematuria, pain lower abdomen, back or sides, chills, fever, nausea, and vomiting



103

12. (any two) nausea, vomiting, diarrhea, abdominal pain, weakness, loss of appetite, fever, tiredness, muscle aches, and headache

13. Residual: severe intellectual disabilities, Code: 318.1 (Disabilities, intellectual, severe)

Cause: encephalitis, viral, Code: 139.0 (Late effect[s] [of], encephalitis or encephalomyelitis, in infectious diseases, viral)

14. Residual Code: 733.82 (Nonunion, fracture) Cause Code: 905.4 (Late effect[s] (of), fracture, extremity, lower) 15. Residual Code: 733.00 (Osteoporosis) Cause Code: 138 (Late effect[s] [of], Poliomyelitis, acute) 16. Residual and Cause Code: 438.21 (Late effect, cerebrovascular disease

with hemiplegia affecting dominant side) 17. 466.0 (Bronchitis, acute), 491.9 (Bronchitis, chronic) 18. 614.0 (Salpingo-oophoritis, acute), 614.1 (Salpingo-oophoritis, chronic) 19. 590.10 (Pyelonephritis, acute), 041.49 (Infection, Escherichia coli) 20. 008.63 (Enteritis, due to Norwalk virus) 21. No code is assigned as there is no code for impending respiratory failure

and no other information is given. 22. 458.9 (Hypotension). There is no code for threatened shock. 23. 482.2 (Pneumonia, Hemophilus infl uenzae) 24. 034.0 (Pharyngitis, streptococcal) 25. 710.0 (Lupus, erythematosus, systemic), 583.9 (Nephropathy)


Practical 1. 110.4 (Infection, fungus NEC, foot) 2. 070.54 (Hepatitis, type C, chronic) 3. 031.0 (Mycobacterium, mycobacterial (infection), atypical pulmonary) 4. 601.0 (Prostatitis, acute); 041.00 (Infection, streptococcal NEC) in this

order 5. 276.8 (Syndrome, hypokalemia) 6. 157.2 (Neoplasm, pancreas, tail, Primary, Malignant) 7. 041.02 (Infection, streptococcal, Group B) 8. 272.2 (Hyperlipidemia, mixed) 9. 279.03 (Defi ciency, immunoglobulin, IgG) 10. 238.8 (Neoplasm, abdomen, uncertain behavior) 11. 250.50 (Diabetes, retinopathy); 362.01 (Retinopathy, diabetic). Note:

These codes need to appear in this order. 12. 211.5 (Adenoma, hepatocellular) 13. 266.2 (Defi ciency, vitamin, B, specifi ed type NEC) 14. 250.71 (Diabetes, type I, gangrene); 785.4 (Gangrene) in this order 15. 275.3 (Rickets, vitamin D-resistant) 16. 287.5 (Thrombocytopenia, unspecifi ed). Note that if not stated as to

type, classify as unspecifi ed. 17. 258.01 (Syndrome, Wermer’s) 18. 299.00 (Autism, autistic [child] [infantile]) 19. 296.7 (Disorder, bipolar, atypical) 20. 289.1 (Lymphadenitis, chronic) 21. 038.0 (Septicemia, streptococcal [anaerobic]) 22. 040.82 (Syndrome, toxic, shock) 23. 295.32 (Schizophrenia, paranoid) 24. 354.0 (Syndrome, carpal tunnel) 25. 305.1 (Tobacco, abuse) 26. 320.1 (Meningitis, pneumococcal)



104

27. 300.01 (Disorder, panic) 28. 332.0 (Parkinsonism) 29. 362.83 (Edema, retina) 30. 386.04 (Ménière’s disease, in remission) 31. 366.22 (Cataract, traumatic, total) 32. 372.12 (Conjunctivitis, follicular, chronic) 33. 389.15 (Loss, hearing, sensorineural, unilateral) 34. 402.01, 428.9 (Hypertension, cardiovascular disease, with heart failure).

An additional code is added to describe the heart failure and in this case it is unspecifi ed.

35. 410.71 (Infarct, infarction, subendocardial, initial episode) 36. 429.2, 414.00 (Disease, cardiovascular). There is an instructional note

in the ICD-9-CM manual to use an additional code for the arteriosclero-sis, so 414.00 is reported.

37. 416.0 (Hypertension, pulmonary (artery), primary) 38. 423.1 (Fibrosis, pericardium) 39. 427.0 (Tachycardia, paroxysmal, supraventricular) 40. 428.32 (Failure, heart, diastolic, chronic) 41. 440.1 (Stenosis, renal artery) 42. 444.01 (Embolism, saddle [aorta]) 43. 457.2 (Lymphangitis, chronic [any site]) 44. 461.1 (Sinusitis, acute, frontal) 45. 478.5 (Abscess, vocal cord) 46. 474.02 (Adenoiditis, chronic, with chronic tonsillitis) 47. 491.21 (Bronchitis, chronic, obstructive, with exacerbation [acute]) 48. 513.0 (Abscess, lung [military] [putrid]) 49. 414.01 (Arteriosclerosis, coronary [artery], native artery); 496 (Disease,

lung, obstructive [chronic] [COPD]) 50. 112.81 (Endocarditis, candidal) 51. 482.41 (Pneumonia, due to, Staphylococcus aureus) 52. 790.7 (Findings, abnormal, without diagnosis, culture, positive, blood);

041.7 (Infection, pseudomonas) 53. 045.02 (Poliomyelitis, cerebral); 784.42 (Dysphonia) 54. 199.1 (Neoplasm, unknown site, primary, no mention of secondary

site); 789.51 (Ascites, malignant) 55. 281.0 (Anemia, progressive, malignant) 56. 291.0 (Alcohol, delirium, tremens); 303.90 (Dependence, alcohol) 57. 310.1 (Syndrome, organic personality) 58. 368.12 (Loss, vision, transient) 59. 382.9 (Otitis, media) 60. 346.40 (Migraine, menstrual) 61. 360.63 (Foreign body, lens, retained or old); V90.89 (Foreign body,

retained, specifi ed NEC) 62. 250.60 (Diabetes, mononeuropathy); 355.8 (Mononeuropathy, diabetic,

lower limb). Code in this order. 63. 008.47 (Diarrhea due to Paracolon bacillus, NEC) 64. 426.12 (Block, atrioventricular, second degree, Mobitz II) 65. 441.02 (Aneurysm, aorta, abdominal, dissecting) 66. 429.4 (Insuffi ciency, cardiac, due to presence of prosthesis); 428.0

(Insuffi ciency, cardiac); V45.81 (Status, aortocoronary bypass) 67. 443.0 (Raynaud’s, gangrene); 785.4 (Gangrene) 68. 455.2 (Hemorrhoids, internal, bleeding, prolapsed, strangulated, or

ulcerated) 69. 451.11 (Thrombophlebitis, leg, deep (vessel), femoral vein) 70. 480.9 (Pneumonia, viral, virus)



105

71. 381.62 (Obstruction, Eustachian tube (complete) (partial) cartilaginous, intrinsic)

72. 401.9 (Elevated, blood pressure) 73. 518.89 (Nodules, nodular, solitary, lung) 74. 275.01 (Hemochromatosis)

Reports 75. Report 7: 214.8 (Lipoma, muscle) 76. Report 9: 174.1 (Neoplasm, breast, central portion, Malignant Primary) 77. Report 19: 513.0 (Abscess, lung) 78. Report 20: 198.82 (Neoplasm, endometrium [gland] [stroma], secondary);

199.1 (Neoplasm, unknown site or, unspecifi ed, primary) 79. Report 34: 455.0 (Hemorrhoids, internal); 455.3 (Hemorrhoids,

external) 80. Report 39: 278.01 (Obesity, morbid); 571.8 (Fatty, liver), V85.42 (BMI,

adult, 45.0-49.0) 81. Report 42: 374.30 (Ptosis, eyelid); 368.46 (Hemianopia) 82. Report 44: 202.81 (Lymphoma; extranodal [orbit]); 375.15 (Syndrome,

dry skin, eye); V43.1 (Pseudophakia)


Practical 1. 601.0 (Prostatitis, acute); 041.00 (Infection, streptococcal NEC) in this

order 2. 528.2 (Stomatitis, aphthous) 3. 531.50 (Ulcer, stomach, with perforation [chronic]) 4. 552.3 (Hernia, hiatal, with obstruction) 5. 564.00 (Constipation) 6. 571.6 (Cirrhosis, biliary) 7. 605 (Phimosis) 8. 016.00 (Tuberculosis, pyelitis); 590.81 (Pyelitis, tuberculosis) in this

order 9. 626.0 (Amenorrhea) 10. 648.13 (Pregnancy, complicated by, thyroid dysfunction); 244.9

(Hypothyroidism, unspecifi ed [acquired]) in this order 11. 651.23 (Pregnancy, quadruplet NEC) 12. 682.7 (Cellulitis, foot); 682.6 (Cellulitis, ankle); 041.10 (Infection,

staphylococcal NEC) 13. 710.0 (Lupus, erythematosus, systemic) 14. 707.03 (Ulcer, decubitus, sacrum); 707.20 (Ulcer, pressure, stage,

unspecifi ed) in this order 15. 698.8 (Itch, winter) 16. 705.83 (Hidradenitis) 17. 556.9 (Colitis, ulcerative); 713.1 (Arthritis, due to or associated with,

colitis, ulcerative) in this order 18. 721.0 (Spondylosis, cervical, cervicodorsal) 19. 726.73 (Spur, bone, calcaneal) 20. 727.1 (Bunion) 21. 730.06 (Osteomyelitis, acute or subacute, patella); 041.10 (Infection,

staphylococcal) 22. V30.01 (Newborn, single, born in hospital, with cesarean delivery or

section); 749.20 (Cleft (congenital), palate, with cleft lip) 23. 730.15 (Osteomyelitis, chronic or old, pelvic region and thigh)



106

24. 789.1 (Hepatomegaly) 25. 784.7 (Epistaxis) 26. 791.0 (Proteinuria) 27. 787.01 (Nausea, with vomiting) 28. 783.5 (Polydipsia) 29. 969.01 (Monoamine Oxidase Inhibitors, Poisoning); 785.1 (Palpitation);

E980.3 (Poisoning, Monoamine Oxidase Inhibitors, Undetermined) 30. 810.00 (Fracture, clavicle, closed, unspecifi ed part); E887 (Fracture,

[circumstances unknown or unspecifi ed]) 31. 845.00 (Sprain, ankle) 32. 913.0 (Injury, superfi cial, elbow) 33. 941.27 (Burn, forehead, second degree) 34. 850.9 (Concussion) 35. 935.2 (Foreign body, entering through orifi ce, stomach); E915 (Foreign

body, object or material, [entrance into (accidentally)], stomach) 36. 924.01 (Contusion, hip) 37. 896.0 (Amputation, traumatic, foot) 38. 832.02 (Dislocation, elbow, posterior [closed]) 39. 887.2 (Amputation, traumatic, arm, at or above the elbow) 40. 578.9 (Bleeding, gastrointestinal); 789.00 (Cramp, abdominal, unspeci-

fi ed site); E935.6 (Poisoning, Ibuprofen, Therapeutic Use) 41. a. 564.2 (Syndrome, dumping) b. The “Excludes:” indicates that 997.4 does not include “postgastric

surgery syndromes.” 42. a. Admission for dialysis and acute renal failure b. V56.0 (Admission, for, dialysis, extracorporeal); 584.9 (Failure, renal,

acute). It was not specifi ed as “due to procedure,” so you would not assign a complication from cardiac surgery code (997.5).

43. 965.01 (Table of Drugs and Chemicals, Heroin, Poisoning); 305.50 (Abuse, opioid, unspecifi ed); E850.0 (Table of Drugs and Chemicals, Heroin, Accident)

44. a. 965.09 (Table of Drugs and Chemicals, Codeine, Poisoning); E850.2 (Table of Drugs and Chemicals, Codeine, Accident)

b. 965.4 (Table of Drugs and Chemicals, Acetaminophen, Poisoning); E850.4 (Table of Drugs and Chemicals, Acetaminophen, Accident)

c. 980.0 (Table of Drugs and Chemicals, Alcohol, Grain, Beverage, Poisoning); E860.0 (Table of Drugs and Chemicals, Alcohol, Grain, Beverage, Accident)

d. 780.79 (Lethargy) e. 787.03 (Vomiting) f. 789.00 (Cramps, abdominal) 45. 792.1 (Blood, in, feces, occult) 46. 790.7 (Bacteremia); 041.7 (Infection, pseudomonas) 47. 692.71 (Sunburn, fi rst degree); E926.2 (Sunburn) 48. 922.32 (Contusion, buttock); E885.9 (Slipping (accidental), on ice) 49. 719.56 (Stiffness, joint, knee) 50. 998.31 (Dehiscence, operation wound, internal) 51. 759.0 (Splenomegaly, congenital); 780.60 (Fever) 52. 533.40 (Ulcer, peptic, with, hemorrhage) 53. 520.6 (Impaction, tooth) 54. 569.62 (Colostomy, malfunctioning) 55. 535.40 (Gastritis, allergic); 716.90 (Arthritis, site unspecifi ed); E935.3

(Table of Drugs and Chemicals, Aspirin, Therapeutic Use) 56. 617.1 (Endometriosis, ovary); 617.3 (Endometriosis, round ligament) 57. 601.1 (Prostatitis, chronic); 041.10 (Infection, Staphylococcal) 58. 625.6 (Incontinence, urine, stress [female])



107

59. 600.00 (Hypertrophy, prostate, benign) 60. 786.50 (Pain, rib) 61. 642.41 (Pre-eclampsia); 656.81 (Pregnancy, management affected by,

fetal distress); V27.0 (Outcome of Delivery, single, liveborn) 62. 684, 373.5 (Impetigo, eyelid) 63. 710.0, 517.8 (Lupus, erythematosus, systemic, with lung involvement).

Note: Must be coded in this order. 64. 756.52 (Marble, bones) 65. 716.15 (Arthritis, traumatic, pelvic region and thigh); 905.3 (Late effect,

fracture, extremity, lower, neck of femur) 66. 715.33 (Osteoarthrosis, localized) 67. 780.09 (Unconscious, unconsciousness) 68. 883.1 (Wound, open, fi nger, complicated); E920.9 (Cut, cutting [any

part of body] [accidental]) 69. 576.8 (Jaundice, obstructive) 70. 786.09 (Distress, respiratory) 71. 789.64 (Tenderness, abdominal, left lower quadrant) 72. 733.13 (Fracture, pathologic, vertebrae [collapse]) 73. 914.6 (Injury, superfi cial, hand); E920.8 (Cut, cutting by, splinters) 74. 944.20 (Burning, hands, second degree); E899 (Burning, burn). Code 948

cannot be assigned unless the percentage is stated in the medical record. 75. 965.61 (Ibuprofen, Poisoning); E850.6 (Poisoning, Ibuprofen,

Accident) 76. 943.20 (Burns, arm(s), second degree); E924.0 (Burning, burns, hot,

liquid). Code 948 cannot be assigned unless the percentage is stated in the medical record.

77. 907.0 (Late effect [of] injury, intracranial); E989 (Late effect of, injury, undetermined whether accidentally or purposely infl icted)

78. 996.73 (Complications, due to any device, implant, or graft classifi ed to 996.0-996.5 NEC, renal dialysis)

79. 916.0 (Injury, superfi cial, leg) 80. 915.6 (Injury, superfi cial, fi nger, not infected); E920.8 (Cut, cutting by,

splinter) 81. 850.2 (Concussion, with, loss of consciousness, moderate) 82. 770.87 (Arrest, respiratory, newborn) 83. 789.06 (Pain, epigastric) 84. 790.22 (Findings, glucose, elevated, tolerance test)

Reports 85. Report 6: 709.2 (Scar) 86. Report 8: 686.9 (Fistula, skin) 87. Report 10: 952.04 (Injury, spinal [cord], cervical [C1-C4], with posterior

cord syndrome); E815.0 (Collision, motor vehicle, and other object [tree])

88. Report 11: 701.9 (Excess, skin) 89. Report 12: 707.05 (Ulcer, pressure, ischial), 707.24 (Ulcer, pressure,

necrosis). Note: The Tabular states to use additional code to identify pressure ulcer stage [707.20-707.25].

90. Report 13: 726.10 (Bursitis, shoulder) 91. Report 14: 729.1 (Myositis), V46.11 (Status, ventilator) 92. Report 15: 813.42 (Fracture, radius, lower end or extremity); E880.9

(Fall, from off, stairs, steps) 93. Report 28: 659.71 (Delivery, complicated (by), fetal heart rate or rhythm);

660.41 (Delivery, complicated (by), dystocia, shoulder girdle); 664.11 (Delivery, complicated (by), laceration, perineum, second degree)



108

94. Report 31: 211.4 (Neoplasm, intestine, large, colon, and rectum, Benign), 211.3 (Neoplasm, cecum and large intestine, Benign)

95. Report 32: 532.70 (Ulcer, duodenum, chronic) 96. Report 33: 608.83 (Fournier’s disease [idiopathic gangrene]) 97. Report 35: 536.3 (Paresis, stomach) 98. Report 36: 617.3 (Endometriosis, peritoneal [pelvic]) 99. Report 38: 788.30 (Incontinence)

100. Report 41: 721.0 (Spondylosis, cervical) 101. Report 43: 722.10 (Displacement, displaced, intervertebral disc, lumbar)

CHAPTER 13: INTRODUCTION TO THE CPT AND LEVEL II NATIONAL CODES (HCPCS)

Theory1-4. any of the following: service or procedure, anatomic site, condition or

disease, synonym, eponym, abbreviation 5. d 6. a 7. b 8. c 9. Radiology 10. Special Report 11. American Medical Association, or AMA 12. The code description has been changed, revised, or modifi ed since the

previous edition. 13. stand-alone code 14. indented code 15. CPT codes and/or HCPCS codes 16. exactly 17. 1966 18. November 19. Health Insurance Portability and Accountability Act, or HIPAA 20. modifi er -51 exempt code 21. g 22. d 23. f 24. e 25. a 26. b 27. c

PracticalRadiology 28. 77799 29. 77299 30. 77499

Pathology and Laboratory 31. 88399 32. 81099

Medicine 33. 95199 34. 96999 35. 90999



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CHAPTER 14: MODIFIERS

Theory 1. A 2. unbundling 3. preoperative services/management or preop 4. postoperative services/management or postop 5. no 6. co-surgeons

Practical 7. -50 ICD-10-CM: M71.21 (Cyst, Baker’s), M71.22 (Cyst, Baker’s) ICD-9-CM: 727.51 (Cyst, Baker’s) 8. None; residents are not paid ICD-10-CM:I25.10 (Arteriosclerosis coronary [artery]) ICD-9-CM: 414.01 [Arteriosclerosis, coronary [artery], mature artery] 9. -53 ICD-10-CM: M17.11 (Osteoarthritis, knee), I97.88 (Complication, cir-

culatory system, intraoperative), I95.89 (Hypotension, iatrogenic) ICD-9-CM: 715.96 (Osteoarthritis, lower leg), 998.9 (Complication, sur-

gical care), 458.29 (Hypotension, iatrogenic)10. -23 ICD-10-CM: S01.501A (Wound, open, lip), W18.30xA (External Cause

Index, Fall, same level, NEC), Y92.010 (External Cause Index, Place of occurrence, residence, house, single family, kitchen)

ICD-9-CM: 873.43 (Wound, open, lip), E888.9 (Fall, same level NEC), E849.0 (Index to External Causes, Accident, residence, home, private)

11. -32 ICD-10-CM: K50.10 (Enteritis, regional, large intestine) ICD-9-CM: 555.1 (Enteritis, regional, intestine, large)12. -47 ICD-10-CM: H72.90 (Perforation, tympanum, unspecifi ed ear) ICD-9-CM: 384.20 (Perforation, tympanum)13. -32 ICD-10-CM: Z02.6 (Examination, medical, insurance certifi cation) ICD-9-CM: V70.3 (Examination, medical, insurance certifi cation) 14. -78 15. -76 16. -50 17. -99 18. -22 Note: You would not use -63 modifi er because this patient weighed

more than 4 kg (8.8 lb). 19. -55 20. -80 21. -FA 22. -E1

CHAPTER 15: EVALUATION AND MANAGEMENT (E/M) SERVICES

Theory 1. c 2. f 3. a 4. g 5. e



110

6. d 7. b 8. h 9. high 10. moderate 11. low 12. straightforward 13. elements 14. high severity 15. moderate severity 16. low severity 17. self-limited/minor severity 18. minimal severity 19. contributory 20. face-to-face or direct, unit/fl oor 21. medical record 22. counseling 23. subjective 24. emergency 25. consultation, attending 26. critical care 27. concurrent 28. transfer of care 29. review of systems 30. no

PracticalOffi ce or Other Outpatient Services and Hospital Inpatient Services31. a. minimal, minimal/none b. minimal c. straightforward d. 99201 32. 99217 (Evaluation and Management, Hospital Services, Observation

Care) ICD-10-CM: Z04.3 (Encounter [for], observation), V29.9xxA (External

Cause Index, Accident, transport, motorcycle) ICD-9-CM: V71.4 (Admission for, observation, accident), E819.2 (Index

to External Causes, Accident, motor vehicle) 33. 99219 (Evaluation and Management, Hospital Services, Observation

Care) 34. 99221 (Hospital Services, Inpatient Services, Initial Hospital Care) ICD-10-CM: B27.90 (Mononucleosis), E86.0 (Dehydration) ICD-9-CM: 075 (Mononucleosis, infection), 276.51 (Dehydration) 35. 99223 (Hospital Services, Inpatient Services, Initial Hospital Care) ICD-10-CM: I21.19 (Infarct, myocardium, inferior [wall]), I25.10 (Arte-

riosclerosis, coronary [artery], native artery), Z98.61 (Status, angioplasty, coronary artery)

ICD-9-CM: 410.41 (Infarct, myocardial, inferior wall), 414.01 (Arterio-sclerosis, coronary, native artery), V45.82 (Status, percutaneous translu-minal angioplasty)

36. 99214 (Evaluation and Management, Offi ce and Other Outpatient) ICD-10-CM: L40.9 (Psoriasis), M25.50 (Pain, joint) ICD-9-CM: 696.1 (Psoriasis); 719.40 (Pain, joint) 37. 99231 (Hospital Services, Inpatient Services, Subsequent Hospital Care) ICD-10-CM: J15.9 (Pneumonia, bacterial) ICD-9-CM: 482.9 (Pneumonia, bacterial)



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38. 99201 (Evaluation and Management, Offi ce and Other Outpatient) ICD-10-CM: I10 (Hypertension, Benign) ICD-9-CM: 401.1 (Hypertension, Benign)

Consultation Services 39. 99243 (Consultation, Offi ce and/or Other Outpatient) ICD-10-CM: R10 (Pain, pelvic [female]), N94.1 (Dyspareunia [female]) ICD-9-CM: 625.9 (Pain, pelvic [female], 625.0 (dyspareunia [female]) Note: All three key components must be met for the service to qualify

for the higher level code. In this case, only the MDM complexity was of a higher level, requiring the choice of the lower level code.

40. 99244 (Consultation, Offi ce and/or other Outpatient) ICD-10-CM: G89.21 (Pain, chronic, due to, injury), M54.5 (Pain, low,

back) ICD-9-CM: 338.21 (Pain, chronic, due to, trauma), 724.2 (Pain, back,

low) 41. 99253 (New Patient, Inpatient Consultations) 42. 99252 (New Patient, Inpatient Consultations) ICD-10-CM: J15.20 (Pneumonia, staphylococcal) ICD-9-CM: 482.40 (Pneumonia, staphylococcal) 43. 99232 (Hospital Inpatient Services, Subsequent Hospital Care) ICD-10-CM: R21 (Rash) ICD-9-CM: 782.1 (Rash) Note that adverse effect from a drug would not be reported as the physi-

cian is looking for another cause. 44. 99242 (Consultation, Offi ce and/or Other Outpatient, New or Estab-

lished Patient) ICD-10-CM: H70.10 (Mastoiditis, chronic, unspecifi ed ear) ICD-9-CM: 383.1 (Mastoiditis, chronic) 45. 99231 (Hospital Inpatient Services, Subsequent Hospital Care) ICD-10-CM: G44.209 (Headache, tension) ICD-9-CM: 307.81 (Headache, tension) 46. 99251 (Consultation, Inpatient, New or Established Patient) ICD-10-CM: E11.9 (Diabetes, diabetic) ICD-9-CM: 250.00 (Diabetes, diabetic) The consultant was asked to render an opinion on diabetes which he

confi rmed. 47. 99241 (Consultation, Offi ce and/or Other Outpatient, New or Estab-

lished Patient) ICD-10-CM: K41.91 (Hernia, femoral, recurrent) ICD-9-CM: 553.01 (Hernia, femoral, unilateral, recurrent) 48. 99254 (New Patient, Inpatient Consultations) ICD-10-CM: J12.1 (Pneumonia, due to, respiratory syncytial virus) ICD-9-CM: 480.1 (Pneumonia, due to, respiratory syncytial virus) 49. 99245-32 (Consultation, Offi ce and/or Other Outpatient, New or Estab-

lished Patient) ICD-10-CM: M51.06 (Disorder, disc, with myelopathy, lumbar region) ICD-9-CM: 722.73 (Myelopathy, due to or with, intervertebral disc

disorder, lumbar, lumbosacral)

Emergency Department Services, Nursing Facility, Domiciliary, and Home Services 50. 99285 (Emergency Department Services) 51. 99282 (Emergency Department Services) ICD-10-CM: S52.539A (Colles, fracture), W22.09xA (External Cause

Index, Striking against, object, stationary), Y93.64 (External Cause Index, Activity, baseball)



112

ICD-9-CM: 813.41 (Colles’ fracture [closed]), E927.0 (Index to External Causes, Overexertion, from, sudden strenuous movement), E007.9 (Index to External Causes, Activity, sports played as a team or group NEC)

52. 99318 (Nursing Facility Services, Annual Assessments) ICD-10-CM: F03 (Dementia, senile), E11.9 (Diabetes), I10 (Hypertension,

unspecifi ed), E03.9 (Hypothyroidism), G45.8 (Ischemia, cerebral, transient)

ICD-9-CM: 290.0 (Dementia, senile), 250.00 (Diabetes), 401.9 (Hypertension, unspecifi ed), 244.9 (Hypothyroidism), 435.9 (Ischemia, cerebral, transient).

Note: All three key components must be met. 53. 99342 (Home Services, New Patient) ICD-10-CM: R60.0 (Edema, legs) ICD-9-CM: 782.3 (Edema, legs) Note that the leg pain is not reported because the medical documentation

indicated that the pain was due to the edema. 54. 99307 (Nursing Facility Services, Subsequent Care) ICD-10-CM: G30.9, F02.80 (Disease, Alzheimer’s) ICD-9-CM: 331.0, 294.10 (Dementia, due to, Alzheimer’s, without

behavioral disturbance) 55. 99309 (Nursing Facility Services, Subsequent Care) ICD-10-CM: R41.0 (Confusion), R42 (Dizziness), I69.30 (Sequelae,

infarction, cerebral) ICD-9-CM: 298.9 (Confusion), 780.4 (Dizziness), 438.9 (Late effect(s),

cerebrovascular disease) 56. 99334 (Domiciliary Services, Established Patient) ICD-10-CM: L97.411 (Ulcer, lower limb, heel, right heel, with skin

breakdown only), L97.511 (Ulcer, lower limb, foot specifi ed NEC, with skin breakdown only)

ICD-9-CM: 707.14 (Ulcer, heel and midfoot) 57. 99324 (Domiciliary Services, New Patient)

Prolonged Services and Preventive Medicine Services 58. 99215 for the offi ce visit (Offi ce and/or Other Outpatient Services,

Established Patient) and 99354 and 99355 � 2 for the Prolonged Services (Prolonged Services). Note: 99215 is for the 40 minutes of initial offi ce service and 99354 and 99355 are for the additional 110 minutes.

59. 99205 for the offi ce visit (Offi ce and/or Other Outpatient Services, New Patient) and 99354 and 99355 for Prolonged Services (Prolonged Services)

60. 99396 (Preventive Medicine, Established Patient)

Services from Throughout the E/M Section 61. 99205 (Offi ce and/or Other Outpatient Services, Offi ce Visit, New

Patient) 62. 99202 (Offi ce and/or Other Outpatient Services, Offi ce Visit, New

Patient) ICD-10-CM: J02.9 (Pharyngitis) ICD-9-CM: 462 (Pharyngitis) 63. 99234 (Discharge Services, Observation Care) ICD-10-CM: T39.8x5A (Table of Drugs and Chemicals, Analgesic NEC,

Adverse Effect), L29.9 (Pruritus), R06.02 (Short, breath) ICD-9-CM: 698.9 (Pruritus), 786.05 (Short, breath), E935.9 (Table of

Drugs and Chemicals, Analgesics, External Cause, Therapeutic) 64. 99238 (Discharge Services, Hospital) ICD-10-CM: E86.0 (Dehydration), E87.1 (Hyponatremia) ICD-9-CM: 276.51 (Dehydration), 276.1 (Hyponatremia) 65. 99251 (Consultation, Inpatient)



113

66. 99318 (Nursing Facility, Services, Annual Assessment) ICD-10-CM: I10 (Hypertension, Unspecifi ed), E11.9 (Diabetes) ICD-9-CM: 401.9 (Hypertension, Unspecifi ed), 250.00 (Diabetes) 67. 99291 (Critical Care Services, Evaluation and Management), 99292 � 3 (Critical Care Services, Evaluation and Management) ICD-10-CM: J96.0 (Respiratory, failure, acute), I50.9 (Failure, heart),

J44.1 (Disease, pulmonary chronic obstructive, exacerbation, [acute]), Z99.11 (Dependence, on, ventilator)

ICD-9-CM: 518.81 (Respiratory, failure, acute), 428.0 (Failure, heart), 491.21 (Disease, pulmonary, with, exacerbation NEC [acute]), V46.11 (Status, ventilator)

68. 99397 (Preventive Medicine, Established Patient) ICD-10-CM: Z00.00 (Checkup, health) ICD-9-CM: V70.0 (Checkup, health)

Reports 69. Report 1: 99283 (Evaluation and Management, Emergency Department) ICD-10-CM: O23.40 (Infection, urinary, complicating pregnancy,

unspecifi ed trimester), N39.0 (Infection, urinary [tract]), R60.0 (Edema, legs)

ICD-9-CM: 646.63 (Infection, urinary, complicating pregnancy), 599.0 (Infection, urinary [tract]), 782.3 (Edema, legs)

70. Report 2: 99239 (Discharge Services, Hospital) ICD-10-CM: C79.89 (Neoplasm, pelvic, Malignant Secondary), C80.1

(Neoplasm, unknown site or unspecifi ed, Malignant Primary) I87.1 (Syndrome, vena cava), T82.898A (Complication, catheter, intravenous infusion, specifi ed type NEC), I10 (Hypertension), M79.2 (Neuralgia)

ICD-9-CM: 198.89 (Neoplasm, pelvic, Malignant, Secondary), 199.1 (Neoplasm, unknown, Malignant, Primary), 459.2 (Syndrome, vena cava), 996.74 (Complications, due to, catheter, vascular NEC), 401.9 (Hypertension), 729.2 (Pain, nerve)

71. Report 3: 99212 (Evaluation and Management, Offi ce and Other Outpatient)

ICD-10-CM: S93.409 (Sprain, ankle) ICD-9-CM: 845.00 (Sprain, ankle) 72. Report 4: 99221 (Evaluation and Management, Hospital) 73. Report 5: 99232 (Evaluation and Management, Hospital)

CHAPTER 16: ANESTHESIA

Theory 1. moderate sedation or conscious sedation 2. certifi ed registered nurse anesthetist 3. base unit 4. modifying 5. preoperative services 6. postoperative services 7. conversion 8. -QX

Practical 9. P4 (A patient with severe systemic disease that is a constant threat to life) 10. P1 (A normal, healthy patient) 11. P3 (A patient with severe systemic disease) 12. P6 (A declared brain-dead patient whose organs are being removed for

donor purposes)



114

13. P2 (A patient with mild systemic disease) 14. P5 (A moribund patient who is not expected to survive without the

operation) 15. 01382 (Anesthesia, Knee) 16. 00846 (Anesthesia, Hysterectomy, Radical) 17. 00144 (Anesthesia, Corneal Transplant) 18. 01961 (Anesthesia, Cesarean Delivery) 19. 00124 (Anesthesia, Otoscopy) 20. 00914 (Anesthesia, Transurethral Procedures) 21. 01920-P2 (Anesthesia, Cardiac Catheterization) 22. 00120-P1 (Anesthesia, Myringotomy) 23. ICD-10-CM: K57.93 (Diverticulitis, intestine, bleeding) ICD-9-CM: 562.13 (Diverticulitis, with hemorrhage) 24. ICD-10-CM: I25.810 (Arteriosclerosis, bypass graft) ICD-9-CM: 414.04 (Arteriosclerosis, bypass graft, autologous artery 25. ICD-10-CM: E05.01 (Hyperthyroidism, with goiter) ICD-9-CM: 242.01 (Goiter, toxic) 26. ICD-10-CM: I34.0 (Regurgitation, mitral valve), T50.5x5A (Adverse

effect, appetite depressants) ICD-9-CM: 424.0 (Insuffi ciency, mitral), 909.0 (Late, effects, poisoning

due to drug)

Reports 27. Report 7: 00400 (Anesthesia, Arm) 28. Report 41: 00670 (Anesthesia, Spinal Instrumentation) 29. Report 44: 00140 (Anesthesia, Eye) 30. Report 83: 00930 (Anesthesia, Testis)

CHAPTER 17: SURGERY GUIDELINES AND GENERAL SURGERY

Theory 1. Female Genital 2. Guidelines 3. categories 4. followed 5. unlisted 6. special 7. major 8. no, only the mastectomy. But if only a biopsy was planned and based

on the result, a mastectomy was performed later in the day—you may report the mastectomy with modifi er -58 and also the biopsy.

9. yes 10. follow-up 11. local 12. exacerbation 13. general 14. global or postoperative 15. 99070 16. A4550 17. same 18. a 19. dehiscence 20. False

Practical 21. 10021-69990 22. Urinary



115

1. b 2. d 3. i 4. g 5. a 6. j 7. f 8. h or e 9. c 10. e or h 11. a

12. d 13. i 14. g 15. c 16. h 17. e 18. b 19. f 20. b 21. d 22. a

23. Operating 24. image guidance or imaging guidance 25. 42400 26. separate procedure 27. therapeutic 28. 59000-59899 29. 40799 30. 53899

CHAPTER 18: INTEGUMENTARY SYSTEM

TheoryIntegumentary System Terminology

Practical 23. 12032 (Repair, Wound, Intermediate), 99070 (Special Services, Supply

of Materials) ICD-10-CM: S41.101A (Wound, open, arm, [upper]) ICD-9-CM: 884.0 (Wound, open, arm) Note: You do not report an E/M code because this is an established

patient and the treatment constitutes the main service provided to the patient.

24. 12016 (Repair, Wound, Simple), 99070 (Special Services, Supply of Materials) Surgical Tray

ICD-10-CM: S01.409A (Wound, open, cheek [external]) ICD-9-CM: 873.41 (Wound, open, cheek) Note: You do not report an E/M code because this is an established

patient and the treatment constitutes the main service provided to the patient.

25. 19102-LT (Breast, Biopsy), 99070 (Special Services, Supply of Materials) ICD-10-CM: D48.62 (Neoplasm, breast, female, unspecifi ed site, left site,

Uncertain Behavior) ICD-9-CM: 238.3 (Neoplasm, breast, Uncertain Behavior) Note: You do not report an E/M code because this is an established patient

and the treatment constitutes the main service provided to the patient. 26. 99024 (Surgical, Services, Post-Op Visit) ICD-10-CM: Z09 (Examination follow-up, surgery NEC) ICD-9-CM: V67.00 (Follow-up, surgery) 27. 11451 (Hidradenitis, Excision) ICD-10-CM: L73.2 (Hidradenitis) ICD-9-CM: 705.83 (Hidradenitis) 28. 11043 (Debridement, Muscle) ICD-10-CM: E11.621 (Diabetes, type 2, with foot ulcer), L97.503

(Ulcer, lower limb, foot specifi ed NEC, with, muscle necrosis) ICD-9-CM: 250.81, 707.15 (Ulcer, diabetes, lower limb, foot)



116

29. 11971 (Removal, Tissue Expanders, Skin) 30. 11772 (Excision, Cyst, Pilonidal) ICD-10-CM: L05.01 (Cyst, pilonidal, with, abscess) ICD-9-CM: 685.0 (Cyst, pilonidal, with abscess) 31. 11976 (Removal, Contraceptive Capsules) ICD-10-CM: Z30.49 (Contraception, contraceptive device, initial

prescription) ICD-9-CM: V25.5 (Insertion, subdermal implantable contraceptive) 32. 11720 (Debridement, Nails) ICD-10-CM: B35.1 (Onychomycosis [fi nger] [toe]) ICD-9-CM: 110.1 (Onychomycosis, fi nger) 33. 11444 (Excision, Skin, Lesion, Benign) for 4 cm face lesion, 11423-51

(Excision, Skin, Lesion, Benign) for 3 cm neck lesion ICD-10-CM: D23.30 (Neoplasm, skin, face, benign), D23.4 (Neoplasm,

skin, neck, Benign) ICD-9-CM: 216.3 (Neoplasm, skin, face, Benign), 216.4 (Neoplasm,

skin, neck, Benign) 34. 11643 (Excision, Skin, Lesion, Malignant) for 2.5 cm lip lesion, 11602-

51 � 2 (Excision, Skin, Lesion, Malignant) for two 1.5 cm chest lesions ICD-10-CM: C44.0 (Neoplasm, skin, lip, Malignant Primary), C44.5

(Neoplasm, chest [wall] NEC, Malignant Primary) ICD-9-CM: 173.00 (Neoplasm, lip, skin, Malignant, Primary), 173.50

(Neoplasm, skin, chest [wall], Malignant, Primary) 35. 17000 (Destruction, Lesion, Facial), 17003 � 2 (Destruction, Lesion,

Facial) ICD-10-CM: L57.0 (Keratosis, actinic) ICD-9-CM: 702.0 (Keratosis, actinic) 36. 17284 (Destruction, Lesion, Skin, Malignant) ICD-10-CM: C44.10 (Neoplasm, skin, eyelid, Malignant Primary) ICD-9-CM: 173.10 (Neoplasm, skin, eyelid, Malignant, Primary) 37. 12035 (Wound, Repair, Intermediate); 11042-51 (Debridement,

Subcutaneous Tissue) ICD-10-CM: S81.801A (Wound, open, leg, multiple), W09.1xxA

(External Cause Index, Fall, from, off, playground equipment), W27.1xxA (External Cause Index, Cut, by, garden fork), Y92.830 (External Cause Index, Place of occurrence, park [public])

ICD-9-CM: 891.0 (Wound, open, leg), E884.0 (Index to External Causes, Fall, from, off, playground equipment), E920.4 (Index to External Causes, Contact with, garden, fork), E004.9 (Index to External Causes, Climbing), E849.4 (Index to External Causes, Accident, occurring, park)

38. 17271 (Destruction, Lesion, Skin, Malignant) ICD-10-CM: C44.4 (Neoplasm, skin, neck, Malignant, Primary) ICD-9-CM: 173.40 (Neoplasm, skin, neck, Malignant, Primary) 39. 17110 (Destruction, Warts, Flat) ICD-10-CM: B07.8 (Wart, Flat) ICD-9-CM: 078.19 (Wart) 40. 17276 � 2 (Destruction, Lesion, Skin, Malignant) (for 5.2 and 4.3

lesion of hands); 17274-51 (Destruction, Lesion, Skin, Malignant) (for 3.4 lesion of hand); 17273-51 (Skin, Destruction, Malignant Lesions) (for 2.1 lesion of hand), 17280-51 � 2 (Destruction, Lesion, Skin, Malignant) (for the 0.3 and 0.05 lesions of eyelid)

ICD-10-CM: C44.61, C44.62 (Neoplasm, skin, hand, Malignant, Primary), C44.12, C44.11 (Neoplasm, skin, eyelid, Malignant, Primary).

ICD-9-CM: 173.60 (Neoplasm, skin, hand, Malignant, Primary), 173.10 (Neoplasm, skin, eyelid, Malignant, Primary).



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Note: The skin is not a paired organ; therefore, -LT and -RT are not used. Note: There are two sets of codes for each diagnosis because the neoplasm chart confl icts with the Tabular for these codes.

41. 11000, 11001 (Debridement, Skin, Eczematous) ICD-10-CM: L30.9 (Eczema) ICD-9-CM: 692.9 (Eczema) 42. 15822, 15822-50 (Blepharoplasty) ICD-10-CM: H02.403 (Blepharoptosis) ICD-9-CM: 374.30 (Ptosis, eyelid) 43. 16000 (Burns, Initial Treatment) ICD-10-CM: T23.169A (Burn, hand, back, fi rst degree, unspecifi ed

hand), T31.0 (Burn, extent, less than 10 percent), X16.xxxA (External Cause Index, Burning, steam, pipe), Y92.00 (External Cause Index, Accident, occurring, house, private)

ICD-9-CM: 944.16 (Burn, hand, back, fi rst degree), 948.00 (Burn, extent, less than 10 percent); E924.8 (Index to External Causes, Burning, steam, pipe), E849.0 (Index to External Causes, Accident, occurring, home, private)

44. 17313 (Mohs Micrographic Surgery) ICD-10-CM: C44.60 (Neoplasm, skin, arm, Malignant Primary) ICD-9-CM: 173.60 (Neoplasm, skin, arm, Malignant, Primary) 45. 19020 (Mastotomy) ICD-10-CM: N61 (Abscess, breast) ICD-9-CM: 611.0 (Abscess, breast)

Reports 46. Report 6: 11423 (Excision, Lesion, Skin, Benign) ICD-10-CM: L90.5 (Scar) ICD-9-CM: 709.2 (Scar) 47. Report 7: 21554 (Excision, Tumor, Thorax) ICD-10-CM: D17.39 (Lipoma, skin, specifi ed site) ICD-9-CM: 214.8 (Lipoma) Note: 11406 because the report indicates “dissected free of the muscle.” 48. Report 8: 11042 (Debridement, Subcutaneous Tissue) ICD-10-CM: L98.8 (Fistula, skin) ICD-9-CM: 686.9 (Fistula, skin) 49. Report 9: 19120-RT (Excision, Breast, Lesion) ICD-10-CM: C50.111 (Neoplasm, breast, female, central portion,

Malignant Primary) ICD-9-CM: 174.1 (Neoplasm, breast, central portion, Malignant,

Primary) 50. Report 11: 15839 (Excision, Skin, Excess) ICD-10-CM: L91.8 (Excess, skin) ICD-9-CM: 701.9 (Excess, skin) 51. Report 12: 15940 (Ulcer, Pressure) ICD-10-CM: L89.224 (Ulcer, pressure, hip) ICD-9-CM: 707.04 (Ulcer, pressure, hip), 707.24 (Ulcer, pressure,

stage, IV) Note: Modifi er -22 may be added to 15940 due to the extensive size of

the ulcer.



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CHAPTER 19: MUSCULOSKELETAL SYSTEM

TheoryMusculoskeletal Terminology 1. d 2. f 3. j 4. i 5. b 6. e

7. c 8. a 9. h 10. k 11. g

Answer the Following 12. yes 13. aspiration of a joint 14. a device that has two or more pins inserted above a fracture and two or

more below a fracture on only one surface and is used to stabilize the fracture (or similar wording)

15. fascia lata graft 16. electric or ultrasound 17. arthroscopy 18. strapping 19. No, the removal is part of the cast service 20. skin traction 21. The primary difference is extent. The codes in the musculoskeletal

system subsection are of biopsies of deep subcutaneous tissue, muscle, and/or bone, whereas the codes in the integumentary system subsection are for skin and subcutaneous tissue.

Practical 22. 29345-58 (Cast, Long Leg) ICD-10-CM: Z46.89 (Admission/Encounter, for, orthopedic [cast]),

S82.90xD (Fracture, leg [lower]) ICD-9-CM: V53.7 (Admission [Encounter], for, fi tting of, orthopedic,

cast), V54.16 (Aftercare, fracture, healing, traumatic, leg, lower) (The fracture is healing, and the patient was seen solely for cast change)

23. 29075 (Cast, Short Arm) ICD-10-CM: Z46.89 (Admission/Encounter, for, orthopedic [cast]),

S52.119D (Fracture, forearm) ICD-9-CM: V53.7 (Admission [Encounter], for, fi tting of, orthopedic

[cast]), V54.12 (Aftercare, fracture, traumatic, arm, lower) 24. 29883 (Arthroscopy, Surgical, Knee) ICD-10-CM: S83.219A (Tear, torn, knee cartilage, medial, bucket

handle), S83.259A (Tear, torn, knee cartilage, medial, bucket-handle), W00.0xxA (External Cause Index, Slipping on ice)

ICD-9-CM: 836.0 (Tear, meniscus, medial), 836.1 (Tear, meniscus, lateral), E889.5 (Index to External Causes, Slipping, on, ice). Note: The diagnostic arthroscopy is included in the surgical repair.

25. 28406 (Fracture, Calcaneus, with Manipulation) ICD-10-CM: S92.009A (Fracture, tarsal, calcaneus) ICD-9-CM: 825.0 (Fracture, calcaneus [closed]) 26. 27193 (Fracture, Pelvic Ring, Closed Treatment) ICD-10-CM: S32.89xA (Fracture, pelvis, specifi ed site NEC) ICD-9-CM: 808.49 (Fracture, pelvis, rim [closed]) 27. 26700 (Metacarpophalangeal Joint, Dislocation, Closed Treatment) ICD-10-CM: S63.269A (Dislocation, fi nger) ICD-9-CM: 834.01 (Dislocation, fi nger, metacarpal, distal end)



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28. 27253 (Dislocation, Hip Joint, Open Treatment) ICD-10-CM: S73.033A (Dislocation, hip, anterior) ICD-9-CM: 835.03 (Dislocation, hip, anterior) 29. 27520 (Fracture, Patella, Closed Treatment, without Manipulation) ICD-10-CM: S82.009A (Fracture, patella) ICD-9-CM: 822.0 (Fracture, knee cap, closed) 30. 27560 (Dislocation, Patella, Closed Treatment) ICD-10-CM: S83.006A (Dislocation, patella) ICD-9-CM: 836.3 (Dislocation, patella [closed]) 31. 27570 (Manipulation, Knee) ICD-10-CM: S83.116A (Dislocation, knee, proximal tibia, anterior) ICD-9-CM: 836.61 (Dislocation, tibia, proximal, anterior, open) 32. 28540 (Dislocation, Tarsal, Closed Treatment) ICD-10-CM: S93.316A (Dislocation, foot, tarsal joint) ICD-9-CM: 838.01 (Dislocation, tarsal) 33. 21343 (Sinuses, Frontal, Fracture, Open Treatment) 34. 21422 (Fracture, Maxilla, Open Treatment) 35. 20615 (Aspiration, Cyst, Bone) 36. 20680 (Removal, Fixation Device) 37. 20822 (Replantation, Digit) 38. 20910 (Graft, Cartilage, Harvesting) 39. 20526 (Injection, Carpal Tunnel, Therapeutic) ICD-10-CM: G56.00 (Syndrome, carpal tunnel) ICD-9-CM: 354.0 (Carpal tunnel syndrome) 40. 20610 (Aspiration, Joint) 41. 20665 (Removal, Halo) 42. No code, as the removal is a part of the cast service 43. 21450 (Fracture, Mandible, Closed Treatment, without Manipulation) 44. 29035 (Cast, Body Cast, Upper Body Only) 45. 29750 (Cast, Wedging) 46. 29515 (Splint, Leg, Short) 47. 29520 (Strapping, Hip) 48. 29105 (Splint, Arm, Long) 49. 29200 (Strapping, Thorax) 50. 29804 (Arthroscopy, Surgical, Temporomandibular Joint) 51. 29049 (Cast, Shoulder) 52. 29837 (Arthroscopy, Surgical, Elbow) 53. 29860 (Arthroscopy, Diagnostic, Hip) 54. 29882 (Arthroscopy, Surgical, Knee) 55. 29877 (Arthroscopy, Surgical, Knee) 56. 29893 (Fasciotomy, Plantar, Endoscopic) 57. 29848 (Ligament, Release, Transverse Carpal) 58. 20612 (Aspiration, Ganglion Cyst) ICD-10-CM: M67.48 (Ganglion, specifi ed site) ICD-9-CM: 727.41 (Ganglion, joint) 59. 21032 (Excision, Maxillary, Torus Palatinus)

Reports 60. Report 10: 20661 (Halo, Cranial) ICD-10-CM: S14.151A (Injury, spinal [cord], cervical [neck], posterior

cord syndrome, C1 level), S12.000A (Fracture, traumatic, neck, cervical vertebra, fi rst), V47.02xA (External Cause Index, Accident, transport, car occupant, driver, collision [with], stationary object, non-traffi c)

ICD-9-CM: 806.08 (Fracture, vertebra, vertebral, spinal cord injury [closed], cervical); E815.0 (Index to External Causes, Collision, motor vehicle, tree)



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61. Report 13: 20610-LT (Injection, Joint) ICD-10-CM: M75.12 (Syndrome, rotator cuff, left shoulder) ICD-9-CM: 726.10 (Syndrome, rotator cuff, shoulder) 62. Report 14: 20205 (Biopsy, Muscle) ICD-10-CM: M60.9 (Myositis), Z99.11 (Dependence, on ventilator) ICD-9-CM: 729.1 (Myositis), V46.11 (Status, respiratory, ventilator) 63. Report 15: 25606-LT (Fracture, Radius, Distal) ICD-10-CM: S52.509A (Fracture, radius, closed, distal end, unspecifi ed) ICD-9-CM: 813.42 (Fracture, radius [closed], lower end or extremity

[distal end]) 64. Report 16: 29881 or 29881-RT (Arthroscopy, Surgical, Knee) ICD-10-CM: M23.221 (Derangement, knee, meniscus, due to old tear

or injury, medial posterior horn), M94.261 (Chondromalacia, knee) ICD-9-CM: 717.2 (Tear, meniscus, medial, posterior horn, old);

717.7 (Chondromalacia, knee) 65. Report 17: 27244 or 27244-RT (Fracture, Femur, Intertrochanteric,

Plate/Screw Implant) ICD-10-CM: S72.141A (Fracture, hip, closed, intertrochanteric section,

right hip, initial encounter), S72.21xA (Fracture, hip, closed, subtro-chanteric section, right hip, initial encounter)

ICD-9-CM: 820.21 (Fracture, femur [closed], neck, intertrochanteric); 820.22 (Fracture, femur [closed], subtrochanteric)

66. Report 18: 24685 or 24685-RT (Fracture, Ulna, Olecranon, Open Treatment)

ICD-10-CM: S52.024A (Fracture, closed, olecranon process of ulna, right ulna, initial episode)

ICD-9-CM: 813.01 (Fracture [closed], olecranon)

CHAPTER 20: RESPIRATORY SYSTEM

TheoryRespiratory Terminology 1. d 2. h 3. k 4. o 5. b 6. n

7. c 8. g 9. f 10. p 11. m 12. i

13. a 14. l 15. e 16. j

Answer the Following 17. nasal button 18. rhinoplasty 19. septoplasty 20. ablation 21. posterior 22. lavage 23. transtracheal and cricothyroid 24. no, procedures are bundled, the chest tube (32551) is a separate

procedure and bundled into the thoracotomy 25. 50 26. bilobectomy

Practical 27. 31267 (Antrostomy, Sinus, Maxillary) 28. 31511 (Laryngoscopy, Indirect)



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29. 31628-RT (Bronchoscopy, Biopsy), 31632-RT (Bronchoscopy, Biopsy). Note: Code 31628 is for a single lobe and two lobes were biopsied. Code 31632 is an add-on code reporting the biopsy of the additional lobe.

30. 31623 (Bronchoscopy, Brushing/Protected Brushing) 31. 31575 (Laryngoscopy, Fiberoptic) 32. 30100 (Biopsy, Nose, Intranasal) 33. 30801 (Ablation, Turbinate Mucosa). Note: Code specifi ed unilateral

or bilateral. 34. 30400 (Rhinoplasty, Primary) 35. 30115 and 30115-50 (Excision, Nose, Polyp) 36. 30220 (Insertion, Prosthesis, Nasal Septal) 37. 31536 (Laryngoscopy, Direct) 38. 31611 (Voice Button) 39. 31400 (Arytenoidectomy) 40. 31579 (Laryngoscopy, Fiberoptic, with Stroboscopy) 41. 31720 (Aspiration, Trachea, Nasotracheal) 42. 31750 (Tracheoplasty, Cervical) 43. 31830 (Revision, Tracheostomy, Scar) 44. 32420 (Pneumocentesis, Lung) 45. 32658 (Thoracoscopy, Surgical) 46. 32854 (Transplantation, Lung, Double, with Cardiopulmonary

Bypass) 47. 32800 (Hernia Repair, Lung) 48. 32815 (Fistula, Bronchi, Repair) 49. 30930 (Fracture, Nasal Turbinate, Therapeutic) ICD-10-CM: S02.2xxA (Fracture, closed, nasal bones, initial episode) ICD-9-CM: 802.0 (Fracture, nose, nasal, [bone][septum][closed]) 50. 31050 (Sinusotomy, Sphenoid Sinus) ICD-10-CM: J01.30 (Sinusitis, sphenoidal, acute) ICD-9-CM: 461.3 (Sinusitis, sphenoidal, acute) 51. 31613 (Tracheostoma, Revision) ICD-10-CM: J95.02 (Tracheostomy, complication, infection), L03.221

(Cellulitis, neck) ICD-9-CM: 519.01 (Tracheostomy [complication], infection), 682.1

(Cellulitis of neck) 52. 31625 (Bronchoscopy, Biopsy) ICD-10-CM: R05 (Cough [chronic]) ICD-9-CM: 786.2 (Cough, chronic) 53. 32440 (Pneumonectomy) ICD-10-CM: J61 (Asbestosis [occupational]) ICD-9-CM: 501 (Asbestosis [occupational]) 54. 32604 (Thoracoscopy, Diagnostic, with Biopsy) ICD-10-CM: I09.2 (Pericarditis, chronic, rheumatic) ICD-9-CM: 393 (Pericarditis, chronic, rheumatic) 55. 32900 (Resection, Ribs) ICD-10-CM: Q76.6 (Deformity, rib, congenital) ICD-9-CM: 756.3 (Deformity, rib, congenital) 56. 31766 (Reconstruction, Trachea, Carina) ICD-10-CM: C34.90 (Neoplasm, lung, Malignant Primary) ICD-9-CM: 162.9 (Neoplasm, lung, Malignant, Primary) 57. 32560 (Pleurodesis) ICD-10-CM: J91.0 (Effusion, pleura, malignant) ICD-9-CM: 511.81 (Effusion, pleura, malignant) 58. 30125 (Excision, Cyst, Nose) ICD-10-CM: D36.7 (Neoplasm, nose, nasally, Benign) ICD-9-CM: 229.8 (Neoplasm, nose, Benign)



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Reports 59. Report 19: 32480-LT (Lobectomy, Lung) ICD-10-CM: J85.2 (Abscess, lung) ICD-9-CM: 513.0 (Abscess, lung) 60. Report 21: 31624 (Lung, Lavage, Bronchial), 31623-51 (Bronchial

Brushings/-Protected Brushing) ICD-10-CM: D38.1 (Neoplasm, lung, lower lobe, left side, Uncertain

behavior) ICD-9-CM: 235.7 (Neoplasm, lung, Uncertain behavior) Note: Third-party payers may require the brushings not be reported

separately. 61. Report 23: 32421 (Thoracentesis) ICD-10-CM: J90 (Effusion, pleura) ICD-9-CM: 511.9 (Effusion, pleural) 62. Report 24: 31625 (Bronchoscopy, Biopsy), 31623-51 (Bronchoscopy,

Brushing/Protected Brushing) ICD-10-CM: J18.9 (Pneumonia) ICD-9-CM: 486 (Pneumonia) Note: Third-party payers may require the brushings not be reported

separately.

CHAPTER 21: CARDIOVASCULAR SYSTEM

TheoryCardiovascular Terminology 1. e 2. g 3. b 4. j 5. d 6. h 7. a 8. k 9. i 10. c 11. f 12. c 13. j

14. f 15. d 16. k 17. i 18. a 19. h 20. g 21. n 22. m 23. b 24. e 25. l

Answer the Following 26. pericardiocentesis 27. internally or externally, or intracardiac or external 28. pacemaker and cardioverter-defi brillator 29. epicardial and transvenous 30. 78 31. no, suture removal is bundled into the pacemaker procedure 32. yes (because the service is unrelated to the implantation) 33. 24 34. aortic, mitral, tricuspid, and pulmonary 35. patient-activated event recorder 36. coronary 37. reversible 38. irreversible 39. embolus 40. contrast material



123

Practical 41. 33403 (Valvuloplasty, Aortic Valve) 42. 33405 (Replacement, Aortic Valve) 43. 33464 (Valvuloplasty, Tricuspid Valve) 44. 33501 (Coronary Artery, Repair) 45. 93000 (Electrocardiography, Evaluation) 46. 92960 (Cardioversion) 47. 92982 (Angioplasty, Coronary Artery, Percutaneous Transluminal) 48. 92950 (CPR, Cardiopulmonary Resuscitation) 49. 93010 (Electrocardiography, Evaluation) 50. 35601 (Bypass Graft, Carotid Artery) 51. 37609 (Ligation, Artery, Temporal) 52. 37660 (Ligation, Vein, Iliac) 53. 35452 (Angioplasty, Aorta, Intraoperative) 54. 33533 (Bypass Graft, Coronary Artery, Arterial) ICD-10-CM: I25.811 (Atherosclerosis, coronary, artery, transplanted

heart) ICD-9-CM: 414.06 (Atherosclerosis, coronary [artery], native artery,

transplanted heart) 55. 33513 (Bypass Graft, Coronary Artery, Venous Graft) ICD-10-CM: I24.8 (Disease, ischemic heart, coronary) ICD-9-CM: 411.89 (Disease, heart, ischemic acute, without myocardial

infarction) 56. 35251 (Repair, Blood Vessel, Abdomen, with Vein Graft) ICD-10-CM: S35.10xA (Injury, vena cava, other) ICD-9-CM: 902.11 (Injury, blood vessel, hepatic, vein) 57. 33967 (Balloon Assisted Device, Aorta) ICD-10-CM: I21.3 (Infarction, myocardium, myocardial [acute]), R57.0

(Shock, cardiogenic) ICD-9-CM: 410.91 (Infarction myocardium myocardial), 785.51 (Shock,

cardiogenic) 58. 35190 (Repair, Arteriovenous Fistula, Lower Extremity, Acquired or

Traumatic) ICD-10-CM: S85.999A (Injury, blood vessel, Leg) ICD-9-CM: 904.8 (Fistula, traumatic, blood vessel, unspecifi ed) 59. 33641 (Heart, Repair, Atrial Septum) ICD-10-CM: Q21.1 (Defect, septal, acquired [atrial]) ICD-9-CM: 429.71 (Defect, atrial septal, acquired) 60. 33822 (Ductus Arteriosus, Repair) ICD-10-CM: Q25.0 (Patent, ductus arteriosus) ICD-9-CM: 747.0 (Patent, ductus arteriosus) 61. 33533 (Bypass Graft, Coronary Artery, Arterial), 33517 (Coronary

Artery Bypass Graft, Arterial-Venous), 33530 (Reoperation, Coronary Artery Bypass, Valve Procedure)

ICD-10-CM: I25.10 (Arteriosclerosis, coronary, artery) ICD-9-CM: 414.01 (Arteriosclerosis, coronary, artery, native artery)

Reports 62. Report 25: 93458-26 (Heart, Catheterization) ICD-10-CM: I25.10 (Arteriosclerosis, coronary, artery), R07.9 (Pains,

chest), R94.30 (Abnormal, function studies, cardiovascular) ICD-9-CM: 414.01 (Arteriosclerosis, coronary, artery, native artery);

786.50 (Pains, chest), 794.30 (Abnormal, function studies, cardiovascular) 63. Report 26: 33533 (Coronary Artery Bypass Graft [CABG], Arterial) ICD-10-CM: I25.10 (Arteriosclerosis, coronary, artery), I51.9 (Dysfunc-

tion, ventricular)



124

ICD-9-CM: 414.01 (Arteriosclerosis, coronary, artery, native artery), 429.9 (Dysfunction, ventricular)

64. Report 27: 35301 (Thromboendarterectomy, Carotid Artery), 95955-26 (Electroencephalography, Intraoperative)

ICD-10-CM: I65.21 (Occlusion, artery, carotid) ICD-9-CM: 433.10 (Narrowing, artery, carotid)

CHAPTER 22: HEMIC, LYMPHATIC, MEDIASTINUM, AND DIAPHRAGM

TheoryHemic and Lymphatic Terminology 1. k 2. b 3. e 4. f 5. g 6. a 7. d 8. h 9. i 10. j

11. c 12. l 13. f 14. g 15. b 16. a 17. h 18. d 19. c 20. e

21. m 22. c 23. j 24. f 25. d 26. h 27. l

28. a 29. k 30. i 31. g 32. e 33. b

Mediastinum and Diaphragm Terminology

Practical 34. 38792-RT (Injection, Sentinel Node Identifi cation) ICD-10-CM: C50.11 (Neoplasm, breast, central portion, right side,

Malignant Primary) ICD-9-CM: 174.1 (Neoplasm, breast, central portion, Malignant,

Primary) 35. 38720 (Lymphadenectomy, Radical, Cervical) ICD-10-CM: C77.0 (Neoplasm, lymph, gland, cervical, Malignant,

Secondary), C50.012 (Neoplasm, breast, nipple, Malignant Primary) ICD-9-CM: 196.0 (Neoplasm, lymph, gland, cervical, Malignant,

Secondary); 174.0 (Neoplasm, breast, nipple, Malignant, Primary) Note: The lymph gland neoplasm is fi rst-listed because it was the reason

for the procedure. 36. 38305 (Abscess, Lymph Node, Incision and Drainage) ICD-10-CM: L04.9 (Lymphadenitis, acute), A49.0 (Infection, staphylo-

coccal NEC) ICD-9-CM: 683 (Abscess, lymph); 041.10 (Infection, staphylococcal

NEC) 37. 38241 (Bone Marrow, T-Cell Transplantation) ICD-10-CM: C92.00 (Leukemia, myelogenous, acute) ICD-9-CM: 205.00 (Leukemia, myelogenous, acute). Fifth digit “0” is

added to indicate the leukemia is not in remission.



125

38. 38101 (Splenectomy, Partial) ICD-10-CM: D57.219 (Disease, sickle-cell, Hb-C, with, crisis) ICD-9-CM: 282.64 (Disease, sickle-cell, Hb-C, with, crisis) 39. 38230 (Harvesting, Bone Marrow) ICD-10-CM: Z52.3 (Donor, bone, marrow) ICD-9-CM: V59.3 (Donor, bone, marrow) 40. 39501 (Repair, Diaphragm, Laceration) 41. 39200 (Resection, Cyst, Mediastinal) 42. 39560 (Resection, Diaphragm) 43. 38209 (Transplantation, Stem Cells, Washing) 44. 38120 (Laparoscopy, Splenectomy) 45. 78195-26 (Nuclear Medicine, Lymph Nodes), 38792-59 (Lymphadenec-

tomy, Injection), 38530 (Excision, Lymph Nodes)

Report 46. Report 89: 38120 (Splenectomy, Laparoscopic) ICD-10-CM: S36.029A (Injury, spleen, unspecifi ed, initial encounter),

W50.10xA (External Cause Index, Accident, kicked by person, football game, initial encounter), Y93.61 (External Cause Index, Activity, Football)

ICD-9-CM: 865.01 (Hematoma, spleen), E917.0 (Index to External Causes, Kicked by, person, in sports)

CHAPTER 23: DIGESTIVE SYSTEM

TheoryDigestive Terminology 1. b 2. d 3. f 4. c 5. g 6. h

7. a 8. e 9. i 10. b 11. i 12. g

13. e 14. c 15. h 16. f 17. a 18. d

Practical 19. 43215 (Endoscopy, Esophagus, Removal, Foreign Body) 20. 42665 (Ligation, Salivary Duct) 21. 43401 (Esophagus, Repair, Varices) 22. 44020 (Intestines, Small, Biopsy) 23. 44345 (Colostomy, Revision, Paracolostomy, Hernia) 24. 40806 (Frenotomy) 25. 42104 (Excision, Lesion, Palate) 26. 42809 (Removal, Foreign Body, Pharynx) 27. 42831 (Adenoids, Excision) 28. 44141 (Colectomy, Partial, with Colostomy) 29. 49521 (Repair, Hernia, Inguinal) 30. 43770 (Laparoscopy, Gastric Restrictive Procedures) 31. 40650 (Repair, Lip) 32. 41250 (Repair, Tongue, Laceration) 33. 42507 (Parotid Duct, Diversion) 34. 43282 (Fundoplasty, paraesophageal) 35. 43605 (Biopsy, Stomach) 36. 44310 (Ileostomy) 37. 44604 (Suture, Intestines, Large, Wound)



126

38. 46040 (Incision and Drainage, Abscess, Rectum) 39. 49320 (Laparoscopy, Diagnostic) 40. 45380 (Colonoscopy, Biopsy) ICD-10-CM: K63.5 (Polyp, colon), Z12.11 (Screening, neoplasm

[malignant] [of], colon) ICD-9-CM: 211.3 (Polyps, polypous, colon), V76.51 (Screening,

malignant neoplasm [of], colon) 41. 99284-25 (Evaluation and Management, Emergency Department),

43752 (Tube Placement, Nasogastric Tube) ICD-10-CM: K92.0 (Hematemesis), R18.8 (Ascites [abdominal]),

D62 (Anemia, due to, blood loss, acute) ICD-9-CM: 578.0 (Hematemesis), 789.59 (Ascites), 285.1 (Anemia,

due to, blood loss, acute)

Reports 42. Report 22: 42821 (Tonsils, Excision, with Adenoids) ICD-10-CM: J35.03 (Adenoiditis, chronic, with chronic tonsillitis) ICD-9-CM: 474.02 (Adenoiditis, chronic, with tonsillitis) 43. Report 31: 45384 (Colonoscopy, Removal, Polyp) ICD-10-CM: K63.5 (Polyp, colon) ICD-9-CM: 211.3 (Neoplasm, intestine, colon, Benign) Note: The entry listed under “Neoplasm, intestine, cecum, Benign”

indicates 211.3, the same code as for the benign polyp of the colon and the code is only reported once.

44. Report 32: 43632 (Gastrectomy, Partial, with Gastrojejunostomy), 43635 (Vagotomy, with Partial Distal Gastrectomy), 47605-51 (Cholecystectomy, Any Method, with Cholangiography)

ICD-10-CM: K26.5 (Ulcer, duodenum, chronic, with perforation), K81.1 (Cholecystitis, chronic)

ICD-9-CM: 532.50 (Ulcer, duodenum, chronic, with perforation), 575.11 (Cholecystitis, chronic)

Note: Code 47605 includes the surgeon’s service of the injection for the cholangiogram. The hospital would report 74300, intraoperative cholangiography, for the facility fee. The surgeon would not report the radiology service 74300 (Cholangiography, Intraoperative), and 47605 included a cholangiography. The exploratory laparotomy is bundled into the major surgical procedure. Also note that 43635 is an add-on code and therefore does not require modifi er -51.

45. Report 33: 44143 (Hartmann Procedure, Open), 43500-51 (Gastrot-omy), 43830 (Gastrostomy, temporary)

ICD-10-CM: N49.3 (Disease, Fournier’s); T18.2xxA (Foreign body, entering through orifi ce, stomach)

ICD-9-CM: 608.83 (Fournier’s disease, idiopathic gangrene), 935.2 (Foreign body, entering through, orifi ce, stomach)

46. Report 34: 46260 (Hemorrhoidectomy Complex) ICD-10-CM: I84.23 (Hemorrhoid, external, with internal) ICD-9-CM: 455.3 (Hemorrhoid, external), 455.0 (Hemorrhoid, internal) 47. Report 35: 43752 (Orogastric Tube Placement) ICD-10-CM: K31.89 (Gastroparesis) ICD-9-CM: 536.3 (Gastroparesis) 48. Report 39: 43644 (Laparoscopy, Gastric Restrictive Procedures), 47001

(Biopsy, Liver) ICD-10-CM: E66.01 (Obesity, morbid), K76.0 (Fatty, liver), Z68.4

(BMI, adult, 40.0 and over) ICD-9-CM: 278.01 (Obesity, morbid), 571.8 (Fatty, liver), V85.42

(BMI, adult, 45.0–49.9)



127

CHAPTER 24: URINARY AND MALE GENITAL SYSTEMS

TheoryUrinary System Terminology 1. d 2. j 3. g 4. a 5. f 6. b 7. k 8. e 9. c 10. i 11. l 12. h

13. i 14. g 15. a 16. k 17. d 18. j 19. f 20. c 21. b 22. l 23. h 24. e

25. c 26. d 27. e 28. f 29. b 30. a 31. d 32. g 33. e 34. h 35. f 36. b 37. i 38. a 39. c 40. d 41. c

42. e 43. a 44. b 45. f 46. f 47. a 48. b 49. d 50. c 51. e 52. f 53. a 54. b 55. d 56. e 57. c

Male Genital Terminology

Practical 58. 50562 (Endoscopy, Kidney, via Stoma) ICD-10-CM: C65.9 (Neoplasm, kidney, pelvis, Malignant Primary) ICD-9-CM: 189.1 (Neoplasm, kidney, pelvis, Malignant, Primary) 59. 50390 (Aspiration, Cyst, Kidney) ICD-10-CM: N28.1 (Cyst, kidney, solitary, acquired) ICD-9-CM: 593.2 (Cyst, kidney, solitary) 60. 50760 (Ureteroureterostomy) ICD-10-CM: N13.9 (Obstruction, urinary, organ or tract) ICD-9-CM: 599.60 (Obstruction, urinary, organ or tract) 61. 52450 (Incision, Prostate, Transurethral) ICD-10-CM: N41.1 (Prostatitis, hypertrophic) ICD-9-CM: 600.00 (Prostatitis, hypertrophic) 62. 52000 (Cystourethroscopy) ICD-10-CM: N02.9 (Hematuria, intermittent) ICD-9-CM: 599.70 (Hematuria, intermittent) 63. 54650-50 (Orchiopexy, Abdominal Approach) ICD-10-CM: Q53.21 (Nondescent, testicles, bilateral, abdominal) ICD-9-CM: 752.51 (Undescended, testis)



128

64. 55720 (Prostatotomy) ICD-10-CM: N42.89 (Cyst, prostate) ICD-9-CM: 600.3 (Cyst, prostate) 65. 50520 (Fistula, Kidney) 66. 52283 (Urethral, Stricture, Injection, Steroids) 67. 53215 (Urethrectomy, Total, Male) 68. 54150-52 (Circumcision, Surgical Excision, Newborn) ICD-10-CM: Z41.2 (Circumcision [routine]) ICD-9-CM: V50.2 (Circumcision, routine) 69. 53270 (Skene’s Gland, Excision) 70. 54420 (Priapism, Repair, with Shunt) 71. 55400 (Vasovasorrhaphy) 72. 55860 (Prostate, Exploration, Exposure) 73. 54600 (Repair, Testis, Torsion) 74. 54322 (MAGPI Operation) 75. 54056 (Destruction, Lesion, Penis, Cryosurgery) 76. 54163 (Circumcision, Repair) 77. 55100 (Abscess, Scrotum, Incision and Drainage) 78. 50650 (Ureterectomy)

Reports 79. Report 36: 52332-50 or 52332-RT and 52332-LT (Cystourethroscopy,

Insertion, Indwelling Ureteral Stent) 80. Report 37: 52204 (Cystourethroscopy, Biopsy) ICD-10-CM: C67.9 (Neoplasm, bladder, Malignant Primary) ICD-9-CM: 188.9 (Neoplasm, bladder, Malignant, Primary) 81. Report 38: 53445 (Insertion, Prosthesis, Urethral Sphincter) ICD-10-CM: R32 (Incontinence), Z85.46 (History, personal, malignant

neoplasm, prostate) ICD-9-CM: 788.30 (Incontinence), V10.46 (History, personal, malig-

nant neoplasm, prostate) 82. Report 81: 55875 (Prostate, Brachytherapy, Needle Insertion), 77778

(Interstitial Radiation Source Application, Complex), 76965-26 (Ultra-sound, Guidance, Radioelement)

83. Report 82: 52630 (Transurethral Procedure, Prostate, Resection) 84. Report 83: 54640-LT (Orchiopexy, Inguinal Approach) ICD-10-CM: Q53.01 (Ectopic, testis, unilateral) ICD-9-CM: 752.51 (Ectopic, testis) 85. Report 84: 53852 (Transurethral Procedure, Prostate, Thermotherapy,

Radiofrequency), 76872 (Ultrasound, rectal)

CHAPTER 25: REPRODUCTIVE, INTERSEX SURGERY, FEMALE GENITAL SYSTEM, AND MATERNITY CARE AND DELIVERY

TheoryFemale Genital Terminology 1. d 2. k 3. h 4. l 5. b 6. e 7. m

8. g 9. c 10. i 11. j 12. a 13. f



129

Maternity Care and Delivery Terminology 14. d 15. e 16. b 17. g 18. c 19. f 20. a 21. j 22. q 23. l 24. h 25. o 26. k 27. i 28. m 29. n 30. p 31. introitus 32. colpotomy 33. colpocentesis 34. pessary 35. False 36. colporrhaphy 37. colposcope 38. general 39. loop electrode excision procedure 40. sampling 41. hysterectomy 42. True 43. Radiology 44. diagnostic 45. Oviduct/Ovary 46. transection, ligation or occlusion (blocking with a device) 47. trimesters 48. 12, 13, 28 49. estimated date (of) delivery 50. ripening 51. E/M 52. postpartum

Practical 53. 57400 (Dilation, Vagina) 54. 57230 (Repair, Urethra, Urethrocele) 55. 56441 (Adhesions, Labial, Lysis) 56. 56625 (Vulvectomy, Simple, Complete) 57. 58558 (Hysteroscopy, Surgical with Biopsy) 58. 58825 (Transposition, Ovary) 59. 58920 (Ovary, Wedge Resection) 60. 59001 (Amniocentesis, Urine, with Amniotic Fluid Reduction) 61. 58800 (Cyst, Ovarian, Incision and Drainage) 62. 59821 (Abortion, Missed, Second Trimester) 63. 59514 (Cesarean Delivery, Delivery Only) 64. 59350 (Hysterorrhaphy) 65. 59020 (Fetal Contraction Stress Test) 66. 58285 (Hysterectomy, Vaginal, Radical)



130

67. 56440 (Marsupialization, Bartholin’s Gland, Cyst) 68. 56740 (Excision, Bartholin’s Gland) 69. 57065 (Destruction, Lesion, Vagina, Extensive)

Reports 70. Report 20: 58100 (Biopsy, Endometrium) ICD-10-CM: C79.82 (Neoplasm, endocervix, Malignant Secondary),

C80.1 (Neoplasm, unknown site or unspecifi ed, Malignant Primary) ICD-9-CM: 198.82 (Neoplasm, endocervix, Malignant, Secondary),

199.1 (Neoplasm, unknown site, Malignant, Primary) 71. Report 28: 59409 (Vaginal Delivery, Delivery Only) ICD-10-CM: O76 (Delivery, complicated by, fetal, heart rate or rhythm),

O66.0 (Delivery, complicated. by, obstruction, due to, dystocia, shoulder), O70.1 (Delivery, complicated, laceration, perineum, second degree), Z37.0 (Outcome of delivery, single liveborn).

ICD-9-CM: 669.51 (Delivery, vacuum extractor), 659.71 (Delivery, fetal, heart rate or rhythm), 652.81 (Delivery, complicated, shoulder, presen-tation), 664.11 (Delivery, complicated, laceration, perineum, second degree, delivered), V27.0 (Outcome of delivery, single liveborn)

Note: You report the delivery only because by reading this note you have no idea if the delivering physician was her regular obstetrician before and after delivery care.

72. Report 29: 59514 (Cesarean Delivery, Only), 58611 (Tubal Ligation, with Cesarean Delivery)

ICD-10-CM: 034.21 (Delivery, previous, cesarean section), Z30.2 (Encounter [for], sterilization), Z37.0 (Outcome of delivery, single liveborn)

ICD-9-CM: 654.21 (Delivery, previous, cesarean delivery, section), V25.2 (Sterilization, admission for), V27.0 (Outcome of delivery, single liveborn)

Note: 58611 is “not a separate procedure,” rather an add-on code, which means it is reported in addition to a major procedure, in this case a cesarean delivery.

73. Report 30: 59000 (Amniocentesis) ICD-10-CM: O41.8x90 (Pregnancy, complicated by, disorder of, amniotic

fl uid and membranes, specifi ed NEC), O09.299 (History of, obstetrical disorder, affecting management of current, pregnancy); Z36 (Screening; antenatal, of mother; based on amniocentesis), Z87.49 (History, personal, disorder, urinary system, specifi ed NEC), Z87.59 (History, personal [of], obstetric complications)

ICD-9-CM: 762.9 (Abnormal, amnion, affecting fetus or newborn), V28.89 (Screening, antenatal, of mother, specifi ed condition), V23.49 (History of, obstetrical disorder, affecting management of current, preg-nancy), V28.2 (Screening, antenatal, of mother; based on amniocente-sis), V13.09 (History, personal, disorder, urinary system, specifi ed NEC)

CHAPTER 26: ENDOCRINE AND NERVOUS SYSTEMS

TheoryEndocrine System Terminology 1. c 2. i 3. f 4. k 5. d 6. j



131

7. g 8. a 9. h 10. e 11. b

Nervous System Terminology 12. c 13. g 14. a 15. h 16. f

17. b 18. e 19. d 20. i

1. a 2. f 3. b 4. e 5. c 6. g 7. d 8. h

9. i 10. j 11. g 12. c 13. k 14. l 15. f 16. b

17. d 18. a 19. h 20. e 21. j 22. i

Practical 21. 60000 (Thyroid Gland, Cyst, Incision and Drainage) 22. 62256 (Removal, Shunt, Brain) 23. 64840 (Suture, Nerve) 24. 64520 (Sympathetic Nerve, Injection, Anesthetic) 25. 64831 (Neurorrhaphy), 69990 (Operating Microscope) 26. 63685 (Insertion, Pulse Generator, Spinal Cord) 27. 62311 (Injection, Spinal Cord, Anesthetic) 28. 61321 (Craniotomy, Surgery) 29. 61619 (Skull Base Surgery, Dura, Repair of Cerebrospinal Fluid Leak) 30. 62223 (Shunt, Brain, Creation) 31. 63030 (Hemilaminectomy), 63035 (Hemilaminectomy)

Reports 32. Report 41: 22551-LT (Arthrodesis, Cervical Anterior, with Discectomy),

22552 (Arthrodesis, Cervical Anterior, with Discectomy), 22845 (Instrumentation, Spinal, Insertion), 20931 (Allograft, Spine Surgery, Structural), 95925 (Evoked Potential, Somatosensory Testing)

ICD-10-CM: M47.812 (Spondylosis, without myelopathy or radiculopa-thy, cervical region)

ICD-9-CM: 721.0 (Spondylosis, cervical) 33. Report 43: 63030-RT (Hemilaminectomy) ICD-10-CM: M51.17 (Displacement, intervertebral disc, [with neuritis,

radiculitis, sciatica, or other pain] lumbar) ICD-9-CM: 722.10 (Displacement, intervertebral disc, [with neuritis,

radiculitis, sciatica, or other pain], lumbar)

CHAPTER 27: EYE, OCULAR ADNEXA, AUDITORY, AND OPERATING MICROSCOPE

TheoryEye and Ocular Adnexa Terminology



132

Auditory System Terminology 23. g 24. m 25. n 26. f 27. h 28. b 29. i 30. e

31. k 32. o 33. a 34. j 35. c 36. d 37. l

1. c 2. e 3. b 4. f 5. a 6. d 7. b 8. e 9. f 10. c 11. a

12. d 13. e 14. d 15. i 16. b 17. h 18. a 19. j 20. g 21. c 22. f

Practical 38. 68020 � 2, or 68020-50 or 68020-RT and 68020-LT (Incision and

Drainage, Cyst, Conjunctiva) ICD-10-CM: H11.443 (Cyst, conjunctival, bilateral) ICD-9-CM: 372.75 (Cyst, conjunctival) 39. 67570-RT (Decompression, Optic Nerve) 40. 67938-E1 (Removal, Foreign Body, Eyelid) ICD-10-CM: T15.10xA (Foreign body, conjunctival sac) ICD-9-CM: 930.1 (Foreign body, eyelid) 41. 69620-LT (Myringoplasty) 42. 69320-RT (Reconstruction, Auditory Canal, External) ICD-10-CM: Q16.1 (Atresia, auditory canal [external]) ICD-9-CM: 744.02 (Atresia, auditory canal, [external]) 43. 69661-LT (Stapedectomy, with Footplate Drill Out) 44. 68520-LT (Excision, Lacrimal Sac)

Reports 45. Report 85: 66720-RT (Glaucoma, Cryotherapy) ICD-10-CM: H40.10 (Glaucoma, open-angle) ICD-9-CM: 365.10 (Glaucoma, open-angle); 365.73 (Glaucoma, severe

stage) 46. Report 86: 65930-RT (Removal, Blood Clot, Eye) 47. Report 87: 66984-RT (Cataract, Removal/Extraction, Extracapsular) 48. Report 88: 65220-RT (Removal, Foreign Body, Cornea, without Slit Lamp)

CHAPTER 28: RADIOLOGY

Theory

Practical 23. 78499 (Nuclear Medicine, Heart, Unlisted Services and Procedures) 24. 92974 (Coronary Artery, Placement, Radiation Delivery Device).

Note: This is an add-on code and cannot be reported alone. 25. -26



133

26. -TC 27. 75705 (Angiography, Spinal Artery) 28. 70030 (X-Ray, Eye) 29. 70130 (X-Ray, Mastoids) 30. 71100 (X-Ray, Ribs) 31. 70542 (Magnetic Resonance Imaging [MRI], Neck) 32. 72128 (CT Scan, without Contrast, Spine, Thoracic) 33. 73510 (X-Ray, Hip) 34. 73110 (X-Ray, Wrist) 35. 76098 (X-Ray, Specimen/Surgical) 36. 99213 (Evaluation and Management, Offi ce and other Outpatient),

70460 (CT Scan, with Contrast, Brain) 37. 99219 for initial observation care (Evaluation and Management, Hospital

Services, Observation Care); 70450 for CT Scan without mention of contrast (CT Scan, without Contrast), 76516 for A-scan (Ultrasound, Eye, Biometry); 77261 for therapeutic radiation (Radiation Therapy, Planning); 77402 for radiation delivery of single treatment area (Radiation Therapy, Treatment Delivery, Single); 77427 for weekly radiology therapy manage-ment (Radiation Therapy, Treatment Delivery, Weekly)

38. 99242 (Evaluation and Management, Consultation), 70492 (CT Scan, without and with Contrast, Neck)

39. 76604 (Ultrasound, Chest); 71550 for the MRI (Magnetic Resonance Imaging, Chest); 33020 for the pericardiotomy (Pericardiotomy, Removal, Clot)

40. 73600 (X-Ray, Ankle) 41. 73092 (X-Ray, Arm, Upper) 42. 75741 (Angiography, Pulmonary) 43. 77002 (Fluoroscopy, Needle Biopsy) 44. 77011 (CT Scan, Guidance, Localization) 45. 76872 (Ultrasound, Rectal) 46. 72110 (X-Ray, Spine, Lumbosacral) 47. 72240 (Myelography, Spine, Cervical) 48. 77057 (Mammography, Screening) 49. 70140 (X-Ray, Facial Bones) 50. 70328 (X-Ray, Temporomandibular Joint [TMJ]) 51. 74010 (X-Ray, Abdomen) 52. 74340 (X-Ray, Gastrointestinal Tract, Guide Intubation) 53. 75870 (Venography, Sagittal Sinus) ICD-10-CM: G08 (Thrombosis, sinus, intracranial) ICD-9-CM: 325 (Thrombosis, sinus, intracranial) 54. 76390 (Magnetic Resonance Imaging, Spectroscopy) ICD-10-CM: D32.0 (Neoplasm, meninges, Benign) ICD-9-CM: 225.2 (Neoplasm, meninges, Benign) 55. 75945 (Ultrasound, Non-Coronary, Intravascular) ICD-10-CM: I70.1 (Stenosis, artery, renal) ICD-9-CM: 440.1 (Stenosis, artery, renal) 56. 75820 (Venography, Arm) ICD-10-CM: N18.6 (Disease, renal, end stage), Z99.2 (Status [post],

dialysis) ICD-9-CM: 585.6 (Disease, renal, end stage), V45.11 (Status, hemodial-

ysis)

Reports 57. Report 45: 71010 (X-Ray, Chest) ICD-10-CM: R07.9 (Pain, chest) ICD-9-CM: 786.50 (Pain, chest)



134

58. Report 46: 76819-26 (Fetal Testing, Ultrasound) ICD-10-CM: Q16.3 (Hypertension, complicating pregnancy, unspecifi ed

trimester) ICD-9-CM: 642.93 (Hypertension, complicating pregnancy) 59. Report 47: 70480-26 (CT Scan, without Contrast, Orbit) ICD-10-CM: H57.10 (Pain, eye, unspecifi ed) ICD-9-CM: 379.91 (Pain[s], ocular) 60. Report 48: 70544-26 (Magnetic Resonance Angiography, Head) ICD-10-CM: H49.00 (Disorder, nerve, third, complete) ICD-9-CM: 378.52 (Disorder, nerve, third, complete) 61. Report 49: 74000-26 (X-Ray, Abdomen) ICD-10-CM: E46 (Malnutrition) ICD-9-CM: 263.9 (Malnutrition) 62. Report 50: 73620-26-LT or 73620-26 (X-Ray, Foot) ICD-10-CM: M79.662 (Pain[s], limb, lower, leg) ICD-9-CM: 729.5 (Pain, foot) 63. Report 51: 74160-26 (CT, with Contrast, Abdomen) ICD-10-CM: R94.5 (Findings, abnormal, inconclusive, function

study, liver) ICD-9-CM: 790.5 (Findings, abnormal, function study, liver) 64. Report 52: 78582-26 (Lung, Nuclear Medicine, Imaging, Perfusion) ICD-10-CM: R06.02 (Shortness, breath) ICD-9-CM: 786.05 (Shortness, breath) 65. Report 53: 78451-26 (Myocardial, Perfusion Imaging) ICD-10-CM: R07.9 (Pain[s], chest), R06.02 (Shortness, breath) ICD-9-CM: 786.50 (Pain, chest), 786.05 (Shortness, breath)

CHAPTER 29: PATHOLOGY/LABORATORY

Theory 1. Surgery 2. presence 3. presence, amount or amount, presence 4. physician supplied agent or supplied agent or agent 5. section 6. 6 7. one

Practical 8. 82550 (CPK, Blood), 82553 (Creatine), 84484 (Troponin, Quantitative) ICD-10-CM: I21.19 (Infarct, myocardium, inferior wall, initial episode) ICD-9-CM: 410.41 (Infarct, myocardium, inferior wall, initial episode) 9. 84520 (Urea Nitrogen, Quantitative), 84295 (Sodium), 84132 (Potas-

sium), 82565 (Creatinine, Blood), 84550 (Uric Acid, Blood) ICD-10-CM: E86.0 (Dehydration), M25.50 (Pain, joint, unspecifi ed),

R50.9 (Fever) ICD-9-CM: 276.51 (Dehydration), 719.40 (Pain, joint), 780.60 (Fever) Note: The Blood Urea Nitrogen (BUN) is part of the blood chemistry

for this patient, and there are two codes for blood as the source of the sample—84520 and 84525. Although there are other CPT codes to identify urea nitrogen, the source of the sample for those codes is the urine (84540, 84545).

10. 83735 (Magnesium), 83540 (Iron), 84100 (Phosphorus), 84155 (Protein, Total)

ICD-10-CM: I12.9 (Hypertensive, kidney), N19 (Failure, renal), D64.9 (anemia)



135

ICD-9-CM: 403.90 (Hypertension, kidney, unspecifi ed), 586 (Failure, renal), 285.9 (anemia)

11. 80076 (Blood Tests, Panels, Hepatic Function), 80061 (Blood Tests, Panels, Lipid Panel)

ICD-10-CM: E78.5 (Hyperlipidemia) ICD-9-CM: 272.4 (Hyperlipidemia) 12. 80198 (Theophylline, Assay) ICD-10-CM: J45.909 (Asthma, unspecifi ed) ICD-9-CM: 493.90 (Asthma, unspecifi ed) 13. 80162 (Digoxin, Assay) ICD-10-CM: I48.0 (Fibrillation, atrial) ICD-9-CM: 427.31 (Fibrillation, atrial)

Reports 14. Report 54: 88305 Endometrium (Pathology, Surgical, Gross and Micro

Exam, Level IV) ICD-10-CM: C79.82 (Neoplasm, endometrium, Malignant Secondary),

C80.1 (Neoplasm, unknown site or unspecifi ed, Malignant Primary) ICD-9-CM: 198.82 (Neoplasm, endometrium, Malignant, Secondary),

199.1 (Neoplasm, unknown site or unspecifi ed, Malignant, Primary) 15. Report 55: 88305 Urinary Bladder (Pathology, Surgical, Gross and Micro

Exam, Level IV) ICD-10-CM: D09.0 (Neoplasm, bladder, Malignant Ca in-situ) ICD-9-CM: 233.7 (Neoplasm, bladder, Malignant, Ca in situ) 16. Report 56: 88305 � 3 Colon Polyp (Pathology, Surgical, Gross and

Micro Exam, Level IV) ICD-10-CM: K63.5 (Polyp[s], colon) ICD-9-CM: 211.3 (Polyp[s], colon) 17. Report 57: 88304 Intervertebral Disc (Pathology, Surgical, Gross and

Micro Exam, Level III) ICD-10-CM: M51.26 (Displacement, intervertebral disc, lumbar region) ICD-9-CM: 722.10 (Displacement, intervertebral disc, lumbar, lumbosacral) 18. Report 58: 88305 � 2 Colon Polyp and Esophagus (Pathology, Surgical,

Gross and Micro Exam, Level IV) ICD-10-CM: K63.5 (Polyp[s], colon), K22.70 (Barrett’s esophagus) ICD-9-CM: 211.3 (Polyp[s], colon), 530.85 (Barrett’s esophagus) 19. Report 59: 88305 Muscle (Pathology, Surgical, Gross and Micro Exam,

Level IV) ICD-10-CM: M62.50 (Atrophy, muscle) ICD-9-CM: 728.2 (Atrophy, muscle, muscular) 20. Report 60: 88304 Soft Tissue, Lipoma (Pathology, Surgical, Gross and

Micro Exam, Level III) ICD-10-CM: D17.7 (Lipoma) ICD-9-CM: 214.8 (Lipoma) 21. Report 61: 88304 Skin Cyst (Pathology, Surgical, Gross and Micro Exam,

Level III) ICD-10-CM: L72.9 (Cyst, skin) ICD-9-CM: 706.2 (Cyst, skin) 22. Report 62: 88305 Skin (Pathology, urgical, Gross and Micro Exam, Level IV) ICD-10-CM: L89.224 (Ulcer, pressure, hip) ICD-9-CM: 707.04 (Ulcer, pressure, hip), 707.20 (Ulcer, pressure, stage) 23. Report 63: 88307 Liver (Pathology, Surgical, Gross and Micro Exam,

Level V) ICD-10-CM: E66.01 (Obesity, morbid), K76.0 (Fatty, liver) ICD-9-CM: 278.01 (Obesity, morbid); 571.8 (Fatty, liver)



136

24. Report 64: 88304 Skin Cyst (Pathology, Surgical, Gross and Micro Exam, Level III)

ICD-10-CM: L72.8 (Cyst, follicular, skin) ICD-9-CM: 704.41 (Cyst, pilar) 25. Report 65: 88309 Lung Lobe (Pathology, Surgical, Gross and Micro

Exam, Level VI) ICD-10-CM: J85.2 (Abscess, lung) ICD-9-CM: 513.0 (Abscess, lung) 26. Report 66: 88104 (Cytopathology, Fluids, Washings, Brushings) ICD-10-CM: J98.11 (Atelectasis) ICD-9-CM: 518.0 (Atelectasis) 27. Report 67: 88104 (Cytopathology, Fluids, Washings, Brushings) ICD-10-CM: J90 (Effusion, pleura) ICD-9-CM: 511.9 (Effusion, pleura)

CHAPTER 30: MEDICINE

Theory 1. m 2. j 3. h 4. d 5. n 6. f 7. i 8. c 9. g 10. b 11. l 12. k 13. a 14. e 15. g 16. d 17. f 18. e 19. a 20. b 21. c 22. vibrating or moving at certain frequencies 23. hearing test 24. procedure for evaluating middle ear disorders 25. stimulation of the cochlea to measure electrical activity 26. corrective or in the correct place 27. studying the capillaries of the eyes 28. measurement of the retina to the stimulation of light 29. a device for detecting color blindness 30. absence of the lens of the eye 31. cornea and sclera together forming one organ 32. transparent front window of the eye that serves as the major refractive

surface 33. the thick outer coat of the eye, mostly white and opaque

Practical 34. 95125 (Allergen Immunotherapy, Allergen, Prescription/Supply/Injection) 35. 95052 � 2 (Allergy Tests, Patch, Photo Patch)



137

36. 92326 (Contact Lens Services, Replacement) 37. 92341 (Spectacle Services, Fitting, Spectacles) 38. 92270 (Electro Oculography) 39. 92534 (Nystagmus Tests, Optokinetic) 40. 92542 (Nystagmus Tests, Positional) 41. 91034 (Esophagus, Acid Refl ux Tests) 42. 90947 (Dialysis, Peritoneal) 43. 90880 (Hypnotherapy) 44. 91030 (Acid Perfusion Test, Esophagus) 45. 92626 (Rehabilitation, Auditory, Status Evaluation) 46. 90846 (Psychotherapy, Family) 47. 90940 (Hemodialysis, Blood Flow Study) 48. 92553 (Audiometry, Pure Tone) 49. 93503 (Catheterization, Cardiac, Flow Directed) 50. 93282 (Analysis, Electronic, Evaluation of Programming) ICD-10-CM: I49.5 (Syndrome, sick, sinus) ICD-9-CM: 427.81 (Syndrome, sick, sinus) 51. 94003 (Ventilation Assist) ICD-10-CM: J96.0 (Failure, respiration, respiratory, acute) ICD-9-CM: 518.81 (Failure, respiration, respiratory, acute) 52. 97761 � 3 (Training, Prosthetics) 53. 99144 (Sedation, Moderate) 54. 91110 (Gastrointestinal Tract, Imaging, Intraluminal) 55. 90471 (Administration, Immunization, One Vaccine/Toxoid), 90472

(Administration, Immunization, each additional Vaccine/Toxoid) 56. 99233 (Evaluation and Management, Hospital) ICD-10-CM: I33.0 (Endocarditis, bacterial), I49.02 (Flutter, heart,

ventricular) ICD-9-CM: 421.0 (Endocarditis, bacterial), 427.42 (Flutter, heart

[ventricular]) 57. ICD-10-CM: I21.19 (Infarct, myocardium, inferolateral), I23.1 (Defect,

atrium, acquired) ICD-9-CM: 410.21 (Infarct, myocardium, inferolateral), 429.71 (Defect,

atrial septal, acquired) 58. ICD-10-CM: I70.213 (Arteriosclerosis, extremities, claudication) ICD-9-CM: 440.21 (Arteriosclerosis, extremities, claudication)

Reports 59. Report 68: 99203 (Offi ce and/or Other Outpatient Services, New

Patient) ICD-10-CM: I25.10 (Arteriosclerosis, coronary, native artery), I10

(Hypertension, Unspecifi ed), N63 (Mass, breast), Z95.1 (Status, coronary artery bypass), Z79.890 (Long-term, hormone replacement)

ICD-9-CM: 414.01 (Arteriosclerosis, coronary, native artery), 401.9 (Hypertension, Unspecifi ed), 611.72 (Mass, breast), V45.81 (Status, coronary artery bypass), V49.81 (Status, postmenopausal)

60. Report 69: 77056 (Mammography) ICD-10-CM: N63 (Mass, breast) ICD-9-CM: 611.72 (Mass, breast) 61. Report 70: 99241 (Consultation, Offi ce and/or Other Outpatient) 62. Report 71: none (scheduling calls are not billable) 63. Report 72: none, as the admission is part of the surgical package 64. Report 73: 19120-59 (Excision, Breast, Lesion). The procedure is billable

with modifi er -59, as the excision of the mass was performed prior to the mastectomy. The surgeon had to wait for results of the biopsy and based on the results a mastectomy was performed.



138

65. Report 74: 19307-LT (Mastectomy, Modifi ed Radical) ICD-10-CM: C50.912 (Neoplasm, breast, Malignant Primary) ICD-9-CM: 174.9 (Neoplasm, breast, Malignant, Primary) 66. Report 75: 99251 (Consultation, Inpatient) 67. Report 76: 99252-57 (Consultation, Inpatient) modifi er -57 indicates

the decision for major surgery ICD-10-CM: I97.89 (Vascular complications following a procedure),

I74.0 (Embolism, aorta, saddle) ICD-9-CM: 997.79 (Complication, vascular, postoperative, other vessels)

for postoperative vascular complications, 444.01 (Embolism, aorta, saddle)

68. Report 77: 34201-50 (Embolectomy, Femoral) 69. Report 78: 32421 (Thoracentesis) ICD-10-CM: J90 (Effusion, pleural) ICD-9-CM: 511.9 (Effusion, pleura). Note that the report indicated the

patient was developing respiratory failure; if the failure was confi rmed, the diagnosis would be reported with 518.81 (Respiratory, failure).

Note: The report indicated the patient was developing respiratory fail-ure; if the failure was confi rmed, the diagnosis would be reported with J96.0 (Respiratory, failure).

70. Report 79: 99024 (Special Services, Post-Op Visit) ICD-10-CM: Z48.3 (Aftercare, following surgery, for, neoplasm),

C50.912 (Neoplasm, breast, Malignant Primary) ICD-9-CM: V58.42 (Aftercare, following surgery, for, neoplasm),

174.9 (Neoplasm, breast, Malignant, Primary) 71. Report 80: 94060 (Spirometry), 94727 (Pulmonology, Diagnostic, Func-

tional Residual Capacity), 94729 (Pulmonology, Diagnostic, Carbon Monoxide Diffusion Capacity), 99070 (Supplies, Materials) for the bronchodilator

CHAPTER 31: INPATIENT CODING

Theory 1. Inpatient 2. Inpatient 3. Outpatient 4. False 5. False 6. False 7. False 8. b

9. a 10. a 11. b 12. c 13. c 14. a 15. c 16. False

Sequencing ExercisesCases of Principal Diagnosis and Other Diagnoses 17. Principal diagnosis: cellulitis ankle or leg Other diagnoses: none 18. Principal diagnosis: congestive heart failure Other diagnoses: none 19. Principal diagnosis: colon cancer, primary malignancy Other diagnoses: bone cancer, secondary 20. Principal diagnosis: postoperative hemorrhage Other diagnoses: ovarian cancer, primary 21. Principal diagnosis: menorrhagia Other diagnoses: acute, bronchitis, canceled surgery



139

22. Principal diagnosis: third-degree burn to arm/stomach (either the arm or stomach could be sequenced fi rst)

Other diagnoses: second-degree burn thigh 23. Principal diagnosis: bronchitis with exacerbation [acute] Other diagnoses: none 24. Principal diagnosis: dehydration Other diagnoses: gastroenteritis Pregnancy is reported with a V code for incidental state.

Principal Diagnosis 25. ICD-9-CM: Principal diagnosis and code: Right orbital fracture,

802.6 (Fracture orbit, fl oor) Other diagnoses and codes: Right zygoma fracture 802.4 (Fracture, zygoma) Abrasion to head 910.0 (Injury, superfi cial, head) Assault by striking E968.2 (Index to External Causes, Assault, weapon,

blunt) Procedure: 76.92 implant (Implant, facial bone, synthetic [alloplastic]) ICD-10-CM: S02.3xxA (Fracture, traumatic, orbit, fl oor, [blowout]),

S02.44xA (Fracture, traumatic, zygoma), S00.81xA (Abrasion, fore-head), S00.01xA (Abrasion, scalp), Y00.xxxA (Index to External Causes, Assault, weapon, blunt)

26. ICD-9-CM: Principal diagnosis and code: Right posterior and ante-rior communicating artery aneurysm 437.3 (Aneurysm, brain)

Other diagnoses and code: Right otitis externa 380.10 (Otitis, external)

Procedure: Right craniotomy for clipping of arterial aneurysm 39.51 (Volume 3, Clipping, aneurysm)

ICD-10-CM: I67.1 (Aneurysm, brain), H60.391 (Otitis, externa, right ear)


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