Solution Manual for Understanding Current Procedural Terminology and HCPCS Coding Systems, 6th Edition

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’s Manual toAccompany UnderstandingCurrent ProceduralTerminology and HCPCSCoding SystemsSixth EditionMARYJOBOWIE,MS, BS, AAS, RHIA, RHITTEXTBOOK GUIDE

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iiiTABLE OF CONTENTSINTRODUCTION1SECTION I: GETTING STARTED2SECTION II: CHAPTER LESSON PLANS AND ANSWER KEYS4Chapter 1:Introduction to Current Procedural Terminology4Chapter 2:Modifiers8Chapter 3:Evaluation and Management12Chapter 4:Anesthesia17Chapter 5:Surgery and the Integumentary System21Chapter 6:Musculoskeletal System26Chapter 7:Respiratory System31Chapter 8:Cardiovascular System36Chapter 9:Hemic and Lymphatic Systems41Chapter 10:Mediastinum and Diaphragm44Chapter 11:Digestive System46Chapter 12:Urinary System51Chapter 13:Male Genital System55Chapter 14:Female Genital System58Chapter 15:Maternity Care and Delivery62Chapter 16:Endocrine System65Chapter 17:Nervous System67Chapter 18:Eye and Ocular Adnexa70Chapter 19:Auditory System and Operating Microscope73Chapter 20:Radiology76Chapter 21:Pathology and Laboratory81Chapter 22:Medicine83Chapter 23:HCPCS Codes87SECTION III: ANSWER KEY FOR APPENDIX VII CASE STUDIES92

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INTRODUCTIONThis instructor’s manual is organized into two sections.SECTION IGetting StartedThis section contains a semester plan that is used for a 15-week semester and a course outline that can be modified andgiven to students on the first day of class.SECTION IIChapter Lesson Plans and Answer KeysThis section contains a lesson plan for each chapter that includes lecture topics, an overview of the chapter, chapterobjectives, and the answers to the exercises and Chapter Review. The authors suggest that students complete theexercises contained in the chapters as homework. The Chapter Reviews and coding cases should be completed as partof laboratory time.SECTION IIIAnswer Key for Appendix VII Case StudiesThis section contains the answer key for the case studies found in the core text, Appendix VII.

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Section IGetting StartedThis section contains a semester plan and a course outline. The semester plan is intended to be used as a guide toorganize the course content. The course outline can be used to develop a course syllabus that can be updated accordingto your specific class needs.SEMESTER PLANThis plan is for 45 hours of lecture and 30 hours of lab time. The lecture time assumes 30 minutes to 1 hour for testingon each chapter. The instructor’s Microsoft PowerPoint presentation that accompanies this manual should be used. Ashomework assignments for each chapter in the following list, students should complete the exercises found within thetextbook chapters and review the Internet links found at the end of the chapters. The lab assignments to be used includethe coding assignments and case studies found at the end of the chapters in the core book. The students also should beinstructed to complete the Chapter Review at the end of each chapter. The Chapter Reviews can be completed ashomework assignments or as lab assignments.Lecture HoursLab HoursChapter 1Introduction to Current Procedural Terminology31Chapter 2Modifiers32Chapter 3Evaluation and Management32Chapter 4Anesthesia32Chapter 5Surgery and the Integumentary System22Chapter 6Musculoskeletal System22Chapter 7Respiratory System22Chapter 8Cardiovascular System22Chapter 9Hemic and Lymphatic Systems10.5Chapter 10 Mediastinum and Diaphragm10.5Chapter 11 Digestive System22Chapter 12 Urinary System21Chapter 13 Male Genital System1.51Chapter 14 Female Genital System1.51Chapter 15 Maternity Care and Delivery21Chapter 16 Endocrine System1.51Chapter 17 Nervous System1.51Chapter 18 Eye and Ocular Adnexa1.51Chapter 19 Auditory System and Operating Microscope1.51Chapter 20 Radiology21Chapter 21 Pathology and Laboratory21Chapter 22 Medicine21Chapter 23 HCPCS Codes11TOTAL HOURS4430

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Section I■Getting Started3COURSE OUTLINEThis outline can be used to organize your class content and to prepare a course syllabus for your students.Course Name:Insert name of course established by your school.Course Number:Insert course number.Course Format:____ hours of lecture and ____ hours of laboratory per week.Prerequisites:List prerequisites established by your school.Semester:Insert current semester.Course Objectives:At the conclusion of this course, the student will be able to:1. Explain the format and organization of CPT.2. Describe the sections found in CPT.3. Describe the procedural codes found in CPT.4. Explain the procedures associated with the various procedural codes found in CPT.5. Assign CPT procedural phrases.6. Assign CPT procedural codes to case studies.Textbook:Bowie, Mary Jo,Understanding Procedural Coding: A Worktext,6th ed., Clifton Park, NY: CengageLearning, 2019.Division of Subject MatterDate to Be Completed(List dates according to schoolcalendar.)Chapter 1Introduction to Current Procedural TerminologyChapter 2ModifiersChapter 3Evaluation and ManagementChapter 4AnesthesiaChapter 5Surgery and the Integumentary SystemChapter 6Musculoskeletal SystemChapter 7Respiratory SystemChapter 8Cardiovascular SystemChapter 9Hemic and Lymphatic SystemsChapter 10 Mediastinum and DiaphragmChapter 11 Digestive SystemChapter 12 Urinary SystemChapter 13 Male Genital SystemChapter 14 Female Genital SystemChapter 15 Maternity Care and DeliveryChapter 16 Endocrine SystemChapter 17 Nervous SystemChapter 18 Eye and Ocular AdnexaChapter 19 Auditory System and Operating MicroscopeChapter 20 RadiologyChapter 21 Pathology and LaboratoryChapter 22 MedicineChapter 23 HCPCS Codes

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Section IIChapter Lesson Plansand Answer KeysCHAPTER 1INTRODUCTION TO CURRENTPROCEDURAL TERMINOLOGYLESSON PLANTime:2–3 hours instructor preparation3 hours in-class lecture time1 hour in-class lab time (if lab component is part of course)Topics:History of Current Procedural TerminologyThe Structure and Design of CPTCPT as Part of HCPCSOverview:This chapter presents an overview, the development, and the format of CPT. It further discussesthe symbols used in CPT and the process of locating codes. The main sections are introduced.Level I and Level II codes that are found in HCPCS are also discussed.OBJECTIVES1. Discuss the purpose of Current Procedural Terminology (CPT).2. Explain the development of CPT.3. Summarize the format of CPT.4. Discuss the symbols used in CPT.5. Understand how to locate a CPT code.6. Outline the six main sections of CPT.7. Differentiate among Level I and Level II codes in HCPCS.

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Chapter 1■Introduction to Current Procedural Terminology5EXERCISE ANSWERS1.1–Check Your UnderstandingCodeSection/Subsection1. 70300Radiology/Diagnostic Radiology (Diagnostic Imaging)2. 60220Surgery/Endocrine System3. 26034Surgery/Musculoskeletal System4. 88036Pathology & Laboratory—Anatomic Pathology5. 43651Surgery/Digestive System6. 38115Surgery/Hemic and Lymphatic Systems7. 99304Evaluation and Management/Nursing Facility Services8. 97010Medicine/Physical Medicine and Rehabilitation9. 77021Radiology/Radiologic Guidance10. 65112Surgery/Eye and Ocular Adnexa11. 90371Medicine/Immune Globulins, Serum, or Recombinant Products12. 99203Evaluation and Management/Office or Other Outpatient Services13. 10160Surgery/Integumentary System14. 33120Surgery/Cardiovascular System15. 50100Surgery/Urinary System16. 21811Surgery/Musculoskeletal System17. 66184Surgery/Eye and Ocular Adnexa18. 52441Surgery/Urinary System19. 61000Surgery/Nervous System20. 59074Surgery/Maternity Care and DeliveryCHAPTER REVIEW ANSWERSTrue/False1. False2. True3. False4. False5. TrueFill in the Blank6. American Medical Association (AMA)7. Appendix A8. Six9. Semicolon10. Index

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Chapter 1■Introduction to Current Procedural Terminology6Coding Assignments1. Anesthesia2. Surgery3. Pathology and Laboratory4. Surgery5. Surgery6. Medicine7. Evaluation and Management8. Radiology9. Surgery10. Medicine11. Surgery12. Radiology13. Surgery14. Pathology and Laboratory15. Medicine16. Medicine17. Pathology and Laboratory18. Radiology19. Surgery20. MedicineShort Answer1.Unlisted procedure or service: A service may be provided that is not specifically listed in the CPT manual. Whenthis occurs, an unlisted procedure code is used from within a specific subsection of the CPT manual.2. Add-on codes are codes that are listed as secondary to a main procedure code and are used in conjunction with themain code. Add-on codes are not to be reported alone.3. Modifiers are two-digit codes that are appended to a CPT code to enhance or further describe a service provided.4. A special report may be required by some third-party payers when an unusual, variable, or new service is provided.Information contained in the special report includes a description of the nature, extent, and need for the procedureand the time, effort, and equipment necessary to provide the service.5. The Alphabetical Reference Index is an expanded alphabetical index that includes listings by the name of theprocedure and anatomic site. Eponyms and other designations are also included in the index.6. The section numbers and their sequences are as follows:Evaluation and Management99201–99499Anesthesia00100–01999, 99100–99140Surgery10021–69990Radiology (including Nuclear Medicine and Diagnostic Ultrasound)70010–79999Pathology and Laboratory80047–89398, 0001U–0071UMedicine (except Anesthesia)90281–99199, 99500–99607

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Chapter 1■Introduction to Current Procedural Terminology77.CodeAnswer11047yes60540no36100no63082yes81416yes8.CodeAnswer99201no20975yes97535no93618yes36620yes

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CHAPTER 2MODIFIERSLESSON PLANTime:2–3 hours instructor preparation3 hours in-class lecture time2 hours in-class lab time (if lab component is part of course)Topics:Definition and Purposes of ModifiersUse of Modifiers for Various Procedures and Service LocationsModifiers Used for Hospital Outpatient ServicesCPT Level I ModifiersHCPCS Level II ModifiersOverview:This chapter discusses the use of modifiers in the CPT and HCPCS coding systems. Themodifiers are defined, and examples are given to illustrate their use. HCPCS Level II modifiersare also introduced.OBJECTIVES1.Explain the use of CPT modifiers.2.Define the various modifiers used.3.Describe the modifiers used for hospital outpatient services.4.Identify and assign CPT modifiers.EXERCISE ANSWERS2.1 – Check Your Understanding1. ND2. US, GW3. 56, QT4. AA, 475. 51, 592.2 – Pricing and Statistical/Informational Modifiers1. Pricing2. Statistical/informational3. Pricing4. Pricing5. Statistical/informational6. Statistical/informational

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Chapter 2■Modifiers97. Statistical/informational8. Pricing9. Statistical/informational10. Statistical/informational2.3 – Modifiers Used for Ambulatory Surgery Center Hospital Outpatient Claims1. No2. Yes3. No4. Yes5. No6. No7. Yes8. Yes9. Yes10. Yes11. Yes12. No13. Yes14. Yes15. YesCHAPTER REVIEW ANSWERSFill in the Blank1. Two2. Appendix A3. 24d4. Informational5. Multiple6. Preoperative7. 328. 549. 8010. Outside laboratoryIdentify the Modifier1. 622. 233. 224. 525. 55

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Chapter 2■Modifiers106. To report the professional component of a code7. Modifier 47 is used only by physicians or surgeons when regional or general anesthesia is provided by the samephysician or surgeon who is completing a procedure or service.8. 509. 5610. Modifier 76 is used to indicate that it was necessary to indicate that a procedure or service was repeated by thesame physician or other qualified health care professional subsequent to the original procedure or service. Modifier77 is used when a physician or other qualified health care professional needs to indicate that a basic procedure orservice performed by another physician or other qualified health care professional had to be repeated.11. 5312. 5713. 6614. 8015. 2616. G217. F818. GM19. 8120. 91Case StudiesCase 1—Modifier 25Rationale:An Evaluation and Management (E/M) code (99213) and a procedure code (OMT-98925) for the same dayrequire a modifier to identify that two separate and distinct services were performed. Modifier 25 is reported with theE/M code.Case 2—Modifier 53Rationale:Because of the extenuating circumstances of the drop in blood pressure, the doctor felt that it was in thepatient’s best interest to stop the procedure.Case 3—Modifier 55Rationale:Modifier 55 is appended to the code to report that the provider is completing postoperative managementonly.Case 4—Modifier 63Rationale:When a procedure is completed and the patient is a newborn and weighs less than 4 kg, modifier 63 isappended to the procedure code.Case 5—33475-80Rationale:Modifier 80 is appended to the procedure code to report that the provider is the assistant surgeon for the case.Case 6—Modifier 57Rationale:Modifier 57 denotes that the decision for surgery was made.Case 7—Modifier 32Rationale:When a service occurs because the service is mandated, modifier 32 is appended to the basic procedure code.

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Chapter 2■Modifiers11Case 8—Modifier 26Rationale:Modifier 26 is appended to the code to report that the provider completed the professional component of theprocedure.Case 9—No, both should report 32854-66Rationale:Because the providers worked as a team, modifier 66 would be reported by both providers.Case 10—32960-76Rationale:Modifier 76 would be appended to the procedure code to denote that the procedure was repeated.

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CHAPTER 3EVALUATION AND MANAGEMENTLESSON PLANTime:2–3 hours instructor preparation3 hours in-class lecture time2 hours in-class lab time (if lab component is part of course)Topics:Documentation Guidelines for Evaluation and Management ServicesOverview of the Evaluation and Management SectionEvaluation and Management CodingOverview:This chapter discusses Evaluation and Management (E/M) coding. An overview of the codesfound in the various subsections of the Evaluation and Management section of the CPT manualare explained. Documentation guidelines that relate to E/M coding are discussed throughout thechapter.OBJECTIVES1.Explain the purpose of Evaluation and Management (E/M) codes.2.Identify the documentation needed to justify the selection of a code from the Evaluation and Management sectionof the CPT manual.3.Differentiate between a new and an established patient.4.Define consultation.5.State the documentation requirements for the selection of a consultation code.6.Identify the services bundled into critical care service codes.7.Explain the services that are considered preventive medicine services.8.Describe the chapter-specific guidelines for Evaluation and Management coding.EXERCISE ANSWERS3.1 – Subsection and Subcategories of the CPT Evaluation and Management Section1. Office and other outpatient services; established patient2. Emergency department services; new or established patient3. Home services; new patient4. Hospital inpatient services; hospital discharge services5. Consultations; inpatient consultation services6. Hospital observation services; observation care discharge services

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Chapter 3■Evaluation and Management137. Hospital inpatient services; subsequent hospital care8. Consultations; office or other outpatient consults9. Advance Care Planning10. Prolonged services; physician standby services3.2 – POS and Evaluation and Management Codes1. 112. 213. 124. 315. 216. 317. 218. 119. 1110. 233.3 – Documentation of Patient History1. 2—Chief complaint2. 4—Severity3. 6—Quality4. 8—Associated signs and symptoms5. 5—Family history6. 3—Past history7. 7—Review of systems8. 1—Social history3.4 – Evaluation and Management Coding1. 992142. 992123. 992134. 992135. 992153.5 – Hospital Service Codes1. 992222. 992323. 992234. 992385. 99232

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