The procedure involves a cystourethroscopy with ureteroscopy/pyeloscopy, lithotripsy for a ureteral calculus, and the insertion of an indwelling stent. CPT® code 52356 is the single, comprehensive code that accurately describes all these components. It bundles the endoscopic approach (cystourethroscopy with ureteroscopy), the definitive procedure (lithotripsy), and the stent placement into one code. Using this all-encompassing code is the correct practice and avoids unbundling of services.

A. 52352 is incorrect because it describes the removal or manipulation of a calculus, not fragmentation via lithotripsy.

B. 52325 is incorrect as it does not include the ureteroscopy/pyeloscopy; the scope is not advanced into the ureter for this code.

C. This option incorrectly unbundles the procedures. The CPT® manual directs the use of 52356 when lithotripsy and stent insertion are performed together.

1. American Medical Association. (2023). CPT® 2024 Professional Edition. Section: Urinary System

Endoscopy-Ureter and Pelvis

Codes 52353

52356. The code descriptor for 52356 explicitly states

"Cystourethroscopy

with ureteroscopy and/or pyeloscopy; with lithotripsy including insertion of indwelling ureteral stent..." A parenthetical note following code 52353 instructs

"(For lithotripsy with stent insertion

use 52356)."

2. AAPC. (2023). CPC® Official Study Guide. Chapter 13: Urinary System and Male Genital System. The guide explains the hierarchy of endoscopic procedures

emphasizing the use of comprehensive codes that include all components of a procedure

such as scope

treatment

and stent placement

as seen in code 52356.

The selection of the correct CPT® code is determined by three key factors from the case description: the type of examination, the age of the deceased, and the extent of the necropsy. The pathologist performed a "gross and microscopic" examination, eliminating codes for gross examination only (88012, 88014). The deceased was a "3-day-old," which is classified as a newborn. The necropsy included the brain. CPT® code 88029 accurately represents a gross and microscopic necropsy performed on a stillborn or newborn, which includes the brain.

A. 88028: This code is for an infant, not a newborn. A more specific code exists for a newborn, making 88029 the correct choice.

B. 88012: This code describes a gross examination only and is for an infant. The scenario specifies a gross and microscopic examination on a newborn.

D. 88014: This code describes a gross examination only. The scenario explicitly states that both a gross and microscopic examination were performed.

1. American Medical Association (AMA). (2023). CPT® 2024 Professional Edition.

Section: Pathology and Laboratory / Anatomic Pathology / Postmortem Examination.

Page/Code: CPT® code descriptors for 88028 and 88029. The manual distinguishes between "infant" (88028) and "stillborn or newborn" (88029) for gross and microscopic necropsies that include the brain. This distinction is critical for correct code selection.

2. AAPC. (2023). 2024 CPC Exam Study Guide.

Chapter: Pathology and Laboratory.

Section: Anatomic Pathology. The guide explains that code selection for necropsy (autopsy) is based on the extent of the examination (gross vs. gross and microscopic) and the specifics of the case

such as the age (e.g.

newborn

infant) and whether the central nervous system (CNS) is included. This reinforces the principle of choosing the most specific code available.

CPT® code 92537 describes a bithermal caloric vestibular test, which requires a total of four irrigations (one warm and one cool in each of the two ears). The scenario specifies that only three irrigations were performed. Because the service described by the code was not fully completed, it is considered a reduced service. Modifier -52 (Reduced Services) is appended to indicate this reduction. The code descriptor for 92537 already includes the term "bilateral," making the use of modifier -50 (Bilateral Procedure) redundant and incorrect.

B. 92537-50-52: This is incorrect because CPT® 92537 is inherently a bilateral procedure, as stated in its description. Appending modifier -50 is inappropriate.

C. 92538-50: This is incorrect as 92538 represents a monothermal test (two irrigations), not the three performed. Modifier -50 is also inappropriate for this bilateral code.

D. 92537-50: This is incorrect because it implies the full service of four irrigations was completed, which contradicts the scenario. Modifier -50 is also incorrectly applied.

1. American Medical Association. (2023). CPT® 2024 Professional Edition.

Code 92537 Description: "Caloric vestibular test with recording

bilateral; bithermal (ie

one warm and one cool irrigation in each ear)." This description confirms the procedure is bilateral and requires four irrigations.

Appendix A

Modifier -52: "Reduced Services: Under certain circumstances a service or procedure is partially reduced or eliminated at the physician's or other qualified health care professional's discretion. Under these circumstances the service provided can be identified by its usual procedure number and the addition of the modifier 52

signifying that the service is reduced." This guideline directly applies to the scenario where only three of the four required irrigations were performed.

Appendix A

Modifier -50: "Bilateral Procedure: ... Note: This modifier should not be appended to a CPT code that has a bilateral description..." This note explicitly prohibits the use of modifier -50 with codes like 92537.

2. AAPC. (2023). 2024 CPC Exam Study Guide. Chapter 11: Medicine.

The section on Vestibular Function Tests explains that 92537 represents the complete bithermal test (four irrigations). It further clarifies that if a procedure is not performed in its entirety as described by the CPT® code

modifier -52 should be used to report the reduced service.

The procedure performed is a posterior laminectomy with facetectomy and foraminotomy for decompression at two cervical levels (C5-C6 and C6-C7). CPT® code 63045 accurately describes this procedure for a single vertebral segment in the cervical region. The code descriptor includes laminectomy, facetectomy, and foraminotomy for decompression. Since the procedure was performed on a second, contiguous segment (C6-C7), the add-on code +63048 is reported for the additional segment. The term "bilateral" in the report is inherent to the code description for 63045, so modifier 50 is not required.

B. 63040-50, 63043, 63043: CPT® 63040 is for a laminotomy (hemilaminectomy), which is a less extensive procedure than the laminectomy performed.

C. 63050-50: CPT® 63050 describes a laminoplasty, a reconstructive procedure where the lamina is hinged open, not a laminectomy where the lamina is removed.

D. 63015: This code is for a laminectomy for decompression without facetectomy or foraminotomy, which contradicts the procedures documented in the operative report.

1. American Medical Association. (2023). CPT® 2024 Professional Edition.

Page 488

Code 63045: "Laminectomy

facetectomy

and foraminotomy (unilateral or bilateral with decompression of spinal cord

cauda equina and/or nerve root[s]

[eg

spinal or lateral recess stenosis])

single vertebral segment; cervical." This description matches the primary procedure.

Page 488

Code +63048: "...each additional segment

cervical

thoracic

or lumbar (List separately in addition to code for primary procedure)." The parenthetical note states

"Use 63048 in conjunction with 63045

63046

63047

" confirming its use for the second segment.

2. AAPC. (2023). 2024 CPC Official Study Guide. Chapter 11: Musculoskeletal System.

The section on Spine and Spinal Cord surgery explains that when a laminectomy includes facetectomy and foraminotomy for decompression

codes from the 63045-63048 series are used. It clarifies that 63045 is the base code for the first segment and +63048 is the add-on code for each additional segment.

The CPT® code 57454 accurately describes all procedures performed. This is a combination code that includes the colposcopy of the cervix, the cervical biopsy, and the endocervical curettage (ECC). When a single CPT® code exists that describes all components of a procedure performed during the same session, that single code must be used rather than reporting the components separately. The documentation supports the use of this comprehensive code.

A. 57456 is incorrect because it specifies a loop electrode biopsy (LEEP), which is a different procedure from the standard biopsy performed.

B. 57420 is incorrect as it represents a colposcopy of the vagina only, without any biopsy or curettage performed.

C. 57455 is incorrect because it includes the colposcopy and cervical biopsy but omits the separately performed endocervical curettage.

1. American Medical Association. (2023). CPT® 2024 Professional Edition. Section: Female Genital System

Vagina

Endoscopy/Laparoscopy

code descriptions for 57454

57455

57456. The code descriptor for 57454 explicitly states

"Colposcopy of the cervix including upper/adjacent vagina; with biopsy(s) of the cervix and endocervical curettage."

2. AAPC. (2023). 2024 CPC Study Guide. Chapter 11: Female Reproductive System. The guide explains the hierarchy and bundling of colposcopy codes

clarifying that 57454 is the appropriate code when both a cervical biopsy and an endocervical curettage are performed with the colposcopy.

According to the ICD-10-CM Official Guidelines for Coding and Reporting, when sepsis is documented with an associated acute organ dysfunction, it is classified as severe sepsis. The coding sequence requires the code for the underlying systemic infection (A41.9 for unspecified sepsis) to be listed first. This is followed by a code from subcategory R65.2 to identify severe sepsis. Since the scenario does not mention septic shock, the correct code is R65.20 (Severe sepsis without septic shock). Finally, the code for the specific acute organ dysfunction, J96.00 (Acute respiratory failure, unspecified), is reported to fully capture the patient's condition.

B: This option is incomplete. It fails to report the severe sepsis (R65.20) and the associated acute respiratory failure (J96.00), which are required by coding guidelines.

C: This option is incorrect because it reports R65.21 (Severe sepsis with septic shock). The clinical scenario does not provide documentation to support a diagnosis of septic shock.

D: This option is incomplete. The guidelines mandate assigning a code from subcategory R65.2 when sepsis is documented with an associated acute organ dysfunction.

1. Centers for Medicare & Medicaid Services (CMS). (2023). ICD-10-CM Official Guidelines for Coding and Reporting FY 2024.

Section I.C.1.d.1.a.i: "For a diagnosis of sepsis

assign the appropriate code for the underlying systemic infection. If the type of infection or causal organism is not further specified

assign code A41.9

Sepsis

unspecified organism." (Supports use of A41.9)

Section I.C.1.d.1.b.i: "For a diagnosis of severe sepsis

assign the appropriate code for the underlying systemic infection

followed by a code from subcategory R65.2

Severe sepsis... A code from subcategory R65.2 should not be assigned unless severe sepsis or an associated acute organ dysfunction is documented." (Supports sequencing and use of R65.20)

Section I.C.1.d.1.b.i

Note: This section lists acute respiratory failure as an example of an associated acute organ dysfunction. (Supports coding J96.00)

2. American Academy of Professional Coders (AAPC). (2023). 2024 CPC® Study Guide. Chapter 11: ICD-10-CM Coding. The guide reiterates the official CMS guidelines for sepsis coding

emphasizing the requirement to code for the underlying infection

followed by the severe sepsis code (R65.2x)

and then the code(s) for the organ dysfunction(s). This confirms the structure A41.9

R65.20

J96.00.

The physician documented providing 45 minutes of critical care time for a patient with diabetic ketoacidosis, a life-threatening condition. According to CPT® guidelines, critical care services are time-based. Code 99291 is used to report the first 30-74 minutes of critical care provided on a given date. Since the documented time of 45 minutes falls within this range, 99291 is the only appropriate code. When critical care criteria are met and services are provided, this code is reported in lieu of other E/M services, such as an emergency department visit code.

B. 99291, 99292: Code 99292 is an add-on code for each additional 30 minutes beyond the initial 74 minutes. It is not applicable here as the total time was only 45 minutes.

C. 99222: This is an initial hospital inpatient care code. The service documented was rendered in the Emergency Department, not as an initial inpatient encounter by the admitting physician.

D. 99285: This is an Emergency Department visit code. Per CPT® guidelines, when the service qualifies as critical care, codes 99291-99292 are reported instead of the ED visit codes.

1. American Medical Association. (2023). CPT® 2024 Professional Edition. In the Evaluation and Management section

under "Critical Care Services

" the guidelines state

"Code 99291 is used to report the first 30-74 minutes of critical care on a given date." The guidelines for code 99292 specify its use for "each additional 30 minutes." This confirms that only 99291 is appropriate for 45 minutes of service.

2. AAPC. (2023). 2024 CPC Official Study Guide. Chapter 2: Evaluation and Management. The guide clarifies that critical care codes (99291

99292) are used for critically ill or injured patients and are based on the total time spent by the provider. It emphasizes that these codes are not used in conjunction with other E/M codes for the same time period by the same provider. This supports reporting 99291 instead of 99285.

The procedure described is a complete cardiac MRI for morphology and function, which includes imaging without contrast, followed by imaging with contrast and further sequences, and also includes stress imaging. CPT® code 75563 accurately represents this entire service as a single, comprehensive code.

For the diagnoses, "systolic left ventricular congestive heart failure" is coded to I50.20 (Unspecified systolic (congestive) heart failure), as the documentation specifies "systolic" but does not indicate if it is acute or chronic. "Premature ventricular contractions" are specifically coded to I49.3 (Ventricular premature depolarization).

A. CPT® codes 75557 and 75559 do not include the stress imaging component. The ICD-10-CM codes are incorrect for the specified conditions.

B. Reporting both 75561 and 75563 is incorrect unbundling. 75563 is the all-encompassing code for the service. The ICD-10-CM codes are also incorrect.

D. CPT® code 75559 is an add-on code that cannot be reported alone and does not include the stress imaging component.

1. American Medical Association. (2023). CPT® 2024 Professional Edition.

Page 541

Code 75563: "Cardiac magnetic resonance imaging for morphology and function without contrast material(s)

followed by contrast material(s) and further sequences; with stress imaging." This description precisely matches the procedure performed.

Page 541

Codes 75557

+75559

75561: These codes describe components of the full service but are incorrect as they either omit the stress component (75557

+75559) or the contrast component (75561).

2. Centers for Medicare & Medicaid Services. (2023). ICD-10-CM Official Guidelines for Coding and Reporting FY 2024.

Section I.C.9.a.1

Heart Failure: The guidelines instruct to code for the specific type of heart failure if known. The term "systolic" directs the coder to subcategory I50.2-. As acuity is not specified

I50.20 is appropriate.

ICD-10-CM Tabular List of Diseases and Injuries:

Code I50.20: Unspecified systolic (congestive) heart failure.

Code I49.3: Ventricular premature depolarization. This is the specific code for premature ventricular contractions.

Code I49.1: Premature atrial depolarization. This is incorrect as the diagnosis is ventricular.

The procedure described is the retrieval of oocytes (eggs) by puncturing the ovarian follicle and aspirating the contents. CPT® code 58970, "Follicle puncture for oocyte retrieval, any method," accurately represents this service. The phrase "any method" indicates this code is appropriate regardless of the specific technique used for retrieval. The use of radiologic guidance is a distinct service and is reported separately (e.g., with 76948 for ultrasonic guidance). Therefore, 58970 is the correct code for the primary surgical procedure of oocyte retrieval.

A. 58976: This code is for the intrafallopian transfer of gametes, zygotes, or embryos, which is a different procedure that occurs after fertilization, not the initial egg retrieval.

B. 58974: This code describes the intrauterine transfer of an embryo, a subsequent step in the in vitro fertilization (IVF) process, not the oocyte retrieval itself.

C. 58999: This is an unlisted procedure code. It is incorrect to use this code because a specific CPT® code (58970) exists that accurately describes the service performed.

1. American Medical Association. CPT® 2024 Professional Edition. Chicago

IL: AMA

2023. Code 58970

Female Genital System/Ovary. The code descriptor is "Follicle puncture for oocyte retrieval

any method." A parenthetical note following this code states

"For radiological supervision and interpretation

see 76948

" confirming that guidance is a separately reportable service.

2. AAPC. 2024 CPC Exam Study Guide. Salt Lake City

UT: AAPC

2023. Chapter 11: Female Reproductive System and Maternity Care and Delivery. The guide clarifies the distinct functions of IVF-related codes

assigning 58970 to oocyte retrieval and codes 58974 and 58976 to the transfer of embryos or gametes.

According to the ICD-10-CM Official Guidelines for Coding and Reporting, if the type of diabetes mellitus is not documented in the medical record, the default type is E11.-, Type 2 diabetes mellitus. The diagnosis "diabetic polyneuropathy" implies a causal relationship between diabetes and the neurological complication. ICD-10-CM provides a specific combination code that captures both the underlying condition and the manifestation. The Alphabetic Index entry for "Polyneuropathy, diabetic" directs the coder to E11.42. This single code fully describes the diagnosis of Type 2 diabetes mellitus with diabetic polyneuropathy.

A. E10.42: This code is for Type 1 diabetes. The guidelines require defaulting to Type 2 when the type is not specified.

B. E11.9, G62.9: This is incorrect because a specific combination code (E11.42) exists. E11.9 indicates diabetes without complications, which contradicts the diagnosis.

C. E10.9, G62.9: This is incorrect as it assumes Type 1 diabetes and fails to use the appropriate, more specific combination code.

1. ICD-10-CM Official Guidelines for Coding and Reporting FY 2024. National Center for Health Statistics.

Section I.C.4.a.1. Type of diabetes: "If the type of diabetes mellitus is not documented in the medical record

the default is E11.-

Type 2 diabetes mellitus."

Section I.C.4.a.3. Complications due to diabetes mellitus: This section details the use of combination codes for diabetic complications

noting that the codes under categories E08-E13 include the type of diabetes and the complication.

2. ICD-10-CM Codebook (2024). American Medical Association (AMA) or other official publisher.

Alphabetic Index: Under the main term "Polyneuropathy

" the subterm "diabetic" directs to "see Diabetes

with

polyneuropathy." Following this path leads to code E11.42 for the unspecified type.

Tabular List: Code E11.42 is explicitly defined as "Type 2 diabetes mellitus with diabetic polyneuropathy."