Assistant

Your practical guide to current coding

May 2008 / Volume 18 Issue 5

Page 3
Screening and
Brief
Intervention
(SBI) for
Alcohol and
Substance Abuse

Page 5
Chromosome
Analysis

Page 9
Manual Muscle
Testing, Range of
Motion Testing,
and Physical
Performance Test
or Measurement

Page 13
Questions and
Answers

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CPT Assistant May 2008 / Volume 18 Issue 5

Coding Communication: Screening and Brief

Intervention (SBI) for Alcohol and Substance
Abuse (Other Than Tobacco)
Screening and Brief Intervention:
What Is It?
Screening and brief intervention (SBI) for alcohol and
substance abuse is a technique used to identify, and intervene with, people who use alcohol or drugs in a harmful or
hazardous way and are at risk for substance use-related
problems or injuries. The goal of SBI is to have sites of
care, such as trauma centers, hospital emergency departments, ambulatory medical practices, and school clinics
screen patients at-risk for substance use and, if appropriate, provide them with a brief intervention or referral to
appropriate treatment. By screening people in these settings, it is possible to identify people who have had an
alcohol-related illness or injury that could provide a motivation for behavior change. In addition, screening serves
as a form of primary prevention by educating patients
about the health effects of using alcohol and other drugs.

Brief Intervention: Brief intervention usually happens in

a single session immediately following a positive screening
result. The physician or other qualified health care professional focuses on increasing the patients understanding of
the impact of substance use on his or her health and motivating the patient to change risky behaviors. If the patient
shows signs of substance dependence or other complications, the provider can refer the patient to specialized substance use assessment and treatment or manage the
patients care through specialty consultation.

Coding
Correct use of codes 99408 and 99409 requires that the
screening and interventional components of this service
be documented in the clinical record.
99408

Background
The impact of hazardous alcohol and substance abuse
can exacerbate medical, mental, and social problems,
resulting in significant public health cost. (The annual
national economic cost to society is estimated to be $375
billion).1 The human suffering and emotional cost of alcohol and drug abuse are devastating for individuals, families, and communities.
Historically, the emphasis of substance use-related intervention has been placed on universal prevention strategies
aimed at people who have never initiated use2 or specialist
treatment for people who are dependent.3 Little attention
has been given to the large group of people who use alcohol and other drugs, are not dependent, and could successfully reduce their use through early intervention.4,5 Early
intervention can substantially reduce health and other
problems associated with hazardous substance use.6

How Does It Work?

Screening: Patients are screened for substance use with a
validated questionnaire. These screening questions should
be simple enough to be administered by a wide range of
health care professionals. The questionnaire should focus
on the frequency and the quantity of substance use over a
particular time frame (generally 1 to 3 months).

Alcohol and/or substance (other than tobacco)

abuse structured screening (eg, AUDIT, DAST),
and brief intervention (SBI) services; 15 to 30
minutes

3
99409

greater than 30 minutes

The work effort for codes 99408 or 99409 is separate and

distinct from all other Evaluation & Management (E/M)
services performed during the same clinical session (ie,
date of service); the work effort of performing code 99408
or 99409 is, therefore, not considered in selecting the
level of any other E/M service on the same date. (If
reporting E/M that qualifies as a significant, separately
identifiable service on the same date as reporting SBI, use
Modifier 25 with the E/M service).
A physician or other qualified health care professional
uses a validated screening instrument (such as the
alcohol use disorder identification test [AUDIT] or the
drug abuse screening test [DAST]). A validated screening
instrument is an instrument that has been psychometrically tested for reliability (the ability of the instrument to
produce consistent results), validity (the ability of the
instrument to produce true results), sensitivity (the probability of correctly identifying a patient with the condition), and specificity (the probability of correctly identifying a patient who does not have the condition). Using an
instrument that has not been validated may increase the
chances of misidentification.

CPT Assistant May 2008 / Volume 18 Issue 5

An intervention is performed when indicated by the score

on the screening instrument. The instrument used and the
nature of the intervention are recorded in the clinical
documentation for the encounter.
If an intervention is not required on the basis of the result
of the screening, the work effort of performing the survey
is included in the selection of the appropriate E/M service
or preventive medicine service. If an intervention is
required on the basis of the screening result, the intervention is conducted. Code 99408 is the most likely screening
service level for the majority of patients.
The Centers for Medicare & Medicaid Services created
codes G0396 and G0397 for reporting comparable
services for Medicare fee-for-service schedule (FFS)
patients because of statutory restrictions on coverage for
screening services.
G0396

G0397

Alcohol and/or substance (other than tobacco)

abuse structured assessment (AUDIT, DAST),
and brief intervention (SBI) services; 15 to 30
minutes
greater than 30 minutes

Clinical Example (99408)

A 21-year-old college student reports to the school infirmary after injuring his leg when he fell down several steps.

Description of Procedure (99408)

A qualified health care professional conducts a detailed
screening interview using the AUDIT and reviews the
medical record for all relevant data related to alcohol
and/or substance use (ie, blood alcohol level, GGT, drug
panel bioassay, and prescribed medications). The screening reveals that the patient uses alcohol regularly and was
intoxicated at the time the fall occurred. The AUDIT
score indicates that the patient requires an intervention.
The intervention seeks to motivate the patient to decrease
or abstain from alcohol consumption and/or drug use. The
components of the intervention include feedback concerning the quantity and frequency of alcohol (or drugs)
consumed by the patient in comparison with national
norms; a discussion of negative physical, emotional, and
occupational consequences; and a discussion of the overall
severity of the problem. Feedback is accompanied by clinically appropriate advice for behavior change that fits the
patients unique medical and social situation. The quali-

fied health care professional engages the patient in a joint

decision-making process regarding alcohol and/or drug use.
Plans for follow-up are discussed and agreed to.
Effective intervention requires specific training and/or
experience in techniques eliciting accurate information,
developing a specific treatment plan to which the patient
is committed, and motivating the patient to change
behavior. Training in motivational enhancement or motivational interviewing is available from a variety of sources.

For More Information

The National Institute on Alcohol Abuse and Alcoholism
provides a useful resource for developing SBI procedures:
Helping Patients Who Drink Too Much: A Clinicians
Guide.
http://pubs.niaaa.nih.gov/publications/Practitioner/Clinici
ansGuide2005/guide.pdf
The Substance Abuse and Mental Health Services
Administration operates a Web site that provides comprehensive information about screening and brief intervention in medical settings: http://sbirt.samhsa.gov/index.htm.
References
1. National Institute on Drug Abuse and the National Institute
on Alcohol Abuse and Alcoholism. The Economic Costs of
Alcohol and Drug Abuse in the United States, 1992. Analysis
by the Lewin Group, Harwood, H.; Fountain, D.; and
Livermore, G. Bethesda, MD: DHHS, NIH, NIH Publication
No. 98-4327 September 1998. Summary available online at
www.niaaa.nih.gov/Resources/DatabaseResources/QuickFacts/
EconomicData/cost7.htm. Accessed April 4, 2008.
Office of National Drug Control Policy. The Economic Costs of
Drug Abuse in the United States, 1992-1998. September 2001.
Available online at www.whitehousedrugpolicy. gov/publications/economic_costs/. Accessed April 4, 2008.
Drug Strategies. Denver on the Horizon: Reducing Substance
Abuse and Addiction. 2002. Available online at
www.drugstrategies.org/denver/DenvCh_4.html#_edn1.
Accessed April 4, 2008. According to Drug Strategies:
NIDA and NIAAA (1998) estimated that alcohol abuse cost
the nation $166.543 billion in 1995, and that drug abuse cost
the nation $109.832 billion in 1995. Updating NIDANIAAAs 1995 alcohol abuse cost figure for population
growth and inflation, Drug Strategies estimates that alcohol
abuse cost the nation $212.680 billion in the year 2000.
ONDCP (2001) revised and updated NIDA-NIAAAs drug
abuse cost figure, estimating that drug abuse cost the nation
$160.664 billion in the year 2000. Combining these revised

continued on the bottom of page 11

CPT Assistant May 2008 / Volume 18 Issue 5

Coding Clarification: Chromosome Analysis

The Pathology and Laboratory section of the CPT codebook includes the Cytogenetic subsection pertaining to
chromosome analysis. The October 1999 and July 2005
editions of CPT Assistant addressed the specific use of
these codes, and the CPT Education and Information
Services CPT Network continues to receive specific questions pertaining to the use of these codes (see Commonly
Asked Questions in this article). Although the descriptors
of codes 88245-88291 include terms well known to the
cytogeneticists, pathologists, and most others ordering or
performing these studies, a review of the descriptor terms
(ie, chromosome, banding, mosaicism, karyotype, and
breakage) and analysis techniques may further understanding of these procedural services.

In the late 1960s, techniques were developed that differentially stain chromosomes. When stained chromosomes
are visualized and enumerated, the resulting pattern is
termed the karyotype of that cell.

Definition

Currently, routine analysis includes that of G-banded

chromosomes, other cytogenetic banding techniques,
molecular cytogenetics such as FISH, and comparative
genomic hybridization (CGH).

Cytogenetics is the study of chromosomes by light or fluorescent microscopy performed to rule out an inherited
(constitutional) or acquired chromosomal abnormality.
Clinical cytogenetics is the branch of cytogenetics concerned with relations between chromosomal abnormalities
and clinical syndromes or conditions. Clinical cytogeneticists use knowledge and techniques from the study of cells
(cytology) and the science of heredity (genetics) to categorize inherited conditions and predict the risk of future
offspring inheriting the same condition.
Cytogenetics examines microscopically visible chromosomal changes, deletions, or additions. Analysis of chromosomes is also useful in the further categorization of certain
forms of cancer (eg, hematological malignancies) and in
guiding therapy as well as identifying a chromosomal
defect associated with congenital disorders (eg, Down syndrome). Human body cells, exclusive of reproductive cells
following meiosis, have 23 pairs of chromosomes. Any
deviation from this number or deletions or additions to a
specific chromosome is considered abnormal.

History
Chromosomes were first observed in plant cells by Karl
Wilhelm von Ngeli in 1842. Chromosomal behavior
in salamander cells was described by Walther Flemming,
the discoverer of mitosis (cell division), in 1882. The
number of human chromosomes remained unknown for
more than 70 years. Modern cytogenetics is generally said
to have begun in 1956 with the discovery that normal
human cells contain 23 chromosome pairs, or 46 total
chromosomes. Previously, humans were thought to have
48 chromosomes.

In the 1980s, advances were made in molecular cytogenetics with the use of fluorescently labeled probes. Hybridizing probes to chromosome preparations using fluorescent
labels came to be known as fluorescence in situ hybridization
(FISH). This change significantly increased the use of
probing techniques because fluorescently labeled probes are
safer (because conventional staining techniques use some
potentially toxic chemicals), provide more specific diagnostic information, and can be used almost indefinitely.

What Does One See Under the

Microscope?
Cells. The bodys individual cells are so small that
a microscope is needed to see the anatomic detail
and biochemical activity condensed into just one cell.
The chromosomes present with cells contain genes (the
units of heredity, such as for height, sex, and hair color).
Each body cell contains 23 pairs of highly condensed
chromosomes that contain about 100,000 genes. Genes
are constructed of repetitive sequences of DNA (deoxyribonucleic acid).
Because the human DNA helix (a spiral ladder formation) occupies too much space in the cell, small proteins
are responsible for packing the DNA into units called
nucleosomes. To simplify, a chromosomal DNA molecule
contains three specific nucleotide sequences that are
required for replication: a DNA replication origin, a centromere to attach the DNA to the mitotic spindle, and a
telomere located at each end of the linear chromosome.
This is important because chromosomes can change their
conformation and degree of compaction throughout the
cell cycle.
Identification of where and when a chromosomal alteration or abnormality occurs provides vital information for
prenatal testing, diagnosing congenital disorders, and diagnosing and assessing the treatment of certain cancers.
Genetic analysis is also being utilized increasingly to predict the best medication or dose for treating a specific disease in an individual patient. Aneuploidy is a change in
the number of chromosomes that can lead to a genetic

CPT Assistant May 2008 / Volume 18 Issue 5

abnormality. The most common form of aneuploidy is

Down syndrome, which is caused by an extra copy of chromosome number 21. Aneuploidy is typically detected
through karyotyping, a process in which a picture of a persons chromosomes is created and then analyzed.
Of course, not all cells are analyzed (because there are
about 100 trillion cells in the human body, with another
3 billion new cells developed every minute to replace
those that die). Also, changes in chromosome number
may not necessarily be present in all cells in a person. A
change may be detected in just a specific tissue or within
different cells in a tissue. Therefore, specimens for cytogenetic analysis can be obtained from a variety of tissues
capable of yielding cells that divide in culture (8823088239), including peripheral blood (lymphocytes), amniotic fluid (amniocytes), chorionic villi (trophoblastic
cells), bone marrow, solid tumors, fluid from cavities (eg,
pleural, peritoneal, spinal), and cultured fibroblasts (usually obtained by skin biopsy).

Newer molecular cytogenetic techniques can be used even

in nondividing cells, such as buccal cells obtained noninvasively by a cheek swab. Enough cells must be examined
so that the chance of missing a cytogenetically distinct
cell line (mosaicism) is statistically minimized. When
chromosomal abnormalities occur variably (more than one
pattern of chromosome is present in the same individual
or tissue) within different cells of a person, it is called
chromosomal mosaicism (88263). Examples of mosaicism
are found in leukemia cases, specifically, chronic lymphocytic leukemia and acute myeloid leukemia.

Detection Methods
The chromosomes in a cell or a single-cell organism are
visible through a microscope during cell division. Each
chromosome is characterized by the length of its arms
(short and long arms) and the location of its centromere,
which appears as an indentation or a lightly stained region.

Karyotype
A karyotype is the complete set of all chromosomes
of a cell of any living organism. In clinical cytogenetics,
karyotyping includes the microscopic analysis of the
stained chromosomes for abnormalities, arranging them
in their proper chronologic order (pair 1 to 23) and then
taking and analyzing a photograph of the chromosomes.
This analysis may also be used to determine other visible
aspects of a persons genotype, such as the number and
pattern of their sex (an XX [female] vs XY [male] chromosomes). The karyotype photograph or image is
created by photographing the stained chromosomes
through a microscope. The chromosomes are then
arranged and displayed in a picture in a standard format,
in pairs, ordered by size. The karyotype result describes all

findings, normal and abnormal. Therefore, karyotypes help

correlate chromosomal abnormalities with the characteristics of specific diseases.

Banding
During cell division (mitosis), the 23 pairs of human chromosomes condense and are visible with a light microscope.
A karyotype analysis usually involves stopping cell division in mitosis and staining the condensed chromosomes.
When they are stained, the mitotic chromosomes have a
banded structure that unambiguously identifies each
chromosome of a karyotype. For example, with the use of
Giemsa stain (G banding), the dye stains regions of chromosomes that are rich in the base pairs adenine (A) and
thymine (T), producing a dark band. Staining methods
may result in banding (eg, 88261, 88262, 88263, 88264,
and 88283) on the chromosomal arms (chromatids); the
chromosomes can then be identified according to their
banding pattern to allow:
construction of physical maps of chromosomes;
analysis of chromosome structure and aberrations; and
identification of individual chromosomes.
Microscopic analysis of banded chromosomes is performed
by a clinical laboratory specialist in cytogenetics.
Generally, 20 cells are analyzed, which is sufficient to
detect mosaicism, if present, at an acceptable sensitivity.
The results are summarized and given to a medical geneticist or a pathologist for review and to generate written
interpretation (88291), taking into account the patients
medical history and other clinical findings.
There are other techniques in addition to banding that
allow for genetic evaluation of chromosomes. Examples
include FISH (88271-88275), quantitative polymerase
chain reaction (PCR) of short tandem repeats, quantitative fluorescence PCR, quantitative real-time PCR dosage
analysis, quantitative mass spectrometry of singlenucleotide polymorphisms, and CGH. Emerging technologies allow molecular karyotyping to be performed using
microarrays (88385 and 88386) via hybridization of
patient DNA to specific isolated chromosomal regions
(array-CGH) or, more generally, with arrays that target
single- nucleotide polymorphisms and/or regions of copy
number variation in the human genome.

Chromosomal Breakage Syndromes

Chromosomal analysis for breakage syndromes (88245,
88248, and 88249) refers to studies performed to identify a
group of rare genetic disorders typically transmitted in an
autosomal recessive mode of inheritance. In culture, cells
from affected individuals exhibit elevated rates of chromosomal breakage or instability, leading to chromosomal
rearrangements. Examples of these disorders include ataxia

CPT Assistant May 2008 / Volume 18 Issue 5

telangiectasia, Bloom syndrome, Fanconi anemia, and

xeroderma pigmentosum. They are characterized by a
defect in DNA repair mechanisms or genomic instability.

additional karyotype analysis. Code 88291, Cytogenetics

and molecular cytogenetics, interpretation and report,
should also be reported for the interpretation and report.

A chromatid is one of two identical copies of DNA making up a chromosome that are joined at their centromeres,
for the process of nuclear division (mitosis or meiosis).
Sister chromatid exchange (SCE) (88245) is a sophisticated
cytomolecular technique commonly applied in a search for
clastogenicity or genotoxicity. A clastogen is any environmental agent, including carcinogens, that causes damage
to genetic material. Therefore, SCE is used to help determine whether the chromosomes and, thus, DNA of a particular interest group have undergone genetic damage
compared with a control group.

Code 88264, Chromosome analysis; analyze 20-25 cells,

refers to complete analysis of the chromosomes, as is done
in cancer studies because mosaicism for structural abnormalities is common. In prenatal diagnosis, structural chromosome mosaicism is so low relative to numerical
mosaicism that it is detected through the simple counting
of the chromosomes.

In the SCE technique, one sister chromatid (half of a

chromosome) is stained darkly and the other one lightly.
In a healthy person, it is not unusual for the sister chromatids of one chromosome to break and swap pieces with
each other. This is SCE and, provided the number of
SCEs does not go beyond a certain threshold, it is not
considered harmful. However, any increase in frequency of
SCEs beyond the threshold indicates genetic damage,
which can lead to ill health. Many environmental agents
(eg, ultraviolet light, X-rays, nicotine, and alcohol) at
home or at work can increase the number of SCEs.

Commonly Asked Questions

Question 1: Our chorionic villus biopsy studies include
culturing of cells and chromosome study to determine fetal
karyotype, which includes counting and analyzing 20 mitotic
cells (two G-banded karyotypes are prepared and analyzed).
Is code 88264 appropriate to report for the chromosome analysis with this study? Can we additionally report code 88280 for
the second karyotype?
Answer: For the scenario described, code 88264 would
not be correct. Code 88235, Tissue culture for nonneoplastic disorders; amniotic fluid or chorionic villus cells,
should be reported for the cell culture. Code 88267,
Chromosome analysis, amniotic fluid or chorionic villus,
count 15 cells, 1 karyotype, with banding, should be reported
for the analysis. (The work involved may vary depending
on whether a laboratory chooses to perform direct chorionic villus sample preparations in addition to the cultured
cells and on whether in situ methods are used or cell culture is performed followed by analysis of dispersed cells.)
Twenty cells would be the standard, although some performing in situ methods argue that the statistical power is
higher in that setting, so fewer cells can be studied.
Code 88285, Chromosome analysis; additional cells counted,
each study, should be reported once for the additional
five cells analyzed. Code 88280, Chromosome analysis;
additional karyotypes, each study, is reported once for the

Question 2: Are cell count and karyotyping included in code

88264, or is only analysis included? If count and karyotype are
included, how many cells and karyotypes are built in? If chromosome analysis is performed on a specimen by counting and
analyzing 20 cells plus two karyotypes with banding, how is
this reported?
Answer: Yes, code 88264 incorporates both cell count and
karyotyping.The basic distinctions in the 88261-88264
series of codes are that code 88262, Chromosome analysis;
count 15-20 cells, 2 karyotypes, with banding, is used for
cytogenetic studies of inherited (constitutional) chromosome status, whereas code 88264, Chromosome analysis;
analyze 20-25 cells, is used to assess acquired chromosome
abnormalities associated with cancer. Therefore, code
88262 is used to describe identification of numerical chromosome abnormalities. Counting the number of chromosomes in 15 to 20 cells and determining two karyotypes to
find abnormal chromosome counts is sufficient because
mosaicism for structural abnormalities is rare.
Regarding code 88264, Chromosome analysis; analyze
20-25 cells, in cytogenetics, the term analysis incorporates two tasks: (1) a count of all chromosomes in the
cell to determine whether the cell contains a normal or
abnormal number of chromosomes and (2) determination
of a karyotype.
Code 88264 describes a procedure that includes both tasks
for each cell reviewed. If 20 cells are reviewed, one performs 20 counts and 20 karyotypes, examining each cell
for the possibility of different cell lines (clones and/or subclones) because when cancer is present, different clones
can have numerical or structural chromosomal differences.
By definition, chromosome counts and karyotypes are
inherent in a complete analysis (88264). It would be inappropriate to use code 88264 with a code (eg, 88262) that
includes a count and/or karyotype.
The interpretation and report of the cytogenetic service
for codes 88264 and 88262 is additionally reported with
code 88291, Cytogenetics and molecular cytogenetics, interpretation and report.

CPT Assistant May 2008 / Volume 18 Issue 5

Question 3: Is code 88285 appropriately reported for each

additional cell counted beyond the number specified in the
base code (eg, 88261 or 88262), or does it cover all additional
cells counted for the study (ie, single test result)? For example,
assume code 88261 accurately applies as the base code for
chromosome analysis for a particular study, but 10 cells are
counted instead of 5 as specified in the descriptor: Do I report
code 88285 five times to account for the additional cells, or
only once?
Answer: Code 88285, Chromosome analysis; additional cells
counted, each study, covers all additional cells counted and,
therefore, should be reported once. The descriptor indicates the analysis of additional cells (plural).

Glossary of Terms
allele One member of a pair or series of genes that occupy
a specific position on a specific chromosome.
aneuploidy The gain or loss of individual chromosomes
from the normal diploid set of 46 chromosomes. As in
structural anomalies, the error may be present in all cells
of a person or in a percentage of cells.

banding Techniques that differentially stain chromosomes,

allowing chromosomes of otherwise equal size to be differentiated and to elucidate the breakpoints. Some types
include the following:
C-banding that stains centromeres;
R-banding, the reverse of C-banding, that stains noncentromeric regions in preference to centromeres;

clastogen Any environmental agent that causes damage

to genetic material and may include carcinogens.
diploid Having two sets of chromosomes in each body
cell. The diploid number of chromosomes includes a haploid set from each parent. Many one-celled organisms are
haploid throughout most of their life cycle. The human
diploid number is 46.
karyotype The chromosomal characteristics of an animal.
When stained chromosomes are visualized and enumerated, the resulting pattern is termed the karyotype of the
cell. Karyotyping is useful in determining the presence of
chromosomal defects.
meiosis The set of two successive cell divisions that serve
to separate homologous chromosome pairs before the formation of gametes (sperm and eggs). A critical component
of sexual reproduction, the major purpose of meiosis is the
precise reduction in the number of chromosomes by half,
so that a diploid cell can create haploid gametes.
mitosis Cell division.
mosaicism A condition in which an individual has two or
more cell populations that differ in genetic makeup. This
situation can affect any type of cell, including blood cells,
gametes (egg and sperm cells), and skin cells. Mosaicism
may be detected through chromosome evaluation. It is
usually described as a percentage of the cells examined.
The normal chromosome finding in males is 46 XY, and
that in females is 46 XX.
References

G-banding, obtained with Giemsa stain and yields a

series of lightly and darkly stained bands; and

Cohen J. Sorting out chromosome errors. Science. June 21, 2002;

296:2164-2166.

Q-banding, a fluorescent pattern obtained using

quinacrine for staining that gives a pattern of bands
similar to that seen in G-banding.

Haines JL, Pericak-Vance MA. Approaches to Gene Mapping

in Complex Human Diseases. New York, NY: John Wiley &
Sons; 1998.

centromere The constricted part of a chromosome that is

responsible for proper segregation of each chromosome
pair during cell division. The chromatids in mitosis and
each pair of homologous chromosomes in meiosis are held
together at the centromere until anaphase, when they separate and move to the spindle poles, thus being distributed
to the two daughter cells.
chromosome The small bodies in the nucleus of a cell
that carry the chemical instructions for reproduction of
the cell. They consist of strands of DNA wrapped in a
double helix around a core of proteins. Each species of
plant or animal has a characteristic number of chromosomes. For human beings, for example, it is 46 (23 pairs
22 pairs of autosomal, or nonsex, chromosomes and 1 pair
of sex chromosomes).

Klug WS, Cummings MR. Concepts of Genetics. Upper Saddle

River, NJ: Prentice Hall; 1997.
Thompson MW, McInnes RR, Huntington WF. Genetics in
Medicine. Philadelphia, PA: WB Saunders Co, 1991.
Verma RS, Babu A. Human Chromosomes: Manual of Basic
Techniques. New York, NY: Pergamon Press; 1989.
Vogel F, Motulsky AG. Human Genetics. Berlin, Germany:
Springer-Verlag; 1986.
Weaver RF, Hedrick PW. Genetics. Dubuque, IA: WMC Brown
Publishers; 1989.
Young ID. Introduction to Risk Calculation in Genetic Counseling.
Oxford, England: Oxford University Press; 1999.
Adapted from Jorgenson KF, van de Sande JH, Lin CC. The use
of base pair specific DNA binding agents as affinity labels for the
study of mammalian chromosomes. Chromosoma. 1978;68:287-302.
Nowell PC, Rowley JD, Knudson AD Jr. Cancer genetics, cytogenetics: defining the enemy within. Nat Med. October, 1998;
4:1107-1111.
This article incorporates text in the public domain from the US
National Library of Medicine.

CPT Assistant May 2008 / Volume 18 Issue 5

Coding Communication: Manual Muscle

Testing, Range of Motion Testing, and
Physical Test or Measurement
Manual Muscle Testing (9583195834)
CPT codes 95831, Muscle testing, manual (separate
procedure) with report; extremity (excluding hand) or
trunk, and 95832, Muscle testing, manual (separate
procedure) with report; hand, with or without comparison
with normal side, are intended to report a manual test of
specific muscles or muscle groups for strength graded by
the physician or other qualified health care professional.
Manual muscle test findings can be reported using either a
numerical scale (0-5) or equivalent semiquantitative language, such as zero, trace, fair, good, or normal. Code
95831 should be reported once for each extremity and/or
once for the trunk, and code 95832 should be reported
once for the hand with or without comparison to the
other hand. Code 95833, Muscle testing, manual (separate
procedure) with report; total evaluation of body, excluding
hands is intended for reporting a total body manual muscle
test excluding the hands, and code 95834, Muscle testing,
manual (separate procedure) with report; total evaluation of
body, including hands is for reporting a total body manual
muscle test including the hands. Manual muscle testing
requires the provider to isolate specific muscles and test
them with or without gravity eliminated and with or without manual resistance.
Manual muscle testing requires a separate report identifying specific muscles and their grades. Manual muscle testing that does not meet these criteria should be considered
part of the evaluation and management (E/M) service or
part of the physical and occupational therapy evaluation/
re-evaluation codes 97001-97004. Gross testing of muscle
strength (eg, testing plantar flexion without separating the
soleus from the gastrocnemius) is typically included as part
of the physical examination, one of the key components
used to determine the level of E/M service codes. Testing
muscle strength is also a typical component of physical
and occupational therapy evaluations/re-evaluations. In
contrast, manual muscle testing of specific muscles of an
extremity, trunk, or hand is indicated when the patients
condition requires a more thorough review of isolated
muscle function (eg, lower motor neuron disease).
Although it is not typical to see reporting of manual muscle testing codes with E/M services or physical therapy and
occupational therapy evaluations/re-evaluations (9700197004), it is possible that a specific condition will require
comprehensive testing above and beyond what is considered integral to an examination. The documentation

should support the need for manual muscle testing services

performed on the same date of service as an E/M service
or a physical therapy evaluation/re-evaluation (9700197004). Manual muscle testing codes 95831-95833 may
be reported on dates subsequent to an E/M service or
physical and occupational therapy evaluations/reevaluations as long as the code requirements are met.
The language included in each of the descriptors for use of
these codes indicates:

the body area(s) addressed by each code in the series

(eg, extremity, trunk, or hand, with or without comparison to normal side, total evaluation of body);

manual muscle testing; and

the preparation of a separate, written report of the

findings as a necessary component of the procedure.

Manual muscle testing that includes standardized scale

comparisons and a separate, written report is separately
reportable from E/M services performed on the same date.
If the key components for a given level of E/M service are
performed, then those services should be reported separately with modifier 25 appended to identify the E/M service as a significant, separately identifiable procedure. As
stated in the E/M services guidelines, Any specifically
identifiable service (ie, identified with a specific CPT
code) performed on or subsequent to the date of initial or
subsequent E/M services should be reported separately.

Range of Motion Measurements

(95851 and 95852)
Range of motion testing measures the degrees of passive
and active movement at a joint, and the provider compares the measurements to expected normal ranges of
movement for that body part or area. Contralateral testing
may be included and indicated. Typically, a goniometer or
inclinometer is used for this testing. The physician or
other qualified health care professional measures the
degree of movement in multiple planes of motion, assesses
the capsular end feel of the joint, observes muscle substitution patterns due to weakness of surrounding muscles, and
notes pain, tonus, and crepitus at specific places in the arc
of motion. This type of testing is not time based and is different than endurance, dexterity, and/or strength testing.

CPT Assistant May 2008 / Volume 18 Issue 5

Code 95851, Range of motion measurements and report

(separate procedure); each extremity (excluding hand)
or each trunk section (spine), may be reported for each
extremity (excluding hand) measured or for each trunk
section measured (eg, cervical, thoracic, or lumbar).
Code 95852, Range of motion measurements and report
(separate procedure); hand, with or without comparison with
normal side, is intended to report range of motion measurements of the hand.
Interpretation of the results with preparation of a separate,
distinctly identifiable, signed written report is required
when reporting codes 95851 and 95852. In instances
when separately reporting these codes is appropriate, written documentation of medical necessity in the medical
record should reflect the need for each individual service.

How to Code

10

Codes 95831-95834 and 95851-95852 are designated

as separate procedures. Some of the procedures or
services listed in the CPT codebook are commonly performed as an integral component of a total service or procedure. These procedures are identified by including the
term separate procedure in the code descriptor. An integral
component would be considered necessary to complete the
total procedure or service. From a CPT coding perspective, codes designated as separate procedures should not be
reported in addition to the code for the total procedure or
service for which they are considered integral components. It is incumbent upon the provider to support the
need for range of motion or manual muscle testing services
in the documentation.

Physical Performance Test or

Measurement (97750)
Code 97750, Physical performance test or measurement (eg,
musculoskeletal, functional capacity), with written report, each
15 minutes, describes tests and measurements performed by
a physician or other qualified health care professional.
Testing may be manual and/or performed using equipment.
Examples include isokinetic testing, functional capacity
testing, timed up and go test, dynamic gait index, and
computerized muscle testing. Standardized testing batteries
may be incorporated into a physical performance test.
Elements involved in physical performance tests or measurements, as reported by code 97750, include the test or
measurement procedure itself, as well as time required to
analyze and interpret the resulting data while the patient
is present. Code 97750 is time based. Documentation of
the following time elements will assist in supporting the
number of units billed for this procedure:

Total time spent with the patient in providing the test

and measurement, including the time spent preparing
the patient for the test and measurement procedure

The time spent performing the selected protocol

The time spent with the patient in providing any

posttesting instructions

The descriptor for code 97750 does include the terminology by report. Documentation to support the reporting of
this code should include a description of the test and
measure protocol, the data collected, and the impact of
the outcome of the test and measure on the patients plan
for care (ie, need for continuing treatment, discharge from
treatment, or referral to other provider[s]).
Although it is atypical, code 97750 may be reported on
the same date of service as an E/M service or a physical
therapy and occupational therapy evaluation/re-evaluation. Documentation should support the need for the
physical performance test or measurement to be done on
the same date of service as physical or occupational therapy evaluation/re-evaluation, as well as a separate written
report stating the findings, as described above.

Clinical Example (97750)

A patient who is a data entry operator requires physical
performance testing to determine if job duties exacerbate
clinical findings of carpal tunnel syndrome. Nerve conduction studies were negative; however, the patient complains of a numbness in the median nerve distribution
and pain in the proximal palm while on the job and often
at night.

Description of Procedure (97750)

The patients level of pain is measured through the
use of the Magill Pain Questionnaire. Sensation testing is performed specifically to assess light touch and
deep pressure with testing of contralateral side for
comparison. Pinch and grip strength are measured,
also bilaterally, through the use of both a pinch and
hand grip dynamometer. Specific functional abilities
related to her identified work activities are measured
and documented. The provider develops a program to
address the instruction or practice of accommodated
work-related activities.

Commonly Asked Questions

Question: When is it appropriate to report code 97750,
Physical performance test or measurement, manual muscle
testing (95831-95834), and/or range of motion testing
(95851-95852)?

CPT Assistant May 2008 / Volume 18 Issue 5

Answer: If the intent of the physician or qualified health

care provider is to perform a range of motion and/or manual muscle test (eg, to compare the right and left sides) as
a separate procedure, it would be appropriate for the
provider to choose the appropriate codes from the 9583195852 series. For example, a patient with a lower motor
neuron disease (eg, post-polio syndrome or Guillian-Barre
syndrome) presents with weakness of isolated muscle
groups. The provider will want to identify any restrictions
in passive and active range of motion as well as specific
muscles that are weak. The provider will use this information to establish a treatment plan that will positively
impact identified impairments. If the provider instead
determines that it is appropriate to measure and test the
patients physical performance during specific activities,
then code 97750 is the appropriate service to report.
Question: What are the appropriate components of documentation that will support the use of code 97750?
Answer: When reporting code 97750, the physician or
other qualified health care professional is required to have
a separate written report noting the findings. The provider
should include the reason for performing the test or measurement, identification of any protocol or standardized test
that was used, data that were collected, direct contact
time spent with the patient, and analysis of the findings.

Question: Can manual muscle testing (95831-95834), range

of motion testing (95851-95852), and physical performance
test and measurement (97750) be performed on the same date
of service?
Answer: No. Codes 95851, Range of motion measurements
and report (separate procedure); each extremity (excluding
hand) or each trunk section (spine), and 95831, Muscle testing, manual (separate procedure) with report; extremity
(excluding hand) or trunk, are designated in the code
descriptors as separate procedures. Codes designated as
separate procedures should not be reported in addition to
the code for the total procedure or service for which they
are considered an integral component. In this case,
because range of motion testing (95851) and manual muscle testing (95831) may be performed as part of a physical
performance test or measurement (eg, musculoskeletal or
functional capacity), only code 97750 should be reported.
Codes 95851 and 95831 should not be reported separately
because both services are designated as separate procedures
and, as such, would be considered integral components of
a physical performance test (97750).
Question: How is computerized muscle testing reported?
Answer: Computerized muscle testing should be reported
using code 97750. A separate written report is required.
Only direct patient contact time is reported.

11

Screening continued from page 4

and updated estimates yields $373.344 billion in economic
costs to the United States due to alcohol and drug abuse in
the year 2000.
2. Muoz, RF, Mrazek, PJ, Haggerty, RJ. Institute of Medicine
Report on Prevention of Mental Disorders: Summary and
Commentary, Psychology in the Public Forum. 1996; Volume
51(11): p 1116-1122.
3. Gerstein D and Harwood H (eds). 1990. Treating Drug
Problems, Vol. I. Washington DC: National Academy Press: p
58-104.

5. Fleming MF. 2002. Screening, assessment, and intervention

for substance use disorders in settings. In: Strategic Plan for
Interdisciplinary Faculty Development: Arming the Nations
Health Professional Workforce for a New Approach to Substance
Use Disorders. Providence RI: Association for Medical
Education and Research in Substance Abuse (AMERSA).
6. Babor TF and Higgins-Biddle JF. 2001. Brief Intervention for
Hazardous and Harmful Drinking: A Manual for Use in Primary
Care. Geneva: World Health Organization. WHO/MSD/
MSB/01.6b.

4. Klitzner M, Fisher D, Stewart K, and Gilbert S. 1992. Early

Intervention for Adolescents. Princeton NJ: Robert Wood
Johnson Foundation.

CPT Assistant May 2008 / Volume 18 Issue 5

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Coding Consultation: Questions and Answers

Evaluation and Management: Office
or Other Outpatient Services
Question: What is the appropriate code to report the service
when a physician uses a fluorescein dye and Woods lamp to
check the eye for a corneal abrasion or foreign body?
Answer: The examination and fluorescein dye test are
included in the evaluation and management (E/M) service
and are not reported separately. However, the work
involving the detailed eye examination and history may
allow the reporting of a higher-level E/M code. It is recommended that the 1997 CMS documentation guidelines
at the following Web site, http://www.cms.hhs.gov/
MLNProducts/Downloads/MASTER1.pdf, which contain
the reporting criteria for single specialty examinations, be
consulted in selecting the appropriate level of E/M service.

Medicine: Physical Medicine and

Rehabilitation
Question: What services do the work hardening/conditioning
codes 97545 and 97546 include? Do they require one-on-one
patient-therapist contact?
Answer: Although these codes appear under the 9711097546 heading of Therapeutic Procedures, these services
do not require one-on-one physician or therapist contact.
These codes represent a program developed to address the
persons strength, endurance, flexibility, motor control,
and cardiopulmonary capacity related to performance of
the work tasks that are identified through a job description or through communication with others involved in
the persons health care and return to work management.
Work hardening and work conditioning are typically performed with people who have experienced an injury at
work or are disabled from an injury or disease process and
have the goal to return to work. These services could be
guided by return-to-work protocols developed by providers
and other external sources. Work hardening and work
conditioning are provided in a program format that typically include certain components, as follows.
Work hardening (1) is a highly structured, goal-oriented,
individually designed intervention program with the goal
of return to work; (2) is multidisciplinary, using real or
simulated work activities designed to restore physical,
behavioral, and vocational functions; (3) addresses the
issues of productivity, safety, physical tolerances, and
worker behaviors specific to a category of work or a specif-

ic job task;
(4) is typically provided for a duration of 4 to 8 weeks
with a typical frequency of 4 or 5 days; and (5) requires
patient attendance for multiple hours at each scheduled
visit depending on the type or category of work for which
the work hardening goals are developed.
The person typically participates 4 to 8 hours at each
treatment session. The therapists content of the service
includes patient education, work simulation, and specific
therapeutic exercises geared toward improving identified
work functions and may be spread over the visits. Time of
work hardening and not the therapists personal time of
direct supervision is reported.
Work conditioning is an intensive, work-related, goal-oriented conditioning program designed specifically to
restore systemic neuromusculoskeletal functions (eg, joint
integrity and mobility; muscle performance, including
strength, power, and endurance; motor function [motor
control and motor learning]; range of motion, including
muscle length; and cardiovascular and pulmonary functions [eg, aerobic capacity and endurance, circulation,
ventilation, respiration, and gas exchange]). The objective
of the work conditioning program is to restore physical
capacity and function to enable the person to begin the
return-to-work process, but it does not have goals related
to a specific job task or category of work.
Work conditioning can be from 1 to 6 hours per day and
is typically for a shorter duration than work hardening
(4-6 weeks). Work conditioning programs can either allow
a person to return to work or can lead to a more specific
work hardening program and more specific work-related
discharge criteria.
If a provider reports code 97545 or 97546 on the same
date of service as the codes that describe other therapeutic
procedures that also address parameters of strength, flexibility, endurance, range of motion, motor control, or
return of function (97110, 97112, and 97530), the documentation must support these as direct contact, separately
identifiable services and must clearly differentiate these
services from services provided in a work hardening or
work conditioning program.
Source: American Physical Therapy Association. Guidelines:
Occupational Health Physical Therapy: Work Conditioning and
Work Hardening Programs. BOD G03-01-17-58 (Program 32)
[Retitled: Occupational Health Guidelines: Work Conditioning
and Work Hardening Programs, Amended BOD 03-00-25-62;
BOD 03-99-16-49; BOD 11-94-33-109; Initial BOD 11-92-29134] [Guideline])
AMA CPT Assistant, Q/A Winter 1992

CPT Assistant May 2008 / Volume 18 Issue 5

13

Pathology and Laboratory: Surgical

Pathology
Question: What is the correct way to report a microarray of
more than 500 probes? If the array has 1500 probes, for example, do I report code 88386, Array-based evaluation of multiple molecular probes; 251 through 500 probes, three
times? Or should I report the unlisted procedure code, 88399,
Unlisted surgical pathology procedure?
Answer: The array-based evaluation of more than 500
probes is an unlisted service and should be reported with
CPT code 88399. When reporting an unlisted code to
describe a procedure or service, it is necessary to submit
supporting documentation (eg, procedure report) along
with the claim to provide an adequate description of the
nature, extent, and need for the procedure and the time,
effort, and equipment necessary to provide the service

Radiology: Diagnostic Radiology

(Diagnostic Imaging)

14

Question: During the insertion of a dual-chamber implantable cardioverter-defibrillator, the physician indicated a left
subclavian venogram was obtained to facilitate entry. Is it
appropriate to report code 75820, Venography, extremity,
unilateral, radiological supervision and interpretation, separately in addition to codes 33249, Insertion or repositioning
of electrode lead(s) for single or dual chamber pacing cardioverter-defibrillator and insertion of pulse generator and
code 71090, Insertion pacemaker, fluoroscopy and radiography, radiological supervision and interpretation?
Answer: No. The service described is not a diagnostic
venogram, but is rather used for guidance of the leads
obtained to facilitate entry. Therefore, it would not be
appropriate to separately report code 75820.
Question: When a gastrointestinal procedure, such as an endoscopic retrograde cholangiopancreatography, is performed and
includes radiological supervision and interpretation, who can
report the radiology services? For example, if the images are
sent to a radiologist for review after the case has ended, would
it be appropriate for the radiologist to report the supervision and
interpretation service? By definition, it seems that for supervision and interpretation, the provider must be in attendance for
the intraoperative session in order to report the service. The
CPT codes in question are code 43260, Endoscopic retrograde cholangiopancreatography (ERCP); diagnostic, with
or without collection of specimen(s) by brushing or washing (separate procedure) and code 74328, Endoscopic
catheterization of the biliary ductal system, radiological
supervision and interpretation.

Answer: Radiologic supervision and interpretation codes

are used to describe the personal supervision of the performance of the radiologic portion of a procedure by one
or more physician(s) and the interpretation of the findings. To report the supervision aspect of the procedure,
the physician must be present during its performance. This
kind of personal supervision of the performance of the
procedure is a service to an individual patient and differs
from the type of general supervision of the radiologic procedures performed in a hospital for oversight of the
department, such as for safety and quality control processes. The interpretation of the procedure may be performed
later by another physician. In situations in which a cardiologist, for example, bills for the supervision (the S) of
the S&I code, and a radiologist bills for the interpretation
(the I) of the code, both physicians should use modifier
52 indicating a reduced service, eg, the interpretation
only, in the case of the radiologist.

Surgery: Digestive System

Question: Which CPT code should be reported for a tonsillectomy and adenoidectomy when the physician excises the tonsils
using electrocautery and then destroys, ablates, or vaporizes
the adenoid tissue using suction diathermy?
Answer: Code 42820, Tonsillectomy and adenoidectomy;
younger than age 12, should be reported if the patient is
younger than age12. Code 42821 is reported for patients
12 and older. Suction diathermy is a term generally
applied to electrosurgery/electrocautery. Medical
diathermy generally indicates that no tissue harm or
destruction is done. Ablation implies removal or destruction of tissue. The same is true for removal of tonsils,
whether with electrosurgical dissection, tonsillotome, cold
knife dissection, laser, microdebrider, harmonic scalpel, or
thermal welding technique. Removal of tonsils is a tonsillectomy, and removal of adenoids is an adenoidectomy, no
matter what the technique.

Surgery: Nervous System

Question: The procedure was right frontal Ommaya reservoir
placement with Stealth guidance and neuroendoscopy placement of the ventricular catheter with intraventricular
chemotherapy infusion. Stealth was used for correct placement
of the catheter because of small ventricles, and the burr hole
was placed. The dura was opened, and the ventricular catheter
was placed. An endoscope was used to verify the correct placement of catheter tip because chemotherapy will be infused. The
endoscope was removed, and a catheter was attached and
secured to the reservoir. Gelfoam was placed in the burr hole,
and the site was irrigated and closed. Chemotherapy was
administered into the reservoir. Should code 0169T,
Stereotactic placement of infusion catheter(s) in the brain for

delivery of therapeutic agent(s), including computerized stereotactic planning and burr hole(s) be reported for this procedure?
Is placement of the ventricular catheter reported separately?
Answer: Code 0169T is to be used only for placing
catheters into the brain for convection-enhanced delivery
of chemotherapy into the brain parenchyma surrounding
a tumor resection cavity. It is not appropriate to use this
code for Ommaya reservoir placement.
Code 61210, Burr hole(s); for implanting ventricular catheter,
reservoir, EEG electrode(s), pressure recording device, or other
cerebral monitoring device (separate procedure) should be
reported for this procedure. Codes 61795, Stereotactic computer-assisted volumetric(navigational) procedure, intracranial,
extracranial, or spinal (List separately in addition to code for
primary procedure) and 62160, Neuroendoscopy, intracranial,
for placement or replacement of ventricular catheter and
attachment to shunt system or external drainage (List separately in addition to code for primary procedure) could also be
reported in this obviously difficult case.

Surgery: Digestive System

Question: What is the appropriate code to report the Malone
procedure (appendicocolostomy) that is performed for fecal
incontinence after repair of an imperforate anus?
Answer: Code 44799, Unlisted procedure, intestine, should be
reported for this procedure. The Malone procedure is used
for children with constipation secondary to congenital
problems and is not commonly performed. When reporting an unlisted code to describe a procedure or service, it
is necessary to submit supporting documentation (eg, procedure report) along with the claim to provide an adequate description of the nature, extent, need for the procedure and the time, effort, and equipment necessary to
provide the service.

Surgery: Cardiovascular System

Question: What is the appropriate code to report for a secondary mechanical arterial thrombectomy?
Answer: Code 37186, Secondary percutaneous transluminal
thrombectomy (eg, nonprimary mechanical, snare basket, suction technique), noncoronary, arterial or arterial bypass graft
including fluoroscopic guidance and intraprocedural pharmacological thrombolytic injections, provided in conjunction with
another percutaneous intervention other than primary mechanical thrombectomy (List separately in addition to code for primary procedure) should be reported for this procedure.
However, it should be noted that secondary mechanical
thrombectomy is not reported when performed in addition
to primary thrombectomy, nor is the fluoroscopic guidance
or intraprocedural injection of thrombolytic agents reported separately in that instance.

Surgery: Respiratory System

Question: If multiple, distinct procedures are performed
during a single bronchoscopy, is it appropriate to report
each separately?
Answer: It is appropriate to report multiple procedures
Sperformed during a single bronchoscopy. For example,
bronchoscopy in a patient with lobar pneumonia to
Sidentify the infectious cause might include a bronchial
alveolar lavage (31624), a protected brush sampling
(31623), and a transbronchial lung biopsy (31628), all
during the same session.

15

Learn to code condentlyorder

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