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The questions for CPC were last updated on Mar 31, 2025.
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A cardiologist attempted to perform a percutaneous transluminal coronary angioplasty of a totally occluded blood vessel. The surgeon stopped the procedure because of an anatomical problem creating risk for the patient and preventing performance of the catheterization.
What modifier is appended to the procedure code?
Modifier 53 is used to report a discontinued procedure. It indicates that a procedure was started but terminated due to the patient's well-being being at risk. In this scenario, the percutaneous transluminal coronary angioplasty was attempted but stopped because of an anatomical problem that created a risk for the patient, preventing the completion of the procedure. Reference: AMA's CPT Professional Edition, coding guidelines on the use of modifiers.
A catheter was placed into the abdominal aorta via the right common femoral artery access. An abdominal aortography was performed. The right and left renal artery were adequately visualized. The catheter was used to selectively catheterize the right and left renal artery. Selective right and left renal angiography were then performed, demonstrating a widely patent right and left renal artery.
What CPT coding is reported?
CPT code 36252 describes selective catheter placement of the main renal artery with angiography of both kidneys, which matches the procedure of selectively catheterizing the right and left renal arteries and performing angiography. Additionally, CPT code 75625-26 is for an abdominal aortography with interpretation and report. The -26 modifier indicates that the professional component of the service was performed.
AMA's CPT Professional Edition (current year), Codes 36252, 75625-26
A patient presents to the labor and delivery department for a planned cesarean section for triplets. She is at 37 weeks gestation. She is given a continuous epidural for the delivery.
What anesthesia coding is reported?
The patient presents for a planned cesarean section for triplets and receives continuous epidural anesthesia. CPT code 01967 is used for neuraxial labor analgesia/anesthesia for planned vaginal delivery, and code 01968 is an add-on code for cesarean delivery following neuraxial labor analgesia/anesthesia. Since this is a planned cesarean section with triplets, both codes 01967 and 01968 are applicable. Reference: CPT Professional Edition (current year), AMA.
View MR 005398
MR 005398
Operative Report
Preoperative Diagnosis: Nonfunctioning right kidney with ureteral stricture.
Postoperative Diagnosis: Nonfunctioning right kidney with ureteral stricture.
Procedure: Right nephrectomy with partial ureterectomy.
Findings and Procedure: Under satisfactory general anesthesia, the patient was placed in the right flank position. Right flank and abdomen were prepared and draped out of the sterile field. Skin incision was made between the 11th and 12th ribs laterally. The incision was carried down through the underlying subcutaneous tissues, muscles, and fasci
a. The right retroperitoneal space was entered. Using blunt and sharp dissection, the right kidney was freed circumferentially. The right artery, vein, and ureter were identified. The ureter was dissected downward where it is completely obstructed in its distal extent. The ureter was clipped and divided distally. The right renal artery was then isolated and divided between 0 silk suture ligatures. The right renal vein was also ligated with suture ligatures and 0 silk ties. The right kidney and ureter were then submitted for pathologic evaluation. The operative field was inspected, and there was no residual bleeding noted, and then it was carefully irrigated with sterile water. Wound closure was then undertaken using 0 Vicryl for the fascial layers, 0 Vicryl for the muscular layers, 2-0 chromic for subcutaneous tissue, and clips for the skin. A Penrose drain was brought out through the dependent aspect of the incision. The patient lost minimal blood and tolerated the procedure well.
What CPT coding is reported for this case?
The procedure involves a right nephrectomy with partial ureterectomy for a nonfunctioning right kidney with ureteral stricture.
Procedure Description:
Right nephrectomy (removal of the kidney).
Partial ureterectomy (removal of part of the ureter).
CPT Coding:
50220: Nephrectomy, including partial ureterectomy, any open approach.
AMA's CPT Professional Edition (current year).
CPT Assistant for detailed coding guidelines on nephrectomy procedures.
The gynecologist performs a colposcopy of the cervix including biopsy and endocervical curettage.
What CPT code is reported?
Colposcopy of the Cervix: This involves a visual examination of the cervix using a colposcope.
Biopsy and Endocervical Curettage: The procedures performed include taking a biopsy and scraping the lining of the cervical canal.
CPT Code 57454: This code represents a colposcopy of the cervix with biopsy and endocervical curettage.
AMA's CPT Professional Edition (current year)
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