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

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’s Manual to
Accompany Understanding
Current Procedural
Terminology and HCPCS
Coding Systems
Sixth Edition
MARY JO B OWIE,
MS, BS, AAS, RHIA, RHIT
TEXTBOOK GUIDE

iii
TABLE OF CONTENTS
INTRODUCTION 1
SECTION I: GETTING STARTED 2
SECTION II: CHAPTER LESSON PLANS AND ANSWER KEYS 4
Chapter 1: Introduction to Current Procedural Terminology 4
Chapter 2: Modifiers 8
Chapter 3: Evaluation and Management 12
Chapter 4: Anesthesia 17
Chapter 5: Surgery and the Integumentary System 21
Chapter 6: Musculoskeletal System 26
Chapter 7: Respiratory System 31
Chapter 8: Cardiovascular System 36
Chapter 9: Hemic and Lymphatic Systems 41
Chapter 10: Mediastinum and Diaphragm 44
Chapter 11: Digestive System 46
Chapter 12: Urinary System 51
Chapter 13: Male Genital System 55
Chapter 14: Female Genital System 58
Chapter 15: Maternity Care and Delivery 62
Chapter 16: Endocrine System 65
Chapter 17: Nervous System 67
Chapter 18: Eye and Ocular Adnexa 70
Chapter 19: Auditory System and Operating Microscope 73
Chapter 20: Radiology 76
Chapter 21: Pathology and Laboratory 81
Chapter 22: Medicine 83
Chapter 23: HCPCS Codes 87
SECTION III: ANSWER KEY FOR APPENDIX VII CASE STUDIES 92

INTRODUCTION
This instructor’s manual is organized into two sections.
SECTION I
Getting Started
This section contains a semester plan that is used for a 15-week semester and a course outline that can be modified and
given to students on the first day of class.
SECTION II
Chapter Lesson Plans and Answer Keys
This section contains a lesson plan for each chapter that includes lecture topics, an overview of the chapter, chapter
objectives, and the answers to the exercises and Chapter Review. The authors suggest that students complete the
exercises contained in the chapters as homework. The Chapter Reviews and coding cases should be completed as part
of laboratory time.
SECTION III
Answer Key for Appendix VII Case Studies
This section contains the answer key for the case studies found in the core text, Appendix VII.

Section I
Getting Started
This section contains a semester plan and a course outline. The semester plan is intended to be used as a guide to
organize the course content. The course outline can be used to develop a course syllabus that can be updated according
to your specific class needs.
SEMESTER PLAN
This plan is for 45 hours of lecture and 30 hours of lab time. The lecture time assumes 30 minutes to 1 hour for testing
on each chapter. The instructor’s Microsoft PowerPoint presentation that accompanies this manual should be used. As
homework assignments for each chapter in the following list, students should complete the exercises found within the
textbook chapters and review the Internet links found at the end of the chapters. The lab assignments to be used include
the coding assignments and case studies found at the end of the chapters in the core book. The students also should be
instructed to complete the Chapter Review at the end of each chapter. The Chapter Reviews can be completed as
homework assignments or as lab assignments.
Lecture Hours Lab Hours
Chapter 1 Introduction to Current Procedural Terminology 3 1
Chapter 2 Modifiers 3 2
Chapter 3 Evaluation and Management 3 2
Chapter 4 Anesthesia 3 2
Chapter 5 Surgery and the Integumentary System 2 2
Chapter 6 Musculoskeletal System 2 2
Chapter 7 Respiratory System 2 2
Chapter 8 Cardiovascular System 2 2
Chapter 9 Hemic and Lymphatic Systems 1 0.5
Chapter 10 Mediastinum and Diaphragm 1 0.5
Chapter 11 Digestive System 2 2
Chapter 12 Urinary System 2 1
Chapter 13 Male Genital System 1.5 1
Chapter 14 Female Genital System 1.5 1
Chapter 15 Maternity Care and Delivery 2 1
Chapter 16 Endocrine System 1.5 1
Chapter 17 Nervous System 1.5 1
Chapter 18 Eye and Ocular Adnexa 1.5 1
Chapter 19 Auditory System and Operating Microscope 1.5 1
Chapter 20 Radiology 2 1
Chapter 21 Pathology and Laboratory 2 1
Chapter 22 Medicine 2 1
Chapter 23 HCPCS Codes 1 1
TOTAL HOURS 44 30

Section I ■ Getting Started 3
COURSE OUTLINE
This 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: Cengage
Learning, 2019.
Division of Subject Matter
Date to Be Completed
(List dates according to school
calendar.)
Chapter 1 Introduction to Current Procedural Terminology
Chapter 2 Modifiers
Chapter 3 Evaluation and Management
Chapter 4 Anesthesia
Chapter 5 Surgery and the Integumentary System
Chapter 6 Musculoskeletal System
Chapter 7 Respiratory System
Chapter 8 Cardiovascular System
Chapter 9 Hemic and Lymphatic Systems
Chapter 10 Mediastinum and Diaphragm
Chapter 11 Digestive System
Chapter 12 Urinary System
Chapter 13 Male Genital System
Chapter 14 Female Genital System
Chapter 15 Maternity Care and Delivery
Chapter 16 Endocrine System
Chapter 17 Nervous System
Chapter 18 Eye and Ocular Adnexa
Chapter 19 Auditory System and Operating Microscope
Chapter 20 Radiology
Chapter 21 Pathology and Laboratory
Chapter 22 Medicine
Chapter 23 HCPCS Codes

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Section II
Chapter Lesson Plans
and Answer Keys
CHAPTER 1
INTRODUCTION TO CURRENT
PROCEDURAL TERMINOLOGY
LESSON PLAN
Time: 2–3 hours instructor preparation
3 hours in-class lecture time
1 hour in-class lab time (if lab component is part of course)
Topics: History of Current Procedural Terminology
The Structure and Design of CPT
CPT as Part of HCPCS
Overview: This chapter presents an overview, the development, and the format of CPT. It further discusses
the 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.
OBJECTIVES
1. 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 Terminology 5
EXERCISE ANSWERS
1.1 – Check Your Understanding
Code Section/Subsection
1. 70300 Radiology/Diagnostic Radiology (Diagnostic Imaging)
2. 60220 Surgery/Endocrine System
3. 26034 Surgery/Musculoskeletal System
4. 88036 Pathology & Laboratory—Anatomic Pathology
5. 43651 Surgery/Digestive System
6. 38115 Surgery/Hemic and Lymphatic Systems
7. 99304 Evaluation and Management/Nursing Facility Services
8. 97010 Medicine/Physical Medicine and Rehabilitation
9. 77021 Radiology/Radiologic Guidance
10. 65112 Surgery/Eye and Ocular Adnexa
11. 90371 Medicine/Immune Globulins, Serum, or Recombinant Products
12. 99203 Evaluation and Management/Office or Other Outpatient Services
13. 10160 Surgery/Integumentary System
14. 33120 Surgery/Cardiovascular System
15. 50100 Surgery/Urinary System
16. 21811 Surgery/Musculoskeletal System
17. 66184 Surgery/Eye and Ocular Adnexa
18. 52441 Surgery/Urinary System
19. 61000 Surgery/Nervous System
20. 59074 Surgery/Maternity Care and Delivery
CHAPTER REVIEW ANSWERS
True/False
1. False
2. True
3. False
4. False
5. True
Fill in the Blank
6. American Medical Association (AMA)
7. Appendix A
8. Six
9. Semicolon
10. Index

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Chapter 1 ■ Introduction to Current Procedural Terminology 6
Coding Assignments
1. Anesthesia
2. Surgery
3. Pathology and Laboratory
4. Surgery
5. Surgery
6. Medicine
7. Evaluation and Management
8. Radiology
9. Surgery
10. Medicine
11. Surgery
12. Radiology
13. Surgery
14. Pathology and Laboratory
15. Medicine
16. Medicine
17. Pathology and Laboratory
18. Radiology
19. Surgery
20. Medicine
Short Answer
1. Unlisted procedure or service: A service may be provided that is not specifically listed in the CPT manual. When
this 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 the
main 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 procedure
and 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 the
procedure 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 Management 99201 –99499
Anesthesia 00100 –01999, 99100 –99140
Surgery 10021 –69990
Radiology (including Nuclear Medicine and Diagnostic Ultrasound)
70010 –79999
Pathology and Laboratory 80047 –89398, 0001U–0071U
Medicine (except Anesthesia) 90281 –99199, 99500 –99607

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CHAPTER 2
MODIFIERS
LESSON PLAN
Time: 2–3 hours instructor preparation
3 hours in-class lecture time
2 hours in-class lab time (if lab component is part of course)
Topics: Definition and Purposes of Modifiers
Use of Modifiers for Various Procedures and Service Locations
Modifiers Used for Hospital Outpatient Services
CPT Level I Modifiers
HCPCS Level II Modifiers
Overview: This chapter discusses the use of modifiers in the CPT and HCPCS coding systems. The
modifiers are defined, and examples are given to illustrate their use. HCPCS Level II modifiers
are also introduced.
OBJECTIVES
1. 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 ANSWERS
2.1 – Check Your Understanding
1. ND
2. US, GW
3. 56, QT
4. AA, 47
5. 51, 59
2.2 – Pricing and Statistical/Informational Modifiers
1. Pricing
2. Statistical/informational
3. Pricing
4. Pricing
5. Statistical/informational
6. Statistical/informational

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Chapter 2 ■ Modifiers 9
7. Statistical/informational
8. Pricing
9. Statistical/informational
10. Statistical/informational
2.3 – Modifiers Used for Ambulatory Surgery Center Hospital Outpatient Claims
1. No
2. Yes
3. No
4. Yes
5. No
6. No
7. Yes
8. Yes
9. Yes
10. Yes
11. Yes
12. No
13. Yes
14. Yes
15. Yes
CHAPTER REVIEW ANSWERS
Fill in the Blank
1. Two
2. Appendix A
3. 24d
4. Informational
5. Multiple
6. Preoperative
7. 32
8. 54
9. 80
10. Outside laboratory
Identify the Modifier
1. 62
2. 23
3. 22
4. 52
5. 55

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Chapter 2 ■ Modifiers 10
6. To report the professional component of a code
7. Modifier 47 is used only by physicians or surgeons when regional or general anesthesia is provided by the same
physician or surgeon who is completing a procedure or service.
8. 50
9. 56
10. Modifier 76 is used to indicate that it was necessary to indicate that a procedure or service was repeated by the
same physician or other qualified health care professional subsequent to the original procedure or service. Modifier
77 is used when a physician or other qualified health care professional needs to indicate that a basic procedure or
service performed by another physician or other qualified health care professional had to be repeated.
11. 53
12. 57
13. 66
14. 80
15. 26
16. G2
17. F8
18. GM
19. 81
20. 91
Case Studies
Case 1—Modifier 25
Rationale: An Evaluation and Management (E/M) code (99213) and a procedure code (OMT-98925) for the same day
require a modifier to identify that two separate and distinct services were performed. Modifier 25 is reported with the
E/M code.
Case 2—Modifier 53
Rationale: Because of the extenuating circumstances of the drop in blood pressure, the doctor felt that it was in the
patient’s best interest to stop the procedure.
Case 3—Modifier 55
Rationale: Modifier 55 is appended to the code to report that the provider is completing postoperative management
only.
Case 4—Modifier 63
Rationale: When a procedure is completed and the patient is a newborn and weighs less than 4 kg, modifier 63 is
appended to the procedure code.
Case 5—33475-80
Rationale: Modifier 80 is appended to the procedure code to report that the provider is the assistant surgeon for the case.
Case 6—Modifier 57
Rationale: Modifier 57 denotes that the decision for surgery was made.
Case 7—Modifier 32
Rationale: When a service occurs because the service is mandated, modifier 32 is appended to the basic procedure code.

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Chapter 2 ■ Modifiers 11
Case 8—Modifier 26
Rationale: Modifier 26 is appended to the code to report that the provider completed the professional component of the
procedure.
Case 9—No, both should report 32854-66
Rationale: Because the providers worked as a team, modifier 66 would be reported by both providers.
Case 10—32960-76
Rationale: Modifier 76 would be appended to the procedure code to denote that the procedure was repeated.

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CHAPTER 3
EVALUATION AND MANAGEMENT
LESSON PLAN
Time: 2–3 hours instructor preparation
3 hours in-class lecture time
2 hours in-class lab time (if lab component is part of course)
Topics: Documentation Guidelines for Evaluation and Management Services
Overview of the Evaluation and Management Section
Evaluation and Management Coding
Overview: This chapter discusses Evaluation and Management (E/M) coding. An overview of the codes
found in the various subsections of the Evaluation and Management section of the CPT manual
are explained. Documentation guidelines that relate to E/M coding are discussed throughout the
chapter.
OBJECTIVES
1. 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 section
of 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 ANSWERS
3.1 – Subsection and Subcategories of the CPT Evaluation and Management Section
1. Office and other outpatient services; established patient
2. Emergency department services; new or established patient
3. Home services; new patient
4. Hospital inpatient services; hospital discharge services
5. Consultations; inpatient consultation services
6. Hospital observation services; observation care discharge services

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Chapter 3 ■ Evaluation and Management 13
7. Hospital inpatient services; subsequent hospital care
8. Consultations; office or other outpatient consults
9. Advance Care Planning
10. Prolonged services; physician standby services
3.2 – POS and Evaluation and Management Codes
1. 11
2. 21
3. 12
4. 31
5. 21
6. 31
7. 21
8. 11
9. 11
10. 23
3.3 – Documentation of Patient History
1. 2—Chief complaint
2. 4—Severity
3. 6—Quality
4. 8—Associated signs and symptoms
5. 5—Family history
6. 3—Past history
7. 7—Review of systems
8. 1—Social history
3.4 – Evaluation and Management Coding
1. 99214
2. 99212
3. 99213
4. 99213
5. 99215
3.5 – Hospital Service Codes
1. 99222
2. 99232
3. 99223
4. 99238
5. 99232

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