Using the coding techniques, you have learned, carefully read through the case study and determine the most accurate procedure code(s) and modifier(s), for all services as appropriate.

WESTON HOSPITAL

629 Healthcare Way SOMEWHERE, FL 32811 407-555-6541

PATIENT: UPTON, MAXINE

ACCOUNT/EHR #: UPTOMA001

Diagnosis: Medulloblastoma

Procedure: Central Venous Access Device (CVAD) insertion

Physician: Vincent Hoyt, MD

Anesthesia: Conscious sedation

PROCEDURE: Patient is a 4-year-old female, with a recent diagnosis of malignancy. Due to an upcoming course of chemotherapy, the CVAD is being inserted to ease administration of the drugs. The patient was placed on the table in supine position and 1 mg of Versed was administered IM; moderate sedation was achieved, 13 minutes. Maxine's vital signs were monitored by the nurse. The incision was made to insert a central venous catheter, centrally. During the placement of the catheter, a short tract (nontunneled) was made as the catheter was advanced from the skin entry site to the point of venous cannulation. The catheter tip was set to reside in the subclavian vein. The patient was gently aroused from the sedation and was awake when transported to the recovery room.

Be sure to list the codes, one code per box, in the correct sequence, from top to bottom, and in the proper row. Capitalization, punctuation, and spacing can impact whether or not your answer is correct. Follow coding best practices. Please list modifiers with the code they relate to as necessary. Include a hyphen in between the code and the modifier. Example Procedure: 43846-74 or for Anesthesia: 00797-P2.

NOTE: The CPT Changes: An Insider's View; CPT Assistant and Clinical Examples are not considered symbols or notations for this exercise.

Determine the accurate surgery CPT code(s) and modifier(s), if appropriate.

The number of spaces provided does not indicate the number of codes required to accurately report this encounter.

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