Top Predictions for Medical Coding Exam

Lab Freeze Stages / Frozen Section – CPT® Codes

When a specimen is quickly frozen and thinly sliced for immediate examination (often during surgery), it is called a frozen section. The most relevant CPT® codes are:

1. 88331 – Pathology consultation during surgery; first tissue block, with frozen section(s), single specimen

• 88331Pathology consultation during surgery; first tissue block, with frozen section(s), single specimen

2. 88332 – Pathology consultation during surgery; each additional tissue block with frozen section(s)

• 88332Pathology consultation during surgery; each additional tissue block with frozen section(s)

What does this mean?

• 88331 is billed once for the first frozen section specimen (first tissue block) during a surgical procedure.

• 88332 is billed for each additional tissue block (specimen) that is processed with a frozen section during the same surgical session.

Summary Table

CPT® Code	Description
88331	Frozen section, first tissue block
88332	Frozen section, each additional tissue block

Key Points for Coders/Educators

• These codes are for intraoperative (during surgery) frozen section consultation.

• The process involves rapid freezing, sectioning, staining, and microscopic examination.

• Do not use these codes for routine (non-frozen) histology or for tissue not processed as a frozen section.

Other Related Codes

• For permanent (paraffin-embedded) sections:Use 88305 (Level IV surgical pathology, gross and microscopic examination) for routine tissue exam, not frozen.

• For Mohs micrographic surgery:Use 17311-17315 for stages/layers processed and examined (specific to Mohs, not general frozen section).

Does All Dialysis Include E/M and Follow-Up (F/U) Visits?

Short Answer:No, not all dialysis automatically includes E/M (Evaluation and Management) and follow-up visits. But some types of dialysis codes do bundle or assume physician management or E/M services, depending on the CPT code you report and the setting.

Detailed Explanation

1. Dialysis Procedure Codes (Technical Services)

• Facility/technical service codes (such as those used by hospitals or dialysis centers) are for the actual dialysis procedure only—not the physician's E/M services.

• These codes bill for the performance of the dialysis procedure itself.

2. Physician Dialysis Management Codes

• Some physician dialysis CPT® codes (like 90935, 90937, 90945, 90947, and 90951–90962 for ESRD) DO include physician evaluation and management (E/M) and sometimes bundled follow-up, as part of the code.

  • Example:

    • 90945 (peritoneal dialysis with single physician evaluation) bundles the physician’s evaluation into the code.

    • 90966 (ESRD monthly management) bundles all physician management for the calendar month, including E/M and follow-up.

3. When to Bill E/M Separately

• If a physician provides a significant, separately identifiable E/M service on the same day as dialysis (for example, treats an unrelated acute condition), you may bill the E/M visit separately with modifier -25, if documentation supports it.

Quick Reference Table

Type of Dialysis Code	Includes E/M or F/U?	Notes
Technical/service-only codes	❌ No	Only covers the dialysis procedure
Physician dialysis management codes	✅ Yes (often includes E/M & F/U)	See code descriptor for specifics
Separate E/M (with -25 modifier)	✅ Yes (if separately documented)	Must be significant and unrelated

Summary

• Not all dialysis codes include E/M or follow-up.

• Physician management dialysis codes often do.

• Technical/procedure-only codes do not.

• You can bill an E/M separately if medically necessary and well documented.

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Sleep Study (General Term)

• Definition:“Sleep study” is a broad term that refers to any test or assessment performed to diagnose sleep disorders.

• Examples:

  • Home sleep apnea testing (HSAT)

  • Overnight oximetry

  • Polysomnography (the most comprehensive type)

Think of “sleep study” as an umbrella term.

Polysomnography (Specific Type of Sleep Study)

• Definition:Polysomnography is a detailed, multi-parameter overnight sleep study performed in a sleep lab, where multiple body functions are recorded.

• What’s Measured:

  • Brain waves (EEG)

  • Eye movements (EOG)

  • Muscle activity (EMG)

  • Heart rate (ECG)

  • Breathing (airflow, effort)

  • Blood oxygen levels (pulse oximetry)

  • Leg movements

• Setting:Usually performed in a sleep center or hospital, sometimes with in-lab technologist monitoring.

Summary Table for Medical Coders

Term	What It Means	Setting	CPT Codes (Examples)
Sleep Study	Any sleep diagnostic test	Home/lab	95800, 95806, 95810…
Polysomnography	Comprehensive, multi-channel sleep study	Lab/Center	95810 (diagnostic), 95811 (with CPAP/BiPAP)

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In Simple Terms:

• All polysomnograms are sleep studies, but not all sleep studies are polysomnograms.

• Polysomnography is the gold standard—it collects the most data and is used for complex or uncertain sleep cases.

Why does this matter for coders?

• CPT Coding:The CPT code you pick depends on how many parameters are measured, the location, and if titration (like CPAP adjustment) is performed.

• Documentation:Always check the provider’s documentation to see what kind of sleep study was done—just “sleep study” isn’t enough!

Example:

• If a patient has an in-lab, attended, overnight study with EEG, EOG, EMG, ECG, airflow, respiratory effort, and oximetry, that’s polysomnography (CPT 95810 or 95811).

• If a patient does a simple, unattended sleep apnea test at home, that’s a home sleep apnea test (CPT 95806).

🦠 Vaccine vs. Immune Globulin: What’s the Difference?

Vaccines

• A vaccine trains your body to recognize and fight a disease before you're exposed or while your immune system can still respond.

• It takes time (usually days or weeks) for your body to build protection after getting the vaccine.

• Think of it as giving your body a "wanted poster" so it knows what to attack if the virus shows up.

✅ Rabies Vaccine Example:Given after exposure to help your body start producing its own protection against the rabies virus. Given in a series of shots.

Immune Globulin

• Immune globulin is ready-made antibodies from a donor who’s already immune.

• It gives your body immediate protection, but it doesn't last long.

• Think of it as "borrowing a bodyguard" until your immune system catches up.

✅ Rabies Immune Globulin (HRIG):Given right away after exposure, especially if you’ve never been vaccinated for rabies before. It's injected near the bite and gives your body instant protection while the vaccine starts working.

🧬 In Summary:

	Rabies Vaccine	Rabies Immune Globulin (HRIG)
Purpose	Long-term protection (make your own antibodies)	Immediate protection (borrowed antibodies)
When Given	After exposure, over a few days	Immediately after a bite/exposure
Who Gets It	Anyone exposed and unvaccinated	Only people who’ve never had the vaccine before
How It Works	Activates your immune system	Gives instant, short-term protection

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Some CPT® codes are tied to a specific setting—like Evaluation and Management (E/M) codes, which are grouped by where the visit happens (office, hospital, ER, etc.).

Other procedures, like injections or infusions, might include special instructions depending on where they’re done—so always double-check the notes in the code book.

Now here’s something important:CPT® is the official code set for reporting services done by physicians and other qualified health care professionals—but it can also be used in certain cases by facilities like hospitals or home health agencies.

You’ll often see the terms:

• Physician

• Qualified health care professional

• Or just individual

These don’t always mean only people can report the code. Sometimes, a service is limited to just a facility—or just a provider—and CPT® will make that clear with instructions.

CPT® uses the term:

• Facility – when the service is done by or on behalf of a healthcare organization (like a hospital or home health agency)

• Nonfacility – when the service is done by a provider not representing a facility

Here’s an example:

• If a home health agency sends a nurse to a patient’s home, that’s a facility service

• But if a physician visits a patient at home, and they don’t work for a facility, that’s a nonfacility service"

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How to Know What to Look Up in the CPT® Index When the Report Uses Different Words

1. Understand What Was Done

• Read the procedure note or summary.In this example, the report says, “CRNA placed arterial line.”

• Ask: What is the medical action?

  • “Placed” means inserted, established, or put in.

  • “Arterial line” is a type of vascular access—a catheter placed in an artery.

2. Recognize Medical Synonyms

• In the CPT® Index, some procedures are listed by their formal or medical term, not always the exact language in the report.

• “Arterial line” is medically known as arterial cannulation or arterial catheterization.

3. How to Look It Up:

• Step 1: Go to the CPT® Index.

• Step 2: If “Arterial line” isn’t listed, think of what was actually done:

  • The provider cannulated (inserted a catheter into) an artery.

• Step 3: Try looking up related words:

  • Cannulation

  • Catheterization

  • Artery or Arterial

Example from the CPT® Index:

• If you look up Cannulation, you’ll see:

  • Cannulation/Arterial → 36620, 36625

• If you look up Catheterization, you may find:

  • Catheterization/Arterial → 36620

36620 is the code for “Arterial catheterization or cannulation, percutaneous.”

Mnemonic/Tip for Students

• If you see “line” or “catheter” placed in an artery or vein, always think:

  • “Was this a cannulation/catheterization?”

  • Look up the medical action, not just the device name.

💡 Medical Coding Cheat Sheet: What to Look Up in the CPT® Index

Report Says / Slang	What Was Done	CPT® Index Term(s) to Look Up	Example CPT® Code(s)
IV line (intravenous line)	Catheter placed in a vein	Catheterization, Venous / Venipuncture	36410, 36415
Arterial line (A-line)	Catheter placed in an artery	Cannulation, Arterial / Catheterization, Arterial	36620
Central line (central venous line, CVL)	Catheter placed in large central vein	Catheterization, Central Venous / Insertion, Catheter, Central Venous	36556, 36561
Foley catheter	Catheter placed in bladder	Catheterization, Bladder	51702, 51701
PICC line	Catheter placed in arm vein, tip in chest	Insertion, Catheter, Peripherally Inserted Central	36568, 36569
Swan-Ganz	Pulmonary artery catheter	Catheterization, Heart, Right / Pulmonary Artery	93503

• Chemodenervation one extremity or multi extremities

• What is the function of the ventricles of the brain

• Rhinoplasty

What does the abbreviation VBAC mean?

a.	Virgin before antenatal care
b.	Very bad anterior colporrhaphy
c.	Vulvar bacterial antimicrobial cyst
d.	Vaginal birth after cesarean

ANS:      D

In the CPT® codebook guidelines under the heading Delivery after Previous Cesarean Delivery, for codes 59610-59622, you will find the abbreviation VBAC. VBAC is the abbreviation for vaginal birth after cesarean although CPT® notes this as vaginal delivery after cesarean delivery.

This 56-year-old female presented with a degenerative posteromedial meniscal flap tear of the right knee. After appropriate preoperative evaluation, the patient was taken to the operating room where general anesthesia was instituted. The patient was placed supine on the operating table. The right lower extremity was sterilely prepped and draped for arthroscopic surgery. The leg was exsanguinated and the tourniquet inflated. The arthroscope was introduced first through the anterolateral portal with medial suprapatellar portal utilized. The lateral compartment looked fairly good. There were some minimal medial degenerative changes. In the medial compartment there was a full-thickness area of osteochondral degeneration with a flap of cartilage noted. It was possible to remove this with a bleeding bony bed with beveled edges of cartilage. The ligament itself was intact. The retropatellar area was normal with Grade I chondromalacia changes noted. The medial joint was inspected and there was a tear at the junction of the middle and posterior portions of the meniscus, a flap tear was based more anteriorly. This was shaved with a combination of small baskets and punches, and the meniscus debrided back to a smooth stable rim. There was additional synovitis in the medial aspect of the intercondylar notch and this was removed with the curved automated meniscal incisor. What CPT® code(s) should be reported?

a.	29880, 29879-51
b.	29881
c.	29882
d.	29881, 29875-59

ANS:      B

This was a surgical arthroscopy of the knee. In the CPT® Index look for Arthroscopy/Surgical/Knee, directing you to 29866-29868, 29871-29889. The medial meniscectomy and debridement are reported with 29881. In this case the synovectomy, code 29875, is a separate procedure and bundled with 29881; it is not reported separately.

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