Best Coding tips for Ventilation and Perfusion imaging of lungs

ventilation and perfusion scan is most often done to detect a pulmonary embolus (blood clot in the lungs). It is also used to: Detect abnormal circulation (shunts) in the blood vessels of the lungs (pulmonary vessels). A list of CPT code 78579, 78580, 78582, 78597, 78598 and 78599 in radiology facility is used for coding these procedures.

During the perfusion scan, a health care provider injects radioactive albumin into your vein. You are placed on a movable table that is under the arm of a scanner. The machine scans your lungs as blood flows through them to find the location of the radioactive particles.
During the ventilation scan, you breathe in radioactive gas through a mask while you are sitting or lying on a table under the scanner arm.
The ventilation scan is used to see how well air moves and blood flows through the lungs. The perfusion scan measures the blood supply through the lungs. Before we move ahead you can check some coding tips below for radiology CPT codes.

Best Coding tips for Ventilation and Perfusion imaging of lungs

Different name of Perfusion and ventilation scan of lungs
V/Q scan; Ventilation/perfusion scan;
Lung ventilation/perfusion scan;
Pulmonary embolism - V/Q scan;
PE- V/Q scan;
Blood clot - V/Q scan
Description of CPT code for Pulmonary perfusion and Ventilation imaging
78579   Pulmonary ventilation imaging (eg, aerosol or gas)

78580   Pulmonary perfusion imaging (eg, particulate)

78582   Pulmonary ventilation (eg, aerosol or gas) and perfusion imaging

78597   Quantitative differential pulmonary perfusion, including imaging when performed

78598    Quantitative differential pulmonary perfusion and ventilation (eg, aerosol or gas), including imaging when performed

78599  Unlisted respiratory procedure, diagnostic nuclear medicine

Procedure Performed for V/Q scan

In this scan, the patient will be asked to lie down and the technician will inject a radionuclide dye into the blood stream through a needle. The dye contains the radioactive technetium. Once the dye gets injected, the technician will remove the needle, and you will be moved to scanner. The scanner will detect the dye and observe the movement of dye into your lungs via your bloodstream.

You may be ask to change your lying position, to capture images from different angles.

For the pulmonary ventilation scan, you will be given a mouthpiece while you’re still lying underneath the scanner. You will be asked to breathe through the mouthpiece, which contains a gas with a radioactive substance, usually radioactive xenon or technetium.
The scanner will take images of your lungs while you’re breathing in the gas. You should try not to swallow this gas. It could interfere with the images that need to be taken of the lungs. You may be asked to hold your breath to capture certain images.


Sample Objective Question and Answers for Non-Certified Medical Coders

Sample Objective Question and Answers for Non-Certified  Medical Coders

1. If both the hard and soft palates are repaired concomitantly, the correct CPT code to report this procedure would be:
    A.  42200
    B.    42235
    C.    42200, 42235
    D.   Inappropriate because hard and soft palates are not repaired concomitantly

2. Surgeon performs the following procedures arthroscopically: biceps tenotomy, followed by a biceps tenodesis, arthroscopic repair of the rotator cuff, distal claviculectomy, bony acromioplasty, debridement of the labrum, synovitis, and a chondroplasty. How do you report this per CPT®/NCCI guidelines?
     A.   29828, 29999, 29827, 29824, 29826, 29822
     B.    29828, 29827, 29824, 29826
     C.    29828, 29827, 29824, 29826, 29823
     D.   29828, 29827, 29824, 29826, 29823-59

3. Extensive debridement of the shoulder may include:
A.   Multiple soft structures
B.    Multiple hard structures
C.    A combination of hard and soft structures
D.   Any of the above

4. The patient is 3 years old. The same physician performing the primary procedure also provides moderate sedation for 40 minutes (intraservice time). Proper coding is:
A: 99151
B: 99152, 99153 x2
C: 99151, 99153
D: 99151, 99153 x2

5. Proper ICD-10-CM coding for cleft soft palate is:
A: Q35
B: Q35.1
C: Q35.2
D: Q35.3

6. Arthrodesis is another term for:
A: Setting a broken bone
B: Draining a purulent abscess
C: Fusion of bone (e.g., of the spine)
D: Removal of the spleen

7. Computer-assited coding and ecoder software are always more reliable than the actual ICD-10-CM and CPT codebooks.
     A.   True
     B.    False

8 .The surgeon performs an arthroscopic distal calviculectomy, bony acromioplasty, and repair of a chronic tear of the supraspinatus, followed by a mini-open repair of the subscapsularis on the patient’s right shoulder. How should this be reported per CPT NCCI guidelines.
A: 29827-59, 29824, 29826, 23412
B: 23412-22, 29824, 29826
C: 23412, 29824
D: 29827-22, 29824, 29826

9. The patient is 33 years old. A different physician performing the primary procedure also provides moderate sedation for 28 minutes (intraservice time). Proper coding is:
A: 99155
B: 99156
C: 99156, 99157
D: 99155, 99157

Practice Sample Medical coding Surgery coded Charts

Sample Medical Coding Chart 1

PREOPERATIVE DIAGNOSIS:   Right laryngeal lesion.
POSTOPERATIVE DIAGNOSIS:   Right laryngeal lesion.
PROCEDURE:   Microsuspension laryngoscopy with excision of right laryngeal
ANESTHESIA:   General.
SPECIMENS REMOVED: Right laryngeal lesions.
The patient is an 84-year-old man with a history of dysphonia. He was found by an outside ENT to have a lesion overlying his right arytenoid surface. This was followed by both the outside ENT and myself and the lesion was concerning for an area of leukoplakia and therefore, intraoperative biopsy was recommended with microsuspension laryngoscopy. Risks and benefits of the procedure were discussed with the patient. He consented to surgery.

DESCRIPTION OF PROCEDURE:   After informed consent was obtained, the patient was brought back to the operating room, placed supine on the operating room table. A time-out was performed to identify the patient, procedure, site of surgery, OR staff, and OR equipment. General anesthesia was induced. An orotracheal tube was placed. He was then turned 90 degrees to his left. Head wrap was placed.
A dental guard was placed. A time-out was performed to identify the patient, procedure, site of surgery, OR staff, and OR equipment.
Next, a Lindholm laryngoscope was inserted into his oral cavity, oropharynx, and then used to expose his larynx. There was an approximately 3 mm smooth soft nodular lesion overlying his right arytenoid. Photodocumentation was performed. The visualization was performed using the microscope.

Next, a micro sickle knife was used to excised the lateral to this lesion. The lesion was then grasped with the microlaryngoscopy grasper and deep dissection plane was made with a microlaryngoscopy scissors. The lesion was then excised and sent as specimen. Epinephrine soaked pledget was applied to the wound and after several minutes, it was removed. There was no further bleeding.
Photodocumentation again was performed to identify the resected lesion. This marked the end of the case. The Lindholm laryngoscope was removed from the patient's oropharynx and oral cavity. The dental guard was removed. He was turned back to anesthesia and returned to the postoperative care in stable condition.

CPT- 31541  Laryngoscopy Dir, Operative, w/Excision, Tumor/Strip Vocal Cords/Epiglottis; w/Microscope/Telescope

ICD 10- J38.7  Other diseases of larynx

Practice Sample Medical coding Surgery coded Charts

Sample Medical Coding Chart 2

PREOPERATIVE DIAGNOSIS:   Spinal stenosis, right L4-L5 and L5-S1 with extruded
disk herniation to the right at L5-S1.

POSTOPERATIVE DIAGNOSIS:   Spinal stenosis, right L4-L5 and L5-S1 with extruded disk herniation to the right at L5-S1 with contained extruded disk herniation, right L5-S1.

1. Microlumbar hemilaminotomies and partial medial facetectomy, right L4-L5
 and L5-S1, and diskectomy right L5-S1.
2. Neurophysiological monitoring.

The patient has continued to experience chronic right lower extremity symptoms despite an appropriate course of nonoperative care including therapeutic steroid injections. She is now scheduled to undergo microdecompression right L4-L5 and L5-S1 with probable diskectomy right L5-S1.

Significant subarticular stenosis was encountered on the right at both L4-L5 and L5-S1 with ongoing compression of the right L5 and S1 nerve roots, respectively. There was also a contained extruded disk herniation that was prominent to the right at L5-S1 with ongoing residual nerve root compression which was subsequently corrected with microdiskectomy.

PROCEDURE IN DETAIL:   The patient was transported to the operating room, after which general anesthesia was obtained via endotracheal intubation. She was transferred to the Jackson table and placed on a Wilson frame attachment. Great care was taken to pad all bony and soft tissue prominences in order to avoid pressure phenomena. Sequential pressure stockings and a Foley catheter were in place as was the neurophysiological monitoring system. A time-out was completed and the patient received appropriate antibiotics. The lumbosacral region was shaved, prepped and draped in usual sterile manner after which needle localization was utilized to determine the site of the posterior lumbar midline incision, which was 5 cm in length and extended from the spinous process of L4- S1. The incision was carried down the lumbar fascia and hemostasis was obtained with electrocautery. Electrocautery was then utilized to incise lumbar fascia in a longitudinal fashion on the right side of the spinous processes extending from L4-S1. A Cobb elevator was then utilized to expose the right side lamina of L4-S1 with the posterior midline structures maintained and not sacrificed. The supraspinous and intraspinous ligaments remained intact. Intraoperative fluoroscopy confirmed we were at our desired levels.
Attention was initially directed to the L5-S1 interlaminar space and the AMA drill bit was utilized to perform an inferior L5 laminotomy and partial medial facetectomy on the right side at L5-S1. The ligamentum flavum was incised and debrided both medially and laterally. The integrity of the right L5-S1 facet joint remained.
A similar procedure was then performed on the right at L4-5 and again, the integrity of the right L4-L5 facet joint remained. The remainder of the operation was performed under microscopic magnification and illumination in order to permit the utilization of microsurgical techniques. Attention was maintained on the right at L4-L5 and was appreciated that residual subarticular stenosis continued to result in significant compression of the right L5 nerve root. Additional debridement of the medial aspect of the right L4-L5 facet joint was then performed using microsurgical techniques. Specifically, 4 but then 3 mm Kerrison rongeurs were utilized to debride the medial aspect of the facet joint until was flushed with the medial wall of the right L5 pedicle. We were then able to gently retract the right L5 nerve root towards the midline to examine the underlying disk which was found to be flat and without residual nerve root compression. The right L5 nerve root was subsequently deemed to be completely free and its foramen open as well when palpated with ball-tipped nerve probe. The wound was irrigated with copious amounts of antibiotic solution prior to which a Valsalva maneuver revealed no evidence of dural punctures. Liquid Gelfoam was utilized to obtain hemostasis.
Attention was then re-directed to the L5-S1 interlaminar space and again, it was appreciated that there was continued residual compression of the right S1 nerve root that appeared to not only be contributed to by subarticular and lateral recess stenosis, but also palpable disk herniation anterior to the right S1 nerve root. Using microsurgical techniques, further debridement of the medial aspect of facet joint was debrided until it was flushed with the medial wall of the right S1 nerve root which permitted exposure of the right S1 nerve root. It was then gently retracted toward the midline and underlying epidural vessels
were coagulated with bipolar coagulation. We were then able to carefully examine the right side of the L5-S1 disk space and it was clear that an extruded, but contained disk herniation existed with ongoing compression of the right S1 nerve root. The extruded, but contained portion appeared to be slightly cephalad to the disk space itself and when that area was palpated with #4 Penfield, it easily popped through the thinned annulus. Multiple small fragments of disk were encountered at that site that existed between the thinned annulus and posterior longitudinal ligament and the posterior aspect of the L5 vertebral body. Using microsurgical techniques including use of micropituitary, multiple small fragments were removed from that site. The rent was then found that extended into the disk space from which additional amount of disk material was removed with micro-pituitaries, but care was taken to avoid penetration of the annulus anteriorly as well as laterally. Reinspection of the canal revealed
the ongoing compression of the right S1 nerve was completely relieved and there was no residual evidence of extruded disk material. The right S1 nerve root was found to be completely free and its foramen open as well when palpated with a ball-tipped nerve probe.
The wound was then irrigated, then was re-irrigated with copious amounts of antibiotic solution. Valsalva maneuvers revealed no evidence of dural punctures. Liquid Gelfoam was again utilized to obtain hemostasis at L5-S1. The microscope was then removed from the field and we continued to re-irrigate the wound with antibiotic solution prior to which hemostasis of the soft tissue had been obtained with bipolar coagulation. No residual bleeding was appreciated, but a small Hemovac drain was placed deep to the fascia and exited through a separate stab wound. Thrombin-soaked Gelfoam was placed over the exposed neural structures on the right at both L4-L5 and L5-S1. The lumbar fascia was then reapproximated to the midline with an interrupted 0 absorbable suture and subcutaneous tissue was reapproximated with interrupted 2-0 absorbable soft suture after Exparel had been injected. The skin was reapproximated with a running subcuticular 4-0 absorbable suture, followed by Mastisol and Steri-Strips. A sterile dressing was applied after which the patient was transferred to her hospital bed, extubated, and transported to the recovery room in good condition, having tolerated the procedure well. No intraoperative complications occurred. Needle and sponge counts were reported to be correct.

ESTIMATED BLOOD LOSS:   Less than 25 cc.
Consisted of the disk material from the right L5-S1 disk space. No changes occurred with regard to the neurophysiological monitoring.

CPT code:
63047 Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [eg, spinal or lateral recess stenosis]), single vertebral segment; Lumbar
63030-RT - Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc; 1 interspace, lumbar

ICD 10-

Sample Medical Coding Chart 3

PROCEDURE PERFORMED: Direct current external cardioversion under deep sedation. 

PREOPERATIVE DIAGNOSIS: Symptomatic atrial fibrillation. 

POSTOPERATIVE DIAGNOSIS: Symptomatic atrial fibrillation. 

CLINICAL HISTORY: An 81-year-old woman with symptomatic atrial fibrillation, rate controlled and anticoagulated, presents for direct current external cardioversion under deep sedation. 

The patient was brought to cardiac EP procedure room under fasting conditions and after informed consent was obtained. Cardioversion patch was placed in the anterior and posterior chest, IV propofol administered for anesthesia. After adequate sedation, the patient received a series of synchronized biphasic shocks at 121, 50, and 170 joules. After the first 3 shocks, there was no conversion. Cardioversion patches were repositioned and a 4th attempt was made with direct pressure applied to the chest and there was a brief conversion to sinus rhythm and then frequent atrial ectopy and then return to atrial fibrillation. There were no immediate complications. 

CONCLUSION: Unsuccessful cardioversion of atrial fibrillation
CPT code :92960- cardioversion, elective, electrical conversion of arrhythmia; external

ICD 10: I48.91- Atrial Fibrillation

Sample Medical Coding Chart 4

PREOPERATIVE DIAGNOSIS: Left breast cancer, personal history with previous partial mastectomy defects and surgery defects and radiation. 

PROCEDURE: Left breast reconstruction with other technique (lipoinfiltration) and Right breast mastopexy 



DRAINS: None. 


1. Left breast reconstruction with other techniques including fat grafting and 
2. Right breast mastopexy for symmetry. 

HISTORY: This patient had left partial mastectomy defect with loss of tissue 
especially in that left upper quadrant and noted a symmetry with the left and 
right breast. I marked her in a sitting position, taking fat from the right and 
left lower abdomen, taking perhaps 400 mL total of fat and aspirate, and then 
after processing, this went down to about 120 mL, and I injected a total of 100 
mL of purified fat. Her right breast mastopexy was performed by lifting the 
areola and nipple, and tracking the sizing of the areolar complex and that is 
the left. 

The patient was prepped and draped under anesthesia. 
Initially, I marked her and I performed liposuction into her lower abdominal 
area after tumescent liposuction. Then, I was able to take this processes, 
placed a small Penrose into both lateral aspects and dressings were used for 
this at the conclusion of the case, and then I took the processed fat and 
prepared this for injection. I used 18, 20, and 16-gauge syringes to perform 
subcision to undermine the tissue lift them and elevate them, and preparing 
them for the fat injection. Then, I used a fat injection using 5 mL in 1.4 mm 
ports to inject the fat in and around breast. I used 70 mL in left breast and 
30 mm in the right breast to achieve symmetry. Then, the right areola was 
spaced with a 42 mm cutter and I went and cut the excess skin around for about a 2 cm lift to lift this and elevate it, and closed circumferentially around 
the areola with PDS as a circumferential stitch, then 4-0 Monocryl and 5-0 
Prolene for the skin. 
Sterile dressings were applied and she was discharged to the recovery room in 
stable condition. 

CPT code: 

19366-LT  Breast Reconstruction w/Other Technique
19316-RT Mastopexy

ICD 10:
Z42.1  Encounter for breast reconstruction following mastectomy.
Z85.3  Personal history of malignant neoplasm of breast

Sample Medical Coding Chart 5 

1. Selective coronary angiography.
2. Ascending aortography.
3. Performed right radial artery without complication.

1. Severe aortic insufficiency.
2. Bicuspid aortic valve.
3. Cardiomyopathy with systolic dysfunction.

1. Severe aortic insufficiency.
2. Bicuspid aortic valve.
3. Cardiomyopathy with systolic dysfunction.

CLINICAL HISTORY:  A 53-year-old male with morbid obesity and symptomatic valvular regurgitation with severe aortic insufficiency and cardiomyopathy with moderate systolic dysfunction, bicuspid aortic valve, dilated aorta, presents for preoperative cardiac catheterization, possible revascularization.

The patient was brought to cardiac catheterization laboratory in fasting state after signed informed consent was obtained. The right wrist was prepped and draped in sterile fashion. Allen's test was normal. Xylocaine 1% used for local anesthesia. A 6-French introducer sheath was placed percutaneously. Intra-arterial heparin and verapamil was administered. It was difficult reaching the aortic root from the right radial approach secondary to the patient's morbid obesity, dilated and tortuous ascending aorta. There was also significant aortic insufficiency causing catheter _____. We were able to selectively engage the right coronary artery with a 6-French JR4 diagnostic catheter and selective right angiography performed multiple views using hand injections. We were unable to selectively engage the left main despite the use of multiple diagnostic catheters including 6-French JL3.5, 4.0, 4.5, 5.0, and 6.0 catheters. We also tried to engage the left main selectively using a 6-French EBU 4.0 and 4.5 guide and 6-French AL1 guide. Therefore, we exchanged these catheters out for an angled pigtail catheter and performed biplane ascending aortography, which did nonselectively fill the left main LAD and no obvious stenosis seen in these segments, although poorly visualized. There was no atrial reached. The left main from the right radial approach femoral access was not obtained secondary to the patient's massive obesity and likely will be able to assess the coronary anatomy further with CT angiography.

Right coronary artery: Large vessel dominant, no significant angiographic stenosis. Left coronary system nonselectively visualized through ascending aortogram as above. There is contrast filling the LAD nonselectively. The left main circumflex and details of the LAD are not well seen on this limited injection.
Aortography: The aortic root and ascending aorta are markedly dilated. There was severe aortic insufficiency. There was no discrete aneurysm identified.
CONCLUSION:   1. Dilated ascending root and ascending aorta with severe aortic insufficiency.
2. Probably normal coronary arteries need further assessment with CT angiogram  for definitive assessment.

CPT code:

93454  Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation;

93567  Injection During Cath; For Supravalvular Aortography

93005  Electrocardiogram, Routine w/At Least 12 Leads; Tracing Only w/o Interpretation & Report

ICD 10:

I35.1  Nonrheumatic aortic (valve) insufficiency
I35.0  Nonrheumatic aortic (valve) stenosis
I50.9  Heart failure, unspecified

When to use CPT code 76856, 76857 and 76830 for Pelvic Ultrasound complete & limited

In radiology, we have a big list of ultrasound procedure codes. We have already discussed about the abdominal and renal ultrasound CPT codes. There are few ultrasound procedure codes used only for female patients.

Yes, for pelvic ultrasound exam we have separate codes for female patients. The transabdominal (CPT code 76856) and Endovaginal ultrasound (CPT code 76830) exam are coded frequently in radiology facility.

76856 Ultrasound Pelvic, real time with image documentation, Complete

76857 Ultrasound Pelvic (Nonobstetric), real time with image documentation; limited or follow-up (Eg. for follicles)

76830 Ultrasound, Transvaginal

When to use CPT code 76856, 76857 and 76830 for Pelvic Ultrasound complete & limited

Difference between Pelvic and Endovaginal ultrasound exam

Pelvic ultrasound helps in investigation of pelvic structures.

We have complete and limited CPT code for pelvic ultrasound. In complete exam, an attempt is made to visualize all of the structures or organs within the anatomic description, with a majority of the included structures actually being diagnostically evaluated. CPT code 76856 is used for complete study for pelvic exam. The documentation should clearly support for the complete study.

On the other side, limited study only includes a single quadrant or a possible single diagnostic problem (i.e., cholecystitis or cyst of the liver, ovarian disease, unilateral study). The documentation should support the limited study (CPT code 76857) for reevaluating a problem after the initial interpretation has been completed to clarify a finding of the initial study. 

Endovaginal or transvaginal ultrasound (CPT code 76830) helps  in depicting abnormalities of the uterus or the adnexa and the surrounding spaces and tissues.

Indication for CPT code 76856, 76857 and 76830

Pelvic pain
Postmenopausal bleeding

New Modifier 96 and 97 of 2018 for Medical coders

There has been lot of new CPT codes added in 2018. Also, their is a big list of revised and deleted CPT codes in new year. But, you will be surprise to know that, two new modifiers have also been added as well in 2018. Yes, in new year coders will be using two new modifiers 96 and 97. Below is the detail description of these modifiers.

New Modifier 96 and 97 of 2018 for Medical coders

Modifier 96 Habilitative Services: When a service or procedure that may either be habilitative in nature or rehabilitative in nature is provided for habilitative purposes, the physician or other qualified healthcare professional may add modifier 96- to the service or procedure code to indicate that the service or procedure provided was habilitative. Such services help an individual learn skills and functioning for daily living that the individual has not yet developed, and then keep or improve those learned skills. Habilitative services also help an individual keep, learn, or improve skills and functioning for daily living.

Modifier 97 Rehabilitative Services: When a service or procedure that may be either habilitative or rehabilitative in nature is provided for rehabilitative purposes, the physician or other qualified healthcare professional may add modifier 97- to the service or procedure code to indicate that the service or procedure provided was rehabilitative. Rehabilitative services help an individual keep, get back, or improve skills and functioning for daily living that have been lost or impaired because the individual was sick, hurt, or disabled.

These two modifiers are intended to be reported with services that are identified as being either habilitative or rehabilitative in nature, such as physical medicine and rehabilitation codes, allowing the payer the ability to differentiate habilitative from rehabilitative services. This differentiation is required by the Patient Protection and Affordable Care Act (PPACA).