A witness of a traffic accident called 911. An ambulance with emergency basic life support arrived at the scene of the accident. The injured party was stabilized and taken to the hospital. What HCPCS Level II coding is reported for the ambulance's service?
A patient presents with 26 skin tags on the neck and shoulder. The provider removes all using a scissoring technique.
What CPT® coding is reported?
(A 55-year-old female with severe coronary arteriosclerosis with angina is admitted for elective coronary artery bypass. The surgeon performed a coronary artery bypass using asaphenous vein harvested endoscopically. The vein graft was anastomosed to theobtuse marginaland theleft circumflex. What CPT® coding is reported for this procedure?)
A CRNA independently administers MAC anesthesia for ICD replacement.
What CPT® and ICD-10-CM codes are reported?
View MR 004397
MR 004397
Operative Report
Preoperative Diagnosis: Calculi of the gallbladder
Postoperative Diagnosis: Calculi of the gallbladder, chronic cholecystitis
Procedure: Cholecystectomy
Indications: The patient is a 50-year-old woman who has a history of RUQ pain, which ultrasound revealed to be multiple gallstones. She presents for removal of her gallbladder.
Procedure: The patient was brought to the OR and prepped and draped in a normal sterile fashion. After adequate general endotracheal anesthesia was obtained, a trocar was placed and C02 was insufflated into the abdomen until an adequate pneumoperitoneum was achieved. A laparoscope was placed at the umbilicus and the gallbladder and liver bed were visualized. The gallbladder was enlarged and thickened, and there was evidence of chronic inflammatory changes. Two additional ports were placed and graspers were used to free the gallbladder from the liver bed with a combination of sharp dissection and electrocautery. Cystic artery and duct are clipped. Dye is injected in the gallbladder. Cholangiography revealed no intraluminal defect or obstruction. Gallbladder is dissected from the liver bed. The scope and trocars are removed.
What CPT® coding is reported for this case?
What is the medical term for a procedure that creates a connection between the gallbladder and the small intestine?
Which one of the following is an example of a case in which a diabetes-related problem exists and the code for diabetes is never sequenced first?
A 1-year-old patient has bilateral supernumerary digits:
Left digit contains bone and joint → amputated
Right digit is a soft-tissue nubbin → simple excision
What CPT® coding is reported?
A pediatrician removes impacted cerumen using irrigation in the right ear and instrumentation in the left ear.
What CPT® coding is reported?
(A 7-year-old child presents with third-degree circumferential burns of his chest, resulting in restricted chest expansion and concern for respiratory compromise. To relieve pressure caused by the eschar, the surgeon performs anescharotomy. During the procedure,two incisionsare made through the eschar down to the subcutaneous tissue to release the constrictive effects. The burns are full-thickness and involve10% TBSA, resulting in all third-degree burns. What CPT® and ICD-10-CM codes are reported for this service?)
A 65-year-old man had a right axillary block by the anesthesiologist. When the arm was totally numb, the arm was prepped and draped, and the surgeon performed tendon repairs of the right first, second, and third fingers. The anesthesiologist monitored the patient throughout the case.
What anesthesia code is reported?
Day 1 - A provider admits the patient to observation care for type 2 diabetes mellitus with hyperglycemia. The provider orders a HbA1c, a urine (microalbumin), and kidney function lab tests.
Blood sugar is high and poorly controlled. The provider discusses the case with the patient's endocrinologist. The provider prescribes an IV insulin drip, along with SQ insulin and keeps the
patient in observation overnight.
Day 2 - Patient is in observation care and the provider orders a blood glucose test. The patient's glucose levels have improved. The provider places an order for the dietitian to see the patient.
Provider
documents spending a total time of 25 minutes with the patient.
Day 3 - Patient has a blood glucose test. The patient's glucose level is back to normal. The provider documents spending 15 minutes with the patient. The provider discharges the patient.
What E/M coding is reported by the physician for the patient in observation care?
(Full Case:Pre/Post-op diagnosis:Grade 1 endometrial cancer.Procedure:Radical hysterectomy and pelvic lymph node sampling.Anesthesia:General.EBL:400 mL.Complications:None.Specimens:pelvic washings; uterus; tubes; ovaries; pelvic lymph nodes.Fluids:2 L crystalloid.Operative details:frog-leg position; perineum prepped sterile; Foley placed; midline vertical incision umbilicus to symphysis; exploration shows normal upper abdomen and bowel; no paraaortic adenopathy; pelvis/perineum normal; washings collected; round ligaments transected; retroperitoneal spaces opened; ureters visualized; ovarian vessels isolated/ligated; bladder flap taken down; uterine arteries, uterosacral and cardinal ligaments clamped/ligated; uterus removed; vagina closed; lymph node sampling left then right with removal of lymphatic tissue from external/internal iliac bifurcation to circumflex iliac vein and down to obturator nerve; tumor ~40% endometrial surface with <50% myometrial invasion; closure in layers; patient tolerated well.Question:What CPT® codes are reported?)
The provider orders a bilirubin test for a patient with bowel flora disturbance. The lab determines the presence of bilirubin in a fecal sample.
What CPT® code is reported for the test?
911 is called by the physician for an ambulance with non-emergency basic life support to pick up a patient from his office that had fainted. The patient was taken to the hospital. What HCPCS
Level II coding is reported for the ambulance's service?
A 56-year-old female patient with a history of degenerative disc disease at levels T2-T3 and T4-T5 underwent a surgical repair procedure. Two surgeons will be working together as primary surgeons
Surgeon X: Carried out the anterior exposure of the spine and mobilized the great vessels, assisted Dr. Z. and performed the closure.
Surgeon Z: Performed a minimal anterior discectomy and fusion at T2-T3 and T4-T5 levels using an anterior interbody technique and solely performed utilizing a structural allograft.
What is the CPT® coding for the two surgeons?
A patient is diagnosed with a healing pressure ulcer on her left heel that is currently being treated.
What ICD-10-CM coding is reported?
(A driver crashes into a guardrail and sustains a fracture of the anterior fossa cranial base with involvement of thesphenoid sinus, withno CSF leak. The patient undergoessurgical nasal sinus endoscopy with sphenoidotomyto evaluate and treat the sinus injury. No CSF leak repair is performed. What is the correct procedure and diagnosis coding combination to report this service?)
An inpatient, suffering from hypertension and chronic kidney disease, is administered continuous venovenous hemofiltration. The on-duty nephrologist performs a series repeated low-level evaluation and management services to monitor the patient's status.
What is the CPT® and ICD-10-CM coding'
A 40-year-old woman with progressive sensory neural hearing loss in the right ear since the age of 13 has not gained benefit from her hearing aid. She has normal hearing in the left ear. A cochlear implant is placed for the right ear. Anesthesia is provided by a CRNA with medical direction by an anesthesiologist who is concurrently directing 5 CRNAs. PS is 3.
What anesthesia CPT® and ICD-10-CM codes are reported by the Anesthesiologist?
View MR 099401
MR 099401
Established Patient Office Visit
Chief Complaint: Patient presents with bilateral thyroid nodules.
History of present illness: A 54-year-old patient is here for evaluation of bilateral thyroid nodules. Thyroid ultrasound was done last week which showed multiple thyroid masses likely due to multinodular goiter. Patient stated that she can “feel" the nodules on the left side of her thyroid. Patient denies difficulty swallowing and she denies unexplained weight loss or gain. Patient does have a family history of thyroid cancer in her maternal grandmother. She gives no other problems at this time other than a palpable right-sided thyroid mass.
Review of Systems:
Constitutional: Negative for chills, fever, and unexpected weight change.
HENT: Negative for hearing loss, trouble swallowing and voice change.
Gastrointestinal: Negative for abdominal distention, abdominal pain, anal bleeding, blood in stool, constipation, diarrhea, nausea, rectal pain, and vomiting
Endocrine: Negative for cold Intolerance and heat intolerance.
Physical Exam:
Vitals: BP: 140/72, Pulse: 96, Resp: 16, Temp: 97.6 °F (36.4 °C), Temporal SpO2: 97%
Weight: 89.8 kg (198 lbs ), Height: 165.1 cm (65”)
General Appearance: Alert, cooperative, in no acute distress
Head: Normocephalic, without obvious abnormality, atraumatic
Throat: No oral lesions, no thrush, oral mucosa moist
Neck: No adenopathy, supple, trachea midline, thyromegaly is present, no carotid bruit, no JVD
Lungs: Clear to auscultation, respirations regular, even, and unlabored
Heart: Regular rhythm and normal rate, normal S1 and S2, no murmur, no gallop, no rub, no click
Lymph nodes: No palpable adenopathy
ASSESSMENT/PLAN:
1) Multinodular goiter - the patient will have a percutaneous biopsy performed (minor procedure).
What E/M code is reported for this encounter?
A physician conducts a 15-minute phone call discussing medication management.
How is this reported?
A 46-year-old female is admitted to the hospital by her urologist for a left ureteral calculus. The urologist visits her again on day two and performs a low for number and complexity of problems
addressed, minimal for amount and/or complexity of data to be reviewed and analyzed, and moderate for risk of complications.
What E/M service is reported for day two?
A 45-year-old has a dislocated patella in the left knee after a car accident. She taken to the hospital by EMS for surgical treatment. In the surgery suite, the patient is placed under general anesthesia. After being prepped and draped, the surgeon makes an incision above the knee joint in front of the patella. Dissection is carried through soft tissue and reaching the patella in attempt to reduce the dislocation. When the patella is exposed, it is severely damaged due to cartilage breakdown. The tendon is dissected and using a saw the entire patella is freed and removed. The tendon sheath is closed with sutures.
What procedure code is reported for this surgery?
A patient arrives for a PEG placement. The patient requires tube feeds for nutrition but frequently pulls out the dobhoffs tube. An EGD was performed. Several attempts were made to place the
PEG tube without success so the procedure was aborted. During the withdraw of the scope, a small hiatal hernia was noted in the stomach. The scope was removed the the patient transferred
to recovery.
What CPT and ICD-10-CM coding is reported?
(Which place of service code is submitted on the claim for a procedure that is performed in a patient’sprivate residence?)
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?
A patient is having a thyroidectomy for malignancy on the right lobe. During the procedure, a lesion was found on the left lower side of the parathyroid gland and is suspected for malignancy.
The total right lobe of the thyroid and the parathyroid gland are removed.
What is the CPT® codes are reported for this encounter?
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?
A mother brings her 2-year-old son to the pediatrician's office because he stuck a bead up his left nostril. The pediatrician uses a nasal decongestant to open the blocked nostril and removes the bead with nasal forceps.
What CPT® coding is reported?
(Full Case:Preoperative diagnosis:Recurrent dysphagia.Postoperative diagnosis:Hiatal hernia with obstruction.Procedure:EGD with dilation.Consent:PAR conference; informed consent signed; premedication given.Position/monitoring:left lateral decubitus; monitored with BP cuff and pulse oximeter throughout.Topical:Hurricaine spray to posterior pharynx.Scope passage:flexible endoscope passed under direct visualization through cricopharyngeus into esophagus; advanced with identification of EG junction into stomach; rugal folds visualized; advanced to antrum/pylorus; pylorus cannulated; duodenal bulb and second portion visualized; retroflexed views of cardia/fundus/lesser curvature.Dilation technique:guidewire placed in antrum; scope removed; wire positioned by markings;#14 French dilatorpassed into stomach area;esophageal dilation performed over guidewire.Findings:tortuous/shortened esophagus; large sliding hiatal hernia; EG junction ~30 cm; stomach abnormal with very large sliding hiatal hernia; duodenum normal.Question:What CPT® coding is reported?)
Preoperative diagnosis: Right thigh benign congenital hairy nevus. *1
Postoperative diagnosis: Right thigh benign congenital hairy 0 nevus.
Operation performed: Excision of right thigh benign congenital>1
nevus, excision size with margins 4.5 cm and closure size 5 cm.
Anesthesia: General.0
Intraoperative antibiotics: Ancef.0
Indications: The patient is a 5-year-old girl who presented with her parents for evaluation of her right thigh congenital nevus. It has been followed by pediatrics and thought to have changed over the past year. Family requested excision. They understood the risks involved, which included but were not limited to risks of general
anesthesia, infection, bleeding, wound dehiscence, and poor scar formation. They understood the scar would likely widen as the child grows because of the location of it and because of the age of the patient. They consented to proceed.
Description of procedure: The patient was seen preoperatively in > I the holding area, identified, and then brought to the operating room. Once adequate general anesthesia had been induced, the patient's right thigh was prepped and draped in standard surgical fashion. An elliptical excision measuring 6 x 1.8 cm had been marked. This was injected with Lidocaine with epinephrine, total of 6 cc of 1% with 1:100,000. After an adequate amount of time, a #15 blade was used to sharply excise this full thickness.
This was passed to pathology for review. The wound required □ limited undermining in the deep subcutaneous plane on both sides for approximately 1.5 cm in order to allow mobilization of the skin for closure. The skin was then closed in a layered fashion using 3-0 Vicryl on the dermis and then 4-0 Monocryl running subcuticular in the skin, the wound was cleaned and dressed with Dermabond and Steri-Strips.
The patient was then cleaned and turned over to anesthesia for S extubation.
She was extubated successfully in the operating room and taken S to the recovery room in stable condition. There were no complications.
What CPT® codes are reported?
(A patient presents with dysuria and lower abdominal pain. The physician suspects UTI. Anautomated urinalysis without microscopyis done in the office and isnegative. UTI is ruled out for the final diagnosis. What CPT® and ICD-10-CM codes are reported?)
A patient has five biopsies performed on the duodenum.
What CPT® coding is reported?
(A wheelchair-bound resident of a skilled nursing facility is seen in the physician’s office. The physician’s office makes arrangements with a social worker to take the patient back to the skilled nursing facility. What is the HCPCS Level II transportation service code?)
A patient presents to the ER with a large sacral pressure ulcer measuring 7 cm. The provider excised the ulcer with 3 mm margins, removed muscle and segmental bone, and performed a layered skin flap closure.
What CPT® and ICD-10-CM coding is reported?
A physician sees a patient for the first observation visit, spends 85 minutes, with moderate MDM.
What CPT® code is reported?
A patient undergoes CABG using the right internal mammary artery anastomosed to three coronary arteries.
What CPT® coding is reported?
The gastroenterologist performs a simple excision of three external hemorrhoids and one internal hemorrhoid, each lying along the left lateral column. The operative report indicates that the internal hemorrhoid is not prolapsed and is outside of the anal canal.
What CPT® and ICD-10CM codes are reported?
A patient has a bone infection being treated with vancomycin. A therapeutic drug assay is performed to measure the concentration of vancomycin in the patient's blood.
What lab test is reported?
A patient with a history of a right-hand mass presents for outpatient surgical excision. The surgeon excises the 1.5 cm mass with margins using a scalpel with dissection extending through the dermis into the subcutaneous tissue. Hemostasis is achieved with electrocautery, and the wound is closed. Final pathology confirms the mass is a subcutaneous arteriovenous hemangioma.
Which CPT® and ICD-10-CM codes are reported?
A cardiologist performs and interprets a 12-lead ECG in the office.
What CPT® coding is reported?
A 47-year-old male recently injured as a passenger in a car accident sustained multiple fractures. The patient now has physical restraints due to pulling out foley catheter, IV catheters and
attempted to pull out NG tube. Emergency department physician is asked to come see patient and injects 0.5 lidocaine into lumbar region of the spine. An indwelling catheter is placed into the
lumbar region for continuous infusion with fluoroscopy for pain management.
What CPT® is reported for the Emergency department physician?
Four malignant peritoneal tumors are excised, the largest measuring 15 cm.
What CPT® and ICD-10-CM coding is reported?
A patient with Parkinson's has sialorrhea. The physician administers an injection of atropine bilaterally into a total of four submandibular salivary glands.
What CPT® coding is reported?
A patient undergoes MRI-guided needle liver biopsy with two core samples taken.
What CPT® codes are reported?
A patient with intermittent asthma with exacerbation undergoes spirometry before and after bronchodilator.
What CPT® and ICD-10-CM codes are reported?
(Regarding the CPT® Surgery Guidelines for a surgical code designated as a“Separate Procedure,”which statement isFALSE?)
A patient presents to the office with dysuria and lower abdominal pain. The physician suspects she has a UTI. A non-automated urinalysis is done in the office and is negative. UTI is ruled out
for the final diagnosis.
What CPT and ICD-10-CM codes are reported?
A patient with a history of chronic venous embolism in the inferior vena cava has a radiographic study to visualize any abnormalities. In outpatient surgery the physician accesses the subclavian vein and the catheter is advanced to the inferior vena cava for injection and imaging. The supervision and interpretation of the images is performed by the physician.
What codes are reported for this procedure?
Regarding the CPT® Surgery Guidelines for a surgical code designated as a "Separate Procedure", which statement is FALSE?
(A 5-year-old patient has a fractured radius. The orthopedist providesmoderate sedationand the reduction. The intra-service sedation time is documented as21 minutes. What CPT® code is reported for the moderate sedation?)
A patient who has colon adenocarcinoma undergoes a laparoscopic partial colectomy. The surgeon removes the proximal colon and terminal ileum and reconnects the cut ends of the distal ileum and remaining colon.
What procedure and diagnosis codes are reported?
An otolaryngologist performs a tympanoplasty with mastoidectomy, reconstruction of the posterior ear canal wall, and ossicular chain reconstruction.
What CPT® code is reported?
(Patient presents to the office for the removal of15 actinic keratoseslesions. The provider destroys these lesions withlaser surgery. What CPT® coding is reported for this visit?)
When a provider’s documentation refers to use, abuse, and dependence of the same substance (e.g., alcohol), which statement is correct?
A 58-year-old with type 1 diabetes mellitus comes in for comprehensive eye examination. She is diagnosed with diabetic retinopathy with macular edema in the right eye. What ICD-10-CM coding is reported?
Refer to the supplemental information when answering this question:
View MR 903096
What CPT® and ICD-10-CM coding is reported?
A 53-year-old male arrived at the ER due to severe ocular trauma to the right eye. He was at work on a metal drilling machine and a metallic item penetrates his right eyeball. A foreign body is in
the posterior segment of the eye and corneal laceration with multiple posterior perforated sites were noted. He is brought back to the surgical suite. The surgeon removes the metallic foreign
body using large retinal forceps. The laceration of the cornea is sutured and the provider also performs a pars plana lensectomy.
What is the CPT® and ICD-10-CM codes are reported?
An interventional radiologist performs an abdominal paracentesis using fluoroscopic guidance to remove excess fluid. The procedure is performed in the hospital. What CPT® coding is reported?
View MR 002395
MR 002395
Operative Report
Pre-operative Diagnosis: Acute rotator cuff tear
Post-operative Diagnosis: Acute rotator cuff tear, synovitis
Procedures:
1) Rotator cuff repair
2) Biceps Tenodesis
3) Claviculectomy
4) Coracoacromial ligament release
Indication: Rotator cuff injury of a 32-year-old male, sustained while playing soccer.
Findings: Complete tear of the right rotator cuff, synovitis, impingement.
Procedure: The patient was prepared for surgery and placed in left lateral decubitus position. Standard posterior arthroscopy portals were made followed by an anterior-superior portal. Diagnostic arthroscopy was performed. Significant synovitis was carefully debrided. There was a full-thickness upper 3rd subscapularis tear, which was repaired. The lesser tuberosity was debrided back to bleeding healthy bone and a Mitek 4.5 mm helix anchor was placed in the lesser tuberosity. Sutures were passed through the subcapulans in a combination of horizontal mattress and simple interrupted fashion and then tied. There was a partial-thickness tearing of the long head of the biceps. The biceps were released and then anchored in the intertubercular groove with a screw. There was a large anterior acromial spur with subacromial impingement. A CA ligament was released and acromioplasty was performed. Attention was then directed to the
supraspinatus tendon tear. The tear was V-shaped and measured approximately 2.5 cm from anterior to posterior. Two Smith & Nephew PEEK anchors were used for the medial row utilizing Healicoil anchors. Side-to-side stitches were placed. One set of suture tape from each of the medial anchors was then placed through a laterally placed Mitek helix PEEK knotless anchor which was fully inserted after tensioning the tapes. A solid repair was obtained. Next there were severe degenerative changes at the AC joint of approximately 8 to 10 mm. The distal clavicle was resected taking care to preserve the superior AC joint capsule. The shoulder was thoroughly lavaged. The instruments were removed and the incisions were closed in routine fashion. Sterile dressing was applied. The patient was transferred to recovery in stable condition.
What CPT® coding is reported for this case?
(Full Case:Patient:V. Bowen.Physician:C.S., MD.Reason for admission:Abdominal pain.HPI:admitted this morning; sudden onset RUQ pain began ~4:00 p.m. yesterday; started while eating; 8/10; chills/sweating/nausea; no vomiting/diarrhea; last BM 2:00 p.m. yesterday; unable to pass stool or gas since; abdominal distention; poor sleep; prior similar episodes relieved by gas tablets but not this time; no discolored stool/urine.PMH:HTN (losartan; missed dose).PSH:bunion surgery right foot.FH:HTN.SH:no smoking/alcohol.Meds:losartan daily.Allergies:NKDA.ROS:nausea, no emesis; no flatus/stool since yesterday; no weight change; no SOB/chest pain; no jaundice; no urinary frequency/urgency.PE:alert/oriented x3; obvious abdominal discomfort. Vitals 139/100, pulse 100, RR 16, temp 36.4. HEENT normal; CV regular; lungs clear. Abdomen: +BS, soft but very tender; worst RUQ;Murphy’s sign; guarding and rebound (worse with palpation). Extremities trace edema.Labs ordered/reviewed:CMP with abnormal LFT/bili; CBC WBC 9.9; etc.Final assessment:RUQ abdominal pain,rule out cholecystitis.Plan:NPO; morphine IV (controlled substance); IV NS 150 cc/hr; abdominal ultrasound and HIDA ordered; consider surgical consult based on results.Question:What CPT® and ICD-10-CM codes are reported?)
From a left femoral access, the catheter is placed within the proper hepatic artery, dye is injected, and imaging is obtained. A stenosis within this artery is identified. A percutaneous
transluminal angioplasty is performed on the proper hepatic (visceral) artery in the outpatient radiology department.
What CPT® coding is reported?
(A patient with abnormal growth had asuppression studythat includedfive glucose testsandfive human growth hormone tests. What CPT® coding is reported?)
A patient in a radiology facility has an X-ray examination of her thoracolumbar junction due to pain while playing golf. The patient also has limited mobility in the hip. A radiologist takes a two view of the thoracolumbar junction.
What CPT® code is reported'
Which place of service code is submitted on the claim for a service that is performed in a skilled nursing facility?
A 23-year-old receives MMR and Hepatitis B vaccines without counseling.
What CPT® codes are reported?
Patient is admitted in observation care on 12/2/20XX in the morning for acute asthma exacerbation. The ED physician requires the patient to stay overnight. Next day, 12/3/20XX the patient is
discharged from observation care in the afternoon. Patient's total stay in observation was 16 hours.
What E/M categories and code ranges are appropriate to report?
(A 1-year-old patient was born with twosupernumerary digits, one extending from the right pinky and one extending from the left pinky. The digit from his left pinky is larger and includes themetacarpal bone with a jointand is amputated. The one on the right is anubbinand containsno bony structure. The hand surgeon removes the extra digit containingsoft tissueby a simple excision. What is the CPT® coding for the procedures performed?)
(A provider documents “pericarditis with effusion” in the assessment. Based on medical terminology, which structure is inflamed?)
(A 78-year-old patient withintermittent asthma with exacerbationis in her pulmonologist’s office for pulmonary function testing. The pulmonologist performs spirometry with flow volume loops, measuring before and after administering a bronchodilator. What CPT® and ICD-10-CM codes are reported?)
(A patient is in her otolaryngologist’s office to receive therapeutic treatment forasthmatic bronchitis with status asthmaticus. A subcutaneous injection ofomalizumab (150 mg)is given in her left upper arm. What is the CPT® and ICD-10-CM coding?)
A 13-year-old established patient is seen for an annual preventive exam. Last visit was two years ago.
What CPT® code is reported?
A patient's left eye is damaged beyond repair due to a work injury. The provider fabricates a prosthesis from silicon materials and makes modifications to restore the patient's cosmetic appearance.
What CPT® code is reported?
What CPT® coding is reported for a subtotal thyroidectomy for malignancy with radical neck dissection?
(Dr. Winston sees a patient with abdominal pain in the observation unit in the hospital. This is hisfirst visitwith this patient during this stay. He spent a total time of85 minuteson that patient on that date of service, including review of the observation admission, labs, X-rays, and EKG results, and examining the patient with amoderate level of medical decision making. What CPT® coding is reported?)
Preoperative diagnosis: Right thigh benign congenital hairy nevus. *1
Postoperative diagnosis: Right thigh benign congenital hairy 0 nevus.
Operation performed: Excision of right thigh benign congenital>1
nevus, excision size with margins 4.5 cm and closure size 5 cm.
Anesthesia: General.0
Intraoperative antibiotics: Ancef.0
Indications: The patient is a 5-year-old girl who presented with her parents for evaluation of her right thigh congenital nevus. It has been followed by pediatrics and thought to have changed over the past year. Family requested excision. They understood the risks involved, which included but were not limited to risks of general
anesthesia, infection, bleeding, wound dehiscence, and poor scar formation. They understood the scar would likely widen as the child grows because of the location of it and because of the age of the patient. They consented to proceed.
Description of procedure: The patient was seen preoperatively in > I the holding area, identified, and then brought to the operating room. Once adequate general anesthesia had been induced, the patient's right thigh was prepped and draped in standard surgical fashion. An elliptical excision measuring 6 x 1.8 cm had been marked. This was injected with Lidocaine with epinephrine, total of 6 cc of 1% with 1:100,000. After an adequate amount of time, a #15 blade was used to sharply excise this full thickness.
This was passed to pathology for review. The wound required □ limited undermining in the deep subcutaneous plane on both sides for approximately 1.5 cm in order to allow mobilization of the skin for closure. The skin was then closed in a layered fashion using 3-0 Vicryl on the dermis and then 4-0 Monocryl running subcuticular in the skin, the wound was cleaned and dressed with Dermabond and Steri-Strips.
The patient was then cleaned and turned over to anesthesia for S extubation.
She was extubated successfully in the operating room and taken S to the recovery room in stable condition. There were no complications.
What is the radiology coding for this encounter?
(A 6-month-old child was brought to the hospital with severe breathing difficulties. After testing, the child was diagnosed withtracheal stenosis present from birth. The pediatric surgeon performed atracheoplasty(surgical widening of the trachea). What CPT® and ICD-10-CM codes are reported?)
A pathologist performs fluorescent microscopy for chromosomal abnormalities, but no specific CPT® code exists.
Which unlisted CPT® code is reported?
An air bag deployed when a driver lost control of the car and crashed into a guardrail on the side of the highway. The driver suffers partial impact resulting in a skull fracture of the anterior
cranial base. The fracture is diagnosed using the MRI scanner and cerebrospinal fluid is noted dripping via the sphenoid sinus into the right nasal passage. The patient requires a surgical nasal
sinus endoscopy to assess and repair the injury.
What is the correct procedure and diagnosis coding combination to report this service?
A 49-year-old patient arrives with hearing loss in his left ear. Impedance testing via tympanometry is performed.
What CPT® code is reported?
During a laparoscopic hemicolectomy, the left kidney is accidentally perforated. A nephrologist performs open repair of the kidney laceration and places a JP drain.
What CPT® and ICD-10-CM coding is reported by the nephrologist?
(What ICD-10-CM coding is reported forType 1 diabeteswithdiabetic chronic kidney disease?)
(A patient is seen for nausea, vomiting, and sharp right lower abdominal pain. CT and labs support a diagnosis ofchronic appendicitis. The physician schedules anopen appendectomyand removes the appendix. What CPT® and diagnosis codes are reported?)
A patient is seen at the doctor's office for nausea, vomiting, and sharp right lower abdominal pain. CT scan of the abdomen is ordered. Labs come back indicating an increased WBC count with review of the abdominal CT scan. The physician determines the patient has a ruptured appendicitis. The physician schedules an appendectomy and takes the patient to the operating room. The appendix is severed from the intestines and removed via scope inserted through an umbilical incision. What CPT® and diagnosis codes are reported?
A 3-day-old died in her sleep. The pediatrician determined this was the result of crib death syndrome. The parents give permission to refer the newborn for a necropsy. The pathologist receives the newborn with her brain and performs a gross and microscopic examination. The physician issues the findings and reports they are consistent with a normal female newborn.
What CPT® code is reported?
An 8-day-old newborn (3 kg) undergoes circumcision using a scalpel (no clamp).
What CPT® coding is reported?
The patient came in with an inflamed seborrheic keratosis on her nose for a shave removal. After applying local anesthesia, a 0.7 cm dermal lesion was removed using an 11 blade.
What CPT® and ICD-10-CM codes are reported?
(A patient presents for surgery due to recurrent lumbar radiculopathy at a previously operated spinal level. The surgeon performs arepeat exploration laminotomywithbilateral foraminotomyto decompress nerve roots at theL1–L2 interspace. No additional spinal levels are treated. What CPT® coding is reported?)
(Miranda is in her provider’s office for follow up of her diabetes. Her blood sugars remain at goal with continuing her prescribed medications. When referring to the MDM Table for number and complexity of problems addressed, what type of problem is this considered?)
A patient with abnormal growth had a suppression study that included five glucose tests and five human growth hormone tests.
What CPT@ coding is reported?
A patient with suspected gynecologic malignancy undergoes laparoscopic staging including bilateral pelvic lymphadenectomy, periaortic lymph node sampling, peritoneal washings, peritoneal and diaphragmatic biopsies, and omentectomy.
What CPT® coding is reported?
A 45-year-old female presents to the ED with chest pain. The provider has an Albumin Cobalt Binding Test to determine if the chest pain is ischemic in nature.
That lab test is reported?
(A female patient underwent a mastectomy on herleft breastlast year due to breast cancer. The surgery was successful in eliminating the cancer and no further treatment was required. However, a recent diagnosis now includes cancer thatmetastasized to her liver. What ICD-10-CM coding is reported?)
(A patient has aliver massand presents for apercutaneous needle biopsy of the liver with CT guidance. Four core specimens are taken to rule out benign hepatic adenoma. What CPT® and ICD-10-CM codes are reported?)
A patient returns for embryo transfer. The lab thaws cryopreserved embryos and cultures them for two additional days.
What CPT® coding is reported?
A 42-year-old male is diagnosed with a left renal mass. Patient is placed under general anesthesia and in prone position. A periumbilical incision is made, and a trocar inserted. A laparoscope is
inserted and advanced to the operative site. The left kidney is partially removed.
What CPT @ code is reported for this procedure?
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?
A patient with severe diverticulitis in the sigmoid colon presents to surgery for a partial colectomy. The physician performs an exploratory laparoscopic laparotomy to verify the location of the diverticulitis. Once identified, it was noted that there was bleeding from the diverticulitis. The physician transects the descending colon and then transects at the line of the rectum.
The physician mobilizes the splenic flexure in order to create a colostomy with the proximal portion of the remaining colon. The distal portion of the colon is closed. The physician washes the patient's abdomen with saline, removes all trocars and instruments, and then closes the abdomen with sutures.
What CPT® and ICD-10-CM codes are reported?
(A 14-month-old male with a unilateral complete cleft lip and alveolar cleft palate had prior repair of the cleft lip. He now presents forreconstruction of the palatewith closing the fissure in the soft tissue of thealveolar ridge with bone graft. What CPT® coding is reported?)
The provider orders a bile test for a patient that has chronic hepatitis that is undergoing treatment. Lab analyst quantitates the total bile acids with an enzymatic method. What CPT® code is
reported for the test?
A patient is brought to the operating room with a right-sided peripheral vertigo. The provider makes a postauricular incision and uses an operating microscope to perform a mastoidectomy using a burr. He next destroys the semicircular canals, the utricle, and saccule completely removing the diseased labyrinth structures. The provider sutures the incision.
What CPT® code and ICD-10-CM codes are reported?
(Full Case:Procedure:Excision of6.0 cm malignant lesionof theright forearmwithadjacent tissue transferusing arotation flap.Pre/Post-op Dx:Basal cell carcinoma, right forearm.Anesthesia:local (1% Xylocaine with epi).Defect size:8 sq cm.Specimen:sent forfrozen section margin control; margins confirmed clear.Closure:rotation flap from adjacent healthy tissue,total area 8 sq cm, secured with layered closure (5-0 Vicryl/6-0 Prolene).Question:What CPT® coding is reported?)
The evisceration of ocular contents was performed using a surgical microscope for enhanced visualization. The procedure was performed on the left eye and an implant was not placed in the ocular cavity.
What CPT® coding is reported?
(What modifier is appended to indicate that during thepostoperative period, a procedure is performed that wasplanned,more extensivethan the original procedure, or done fortherapeutic reasons?)
An 8-year-old patient is placed under general anesthesia for treatment of a right orbital fracture due to a traumatic fall to the nose and face from a swing set. An on-call otolaryngologist is
asked to perform a general otolaryngologic examination to evaluate the patient. A mild nasal fracture is the diagnosis given by the otolaryngologist.
What is the CPT® and ICD-10-CM coding for the otolaryngologist's services?
Patient has a 5 cm tumor in the left lower quadrant abdominal wall. A horizontal skin incision is made directly over the tumor in the patient's left lower quadrant and dissection was carried
down through the dermis and subcutaneous tissue. The tumor is located and completely excised using electrocautery. The specimen is sent immediately to pathology to rule out cancer. What
CPT® and ICD-10-CM codes are reported?
(Chief Complaint: Palpable lump in the left breast. Adiagnostic mammogram (unilateral)was performed on theleft breastusingdigital imaging with CAD, with standard and additional views. What CPT® codes are reported for the radiological services?)
Preoperative diagnosis: Right thigh benign congenital hairy nevus. *1
Postoperative diagnosis: Right thigh benign congenital hairy 0 nevus.
Operation performed: Excision of right thigh benign congenital>1
nevus, excision size with margins 4.5 cm and closure size 5 cm.
Anesthesia: General.0
Intraoperative antibiotics: Ancef.0
Indications: The patient is a 5-year-old girl who presented with her parents for evaluation of her right thigh congenital nevus. It has been followed by pediatrics and thought to have changed over the past year. Family requested excision. They understood the risks involved, which included but were not limited to risks of general
anesthesia, infection, bleeding, wound dehiscence, and poor scar formation. They understood the scar would likely widen as the child grows because of the location of it and because of the age of the patient. They consented to proceed.
Description of procedure: The patient was seen preoperatively in > I the holding area, identified, and then brought to the operating room. Once adequate general anesthesia had been induced, the patient's right thigh was prepped and draped in standard surgical fashion. An elliptical excision measuring 6 x 1.8 cm had been marked. This was injected with Lidocaine with epinephrine, total of 6 cc of 1% with 1:100,000. After an adequate amount of time, a #15 blade was used to sharply excise this full thickness.
This was passed to pathology for review. The wound required □ limited undermining in the deep subcutaneous plane on both sides for approximately 1.5 cm in order to allow mobilization of the skin for closure. The skin was then closed in a layered fashion using 3-0 Vicryl on the dermis and then 4-0 Monocryl running subcuticular in the skin, the wound was cleaned and dressed with Dermabond and Steri-Strips.
The patient was then cleaned and turned over to anesthesia for S extubation.
She was extubated successfully in the operating room and taken S to the recovery room in stable condition. There were no complications.
What CPT® coding is reported?
The patient has a ruptured aneurysm in the popliteal artery. The provider makes an incision below the knee and dissects down and around the popliteal artery. After clamping the distal and
proximal ends of the artery, the provider cuts out the defect, sutures the remaining ends of the artery together, and places a patch graft to fill the gap. What is the correct CPT® code for the
aneurysm repair?
A patient undergoes a laparoscopic appendectomy for chronic appendicitis.
What CPT® and diagnosis codes are reported?
A driver loses control of a vehicle and crashes into a guardrail on the side of the highway. The patient sustains a fracture of the anterior fossa cranial base. Imaging confirms Involvement of the sphenoid sinus, but no cerebrospinal fluid (CSF) leak is identified. The patient undergoes a surgical nasal sinus endoscopy with sphenoidotomy lo evaluate and treat the sinus injury. No CSF leak repair is performed.
What is the correct procedure and diagnosis coding combination to report this service?
An ED provider evaluates a patient with NSTEMI, consults cardiology, and the patient is admitted for PCI.
What E/M service and ICD-10-CM coding is reported by the ED provider?
(A 47-year-old patient previously had a right mastoidectomy and an implanted osseointegratedBAHAdevice. Now presents with chronic infection, implant migration, and osteomyelitis of the right temporal bone. Surgeon performs arevision mastoidprocedure with debridement, removes the existing BAHA implant, and places anew osseointegrated BAHAin a new skull location. What CPT® codes are reported?)
A 45-year-old patient comes In with chronic sinusitis that has not responded to medication. The physician decides to use a sinus stent implant to help alleviate the patients symptoms.
The physician inserts the implant into the ethmoid sinus using a delivery system. This implant is designed to keep the surgical opening clear, prop open the sinus, and gradually release a corticosteroid with anti-inflammatory properties directly to the sinus lining. The implant is not permanent and will dissolve over time.
What HCPCS Level II code is reported?
(A 65-year-old male patient passed away due to unknown causes. An autopsy was ordered by the attending physician to determine the cause of death. The pathologist performed agross and microscopic examination autopsy, that includes thebrain and spinal cord. What CPT® coding is reported?)
A patient had surgery a year ago to repair two extensor tendons in his wrist. He is in surgery for a secondary repair for the same two tendons with free graft. What CPT® coding is reported?
(A physician performsexcisional debridementfor a patient with multiple wounds. A wound on thelower backmeasures12 cmand involves thefasciafor the debridement. A wound on theleft shouldermeasures8 cmand one on theleft lower legmeasures16 cminvolvessubcutaneous tissuefor the debridement. What CPT® codes are reported?)
A patient with three thyroid nodules is seen for an FNA biopsy. Using ultrasonic guidance, the provider inserts a 25-gauge needle into each nodule. Nodular tissue is aspirated and sent to pathology.
What CPT® coding reported?