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?
According to the Application of Cast and Strapping CPT® guidelines, what is reported when an orthopedic provider performs initial fracture care treatment for a closed scaphoid fracture of the wrist, applies a short arm cast, and the patient will be returning for subsequent fracture care?
A patient complains of tarry, black stool, and epigastric tightness. An esophagogastroduodenoscopy is recommended to evaluate the source of the bleeding. The endoscope is inserted orally. The esophagus appears normal on scope insertion. No evidence of bleeding in the stomach. The scope is then passed into the duodenum, where a polyp is found and removed with hot biopsy forceps. No evidence of bleeding post procedure.
What CPT® code is reported?
Patient has esotropia of the right eye and presents to operating suite for strabismus surgery. The physician resects the medial rectus horizontal and lateral rectus muscles of the eye and secures them with adjustable sutures. Extensive scar tissue is noted, due to a previous surgery involving an extraocular muscle. Extraocular muscle is isolated, and the muscle is freed from surrounding scar tissues.
What CPT® codes are reported for this surgery?
(Which place of service code is submitted on the claim for a procedure that is performed in a patient’sprivate residence?)
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?
(Which punctuation is used in the ICD-10-CM Tabular List to denotesynonyms, alternative wording, or explanatory phrases?)
A physician performs excisional debridement on multiple wounds:
Lower back: 12 cm, involving fascia
Left shoulder: 8 cm, involving subcutaneous tissue
Left lower leg: 16 cm, involving subcutaneous tissue
What CPT® codes are reported?
A 4-year-old, critically ill child is admitted to the PICU from the ED with respiratory failure due to an exacerbation of asthma not manageable in the ER. The PICU provider takes over the care of the patient and starts continuous bronchodilator therapy and pharmacologic support with cardiovascular monitoring and possible mechanical ventilation support.
What is the E/M code for this encounter?
A cystic lesion on the chest is excised with margins totaling 2.5 cm. Simple closure performed.
What CPT® coding is reported?