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?
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?
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?
An autopsy is ordered for a deceased patient of unknown cause. The pathologist performs gross and microscopic examination, including the brain and spinal cord.
What CPT® coding is reported?
Which medical term refers to inflammation of the cornea?
(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 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?
(An orthopedic surgeon evaluated a patient in the emergency room two months after a surgical repair of a right radius and ulnar shaft fracture. After reinjury, imaging shows a displaced proximal fixation screw andmalunion of only the radial shaft. The same surgeon performs surgery to repair the malunion using a graft from the hip. What CPT® and diagnosis codes are reported?)
The documentation states:
He was then sterilely prepped and draped along the flank and abdomen in the usual sterile fashion. I first made a skin incision off the tip of the twelfth rib, extending medially along the banger’s lines of the skin. This was approximately 3.5 cm in length. Once this incision was carried sharply, electrocautery was used to gain access through the external oblique, internal oblique, and transverse abdominis musculature and fascia.
What surgical approach was used for this procedure?
A surgeon removes the right and left fallopian tubes and the left ovary via an abdominal incision. How is this reported?
