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?
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.
Which CPT® and ICD-10-CM codes are reported for this procedure?
What does NCCI stand for, and what is its purpose?
Which is a TRUE statement for Place of Service (POS) codes for professional claims?
Patient had polyps removed on a previous colonoscopy. The patient returns three months later for a follow-up examination for another colonoscopy. No new polyps are seen.
What diagnosis coding is reported for the second colonoscopy?
A 49-year-old patient arrives with hearing loss in his left ear. Impedance testing via tympanometry is performed.
What CPT® code is reported?
A retinal specialist diagnoses type 2 diabetic mild nonproliferative retinopathy with macular edema, bilateral. Diabetes is secondary to Cushing’s syndrome and controlled with oral hypoglycemics. What ICD-10-CM codes are reported?
A provider orders LC-MS definitive drug testing for suspected acetaminophen overdose.
What CPT® code is reported?
A three-year-old patient is in the operative suite for stage 2 of treatment for double right outlet syndrome. The patient previously had the pulmonary artery banded and is returning for removal of
the pulmonary band and transposition repair of the great vessels via aortic pulmonary reconstruction.
The surgeon performs a time-out and pre-incision review of respiration and BP then the previous sternal incision site is inspected and lightly painted with povidone. Next, reopens the sternal
cavity and inserts central cannulae in the IVC, SVC and ascending aorta for extra corporeal membrane oxygenation (ECMO) bypass, chemical cardioplegia is initiated, stopping the heart and
ECMO is initiated. A physician assistant monitors vitals and oxygenation until heart function resumes. The surgeon carefully incised and removes the Dacron band encircling the pulmonary
artery, with nominal need for dilation. A section of coronary ostia is removed and sutured to the root of the pulmonary trunk. The pulmonary trunk and aortic root are then transected and
transposed to allow for ideal cardiac circulation. Once structural integrity is visually confirmed, the physician assistant is permitted to administer the cardioplegia reversal solution and the
surgeon removes the central cannulae after heart function safely resumes. The sternotomy is closed and the patient is transported to the NICU.
What CPT® codes are reported for the surgery today?
A pathologist performs fluorescent microscopy for chromosomal abnormalities, but no specific CPT® code exists.
Which unlisted CPT® code is reported?
