Patient has cervical spondylosis with myelopathy. The surgeon performed a bilateral posterior laminectomy with facetectomies at each level and foraminotomies performed between interspaces C5-C6 and C6-C7. Bilateral decompression of the nerve roots is achieved.
What CPT® coding is reported?
A patient that delivered her second child vaginally has a history of having a previous cesarean delivery for the first child.
What CPT® code is reported for the delivery of the second child with antepartum care and postpartum care with the same provider?
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?
Adenoids, tonsils, appendix, and spleen belong to which organ system?
(A patient visits her provider’s office because she is experiencing persistent headaches. Her provider sends her to a radiology facility to do aCT scan of the brain without contrast. The images are sent to the provider, and the providerreads and interpretsthe scan. What CPT® coding of the radiology service is reported by the provider?)
The epididymis is part of which organ system?
(A 45-year-old patient has a history of chronic otitis media in the left ear. The otolaryngologist performs atympanoplastyand doesnot remove the mastoidto repair the patient’s perforated tympanic membrane.What CPT® and ICD-10-CM codes are reported?)
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 patient has suspicious lesions on his feet. Biopsies confirm squamous cell carcinoma. The patient elects to destroy a 0.6 cm lesion on the right dorsal foot and a 2.0 cm lesion on the left dorsal foot using cryosurgery.
What CPT® coding is reported?
A 74-year-old arrived at the ED experiencing bright red rectal bleeding when using the toilet. She does not have any abdominal pain, no nausea or vomiting. She has been undergoing dialysis for
years due to end-stage renal failure and has a diagnosis of myelodysplastic syndrome with a platelet count of just 3,000. Her hemoglobin level, which was 10 at her dialysis session the
previous day, dropped to 7. Abdominal films are negative. An urgent esophagogastroduodenoscopy (EGD) was performed, and no active bleeding was found in the esophagus or the stomach.
However, the scope was passed into the upper duodenum which did reveal some oozing, and was controlled with cautery. Next, the patient was then positioned on her left side for a
colonoscopy that extended from the colon to the ileum and into the lower duodenum, but no definitive sources of bleeding were found. Again, no outright bleeding sources were identified. A
CRNA performed the anesthesia and documented PS III.
What CPT® codes are reported for the CRNA?