A patient had surgery a year ago to repair two flexor tendons in his forearm. He is in surgery for a secondary repair for the same two tendons.
Which CPT® coding is reported?
An anesthesiologist medically directs two cases during EGD and colonoscopy in a PS III patient with severe bleeding risk.
What CPT® codes are reported?
A 32-year-old vialled a provider due to skin itching and ongoing irritation and watering of the eyes. Suspecting an allergy, the provider suspects an allergic reaction and decides to conduct allergy testing. A prick on the skin of the patient's forearm is performed by introducing a small amount of an allergen and monitored for signs of an allergic reaction.
What CPT® code is reported?
A patient comes in complaining of pain in the lower left back, which is accompanied by a numbing sensation that extends into the leg. Attempts to alleviate the pain with home treatments have been unsuccessful. The provider orders an MRI of the lumbar spine initially without, and then with, contrast material. The images are interpreted by the physician, the final diagnosis is left-sided low back pain with sciatica.
What CPT® and ICD-10-CM 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?
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?
View MR 007400
MR 007400
Radiology Report
Patient: J. Lowe Date of Service: 06/10/XX
Age: 45
MR#: 4589799
Account #: 3216770
Location: ABC Imaging Center
Study: Mammogram bilateral screening, all views, producing direct digital image
Reason: Screen
Bilateral digital mammography with computer-aided detection (CAD)
No previous mammograms are available for comparison.
Clinical history: The patient has a positive family history (mother and sister) of breast cancer.
Mammogram was read with the assistance of GE iCAD (computerized diagnostic) system.
Findings: No dominant speculated mass or suspicious area of clustered pleomorphic microcalcifications is apparent Skin and nipples are seen to be normal. The axilla are unremarkable.
What CPT® coding is reported for this case?
A patient presents with keratosis lesions on her left cheek, above the left eyebrow, and on the chin area. The dermatologist treats those areas by lightly sanding the surface of a total of 5 lesions.
What CPT® coding is reported?
A patient presents for planned sterilization via bilateral excisional vasectomy.
What CPT® and ICD-10-CM codes are 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 E/M coding is reported?
