Which codes should be reported for the following case ? Preoperative diagnosis : Lesion, left hand Confirmed by pathology postoperative diagnosis : Primary malignant carcinoma, left hand. Procedure performed : Excision of malignant carcinoma, left hand Anesthesia : General, 40 ml of lidocaine was infiltrated into the wound prior to making the incision. Procedure : The patient was brought to the operative suite where the left hand was prepped and dressed. A circular incision was made to include the 1-cm lesion with narrowest margins of 0.6 cm with dissection down to subcutaneous tissue. Homeostasis was obtained the wound was closed with simple mattress sutures. The patient tolerated the procedure well and was returned to the recovery room in good condition with sterile dressing in place.

Nancy underwent a fine needle aspiration with ultrasound guidance for a lesion in the right breast. During the aspiration procedure, a percutaneous metallic clip was placed in the right breast under ultra sound guidance. Which codes describe this procedure ?

Barry underwent a complex incision and drainage due to a postoperative wound infection, which acquired an extensive secondary closure of the surgical site. Which codes describe this procedure ?

Stephanie discovered a lesion on her trunk and was referred to Dr. Ralph, a trained Mohs surgeon, for treatment. Stephanie had no prior pathology of this lesion ; therefore, Dr.Ralph completed a diagnostic incisional skin biopsy with frozen section prior to the surgery. After reviewing the biopsy results, Dr.Ralph took the patient to the procedure suite and performed a Mohs surgery that same day. Dr.Ralph’s final report indicated the procedure required three stages, including five tissue blocks in each stage. He had to take an additional four blocks in stage two to verify margins and cell structure. Which codes should Dr. Ralph report for this entire encounter ?

A patient underwent an excision of a 2.1-cm diameter malignant lesion on her nose. An 11.2-sq-cm adjacent tissue transfer was required to repair the primary and secondary defect sites. How should you code this procedure ?

Glen required a replacement of his nonbiodegradable drug delivery implant system. Glen was taken into the procedure suite where he was prepped, Dr.Roberts injected a local anesthetic and made a 3.2-cm incision in the skin for removal of the previous cylinder. He then replaced the cylinder a sutured the new device in place with a single running stitch. The 3.2-cm trunk wound was closed with simple sutures. The device was tested, with excellent results. The patient tolerated the procedure well and was released from care with a sterile dressing in place. How should this procedure be coded ?

A patient reports a history of right groin pain, which is worse with sitting and rising from a sitting position Physical examination, x-rays, and CT scans confirm a cam lesion in the right femoral head-neck region and noted as the cause for loss of rotation. Dr.Curtis completed an arthroscopy of the right hip with debridement and a femoroplasty. How should Dr. Curtis report her procedure ?

Which code(s) should you report for the following case ? Preoperative diagnosis : Procedures : Left knee medial collateral ligament tear Exam under anesthesia Anterior cruciate ligament tear Diagnostic arthroscopy of left knee Possible meniscus tear Left knee arthroscopic repair of lateral meniscus. Postoperative diagnosis : Same Tourniquet time : 2.5 hours Procedure : The patient was taken to the operating room and positioned, and an epidural anesthetic was placed. Once the anesthetic had taken effect, the patient’s left leg was examined under anesthesia and noted to have increased valgus laxity with end point, a positive Lachman test, and positive pivot-shift test. The patient was prepped and draped in the normal fashion, exsanguinated, and the tourniquet applied to a 350 mmHg. The knee was then insuffiated and irrigated with fluid. Using the arthroscopic sheath, visualization of the knee joint began. Attention was turned to the lateral meniscus where the tear was debrided. Using the arthroscope, the lateral meniscus was sutured with two mattress-type sutures of non-absorbable 2-0 material. The sutures were then tied and visualized with arthoroscopy to reveal the meniscus to be in excellent shape and stable position. The 3.5-cm wound was thoroughly irrigated and closed with intermediate subcutaneous sutures. A sterile compression dressing was applied. The patient was placed in a TED hose a Watco brace, setting the brace between 40 and 60 of free motion. He was then taken to the recovery room in stable condition. The instrument, sponge, and needle counts were correct.

Two weeks ago, Sam underwent an open repair of his lower femur due to a traumatic fracture suffered while snow skiing. His leg is healing as expected, and no new treatment is required to the femur. Today, he returns as planned for an application of a new long leg cast. The cast application is completed by the same physician who performed the surgery. How should today’s services be reported ?

A patient was stabbed in the right arm. A surgeon took the patient to an operating suite and completed wound exploration. The surgeon widened the wound to achieve proper visualization and completed subcutaneous debridement and ligation of minor subcutaneous blood vessels. No further procedures were required for this wound exploration. The arm wound was closed and dressed in the usual fashion. The patient tolerated the procedure well and was returned to the recovery room in good condition.How would you report this procedure?

A patient underwent an anterior interbody arthrodesis with discectomy, osteophytectomy, fusion, and decompression of nerve roots at level C3, C4 and C5. The fusion was explored and then stabilized with application of anterior instrumentation placed from C3 to C5. Which codes would you use to report this procedure ?

Dr. Bender completed a therapeutic manipulation of the temporomandibular joint. An anesthesiologist placed this healthy 54-year-old patient under general anesthesia and monitored the patient during the procedure. The intraservice time was noted as one hour. The patient tolerated the procedure well and was returned to the recovery room in good condition. How would Dr. Bender’s services be reported ?

Alicia is 20 months old and suffering from chronic inflammation of the trachea, which is causing difficulty in breathing. Dr. Marion inserted a planned incisional tracheal tube for Alicia. This procedure was completed under general endotracheal anesthesia. The patient tolerated the procedure well and was returned to the recovery room in stable condition. How should Dr. Marion report this procedure ?

Dr. Manning, a thoracic surgeon, was asked to consult with Nancy, a 66-year-old female with atherosclerotic heart disease. The patient, who requested the visit, is well known to Dr. Manning, who performed thoracic surgery on her two years ago. She was seen in his office Monday morning for a consultative visit with mild complaints of fatigue and shortness of breath. Dr. Manning dictated a comprehensive history, comprehensive examination, and high-complexity decision-making. During this consultation, Dr. Manning made the decision to reoperate on Nancy. He sent a written report back to her cardiologist, Dr. Shaw, regarding the need for another surgery to take place the following day. Monday evening, Nancy was admitted to the hospital to start the prep for the planned bypass surgery Tuesday morning. Tuesday’s operative report Preoperative diagnostis : Atherosclerotic heart disease. Postoperative diagnosis : Same Anesthesia : General Procedure : The patient was brought to the operating room and placed in the supine position. With the patient under general intubation anesthesia, the anterior chest, abdomen, and legs were prepped and draped in the usual fashion. Review of a postoperative angiography showed severe, recurrent, two-vested disease with normal ventricular function. A segment of the femoropopliteal vein was harvested using endoscopic vein-harvesting technique and prepared for grafting. The patient was heparinized and placed on cardiopulmonary bypass. The patient was cooled as necessary for the remainder of the procedure and an aortic cross-clamp was placed. The harvested vein was anastomosed to the aorta and brought down to the circumflex and anastomosed into place. An artery was anastomosed to the left subclavian artery and brought down to the left anterior descending and anastomosed into place. The aortic cross-clamp was removed after 55 minutes with spontaneous cardioversion to a normal sinus rhythm. The patient was warmed and weaned from the bypass without difficulties after 104 minutes. The patient achieved homeostasis. The chest was drained and closed in layers in the usual fashion. The leg was closed in the usual fashion. Sterile dressings were applied and the patient returned to intensive care recovery in satisfactory condition. How should Dr. Manning report his services for Monday and Tuesday in this case ?

Marvin, a 51-year-old patient, required a conversion of a single-chamber pacemaker system to a dual-chamber system. The previously placed electrode was removed transvenously. The skin pocket was opened and the pulse generator removed. The skin pocket was then relocated and a dual system was placed with transvenous electrodes in both the right atrial and ventricular chambers. The system was tested and the new skin pocket was then closed. The patient tolerated the procedure well. How should you report these services ?

A patient required a battery change for a single-chamber pacing cardioverter-defibrillator system. The battery was taken out in a subcutaneous fashion and a new battery placed. The cardioverter-defibrillator was then reattached to the electrodes, which were intact and tested, and the skin pocket was then closed. How should these services be reported ?

A patient had an endarterectomy during the same surgical session for a repair to a coronary arteriovenous chamber fistula. The fistula repair did not require cardiopulmonary bypass to complete the procedure. How should these services be reported ?

A patient suffering from chronic inflammation of the maxillary sinus underwent a surgical endoscopic transnasal balloon dilation procedure to restore normal sinus function. During this procedure, maxillary antrostomy with removal of tissue was completed. How should you report these procedure ?

A patient with ongoing symptoms of weight loss, constipation, and blood in stool verified with occult testing underwent a rectal approach colonoscopy with snare removal of three colonic polyps. The pathology report, which was returned to the physician the same day of the procedure, revealed benign colon polyps. How should you report this ?

A patient was fully prepped for a diagnostic colonoscopy; however, an object then shifted into the descending colon just below the splenic flexure. The physician was unable to advance the scope to the splenic flexure. How would you report this diagnostic colonoscopy ?

Jennifer, a 3-year-old patient, swallowed a marble that became lodged in her esophagus. An esophagotomy via thoracic approach was completed for removal of the foreign body. The patient tolerated the procedure well and was returned to the recovery room in good condition. How should you code this procedure ?

An otherwise healthy 22-year-old patient was scheduled for repair of an incarcerated bilateral recurrent inguinal hernia. The patient was taken into a same-day OR, where she was prepped, positioned, and draped in the usual fashion. The anesthesiologist administered general anesthesia and indicated the patient was ready for the surgery to begin. The surgeon created the incision and started the procedure. At this point, the patient went into shock due to the anesthesia and the procedure was halted. The patient was stabilized and returned to the recovery room. How should the surgeon report this procedure ?

A patient underwent an EGD with transendoscopic ultrasound-guided transmural fine needle aspiration. How should you code this procedure ?

A patient underwent a laparoscopic repair of a paraesophageal hernia with fundoplasty with implantation of mesh. During the procedure, a laparoscopic esophageal lengthening was completed. Which codes capture this procedure?

A patient underwent destruction of extensive condyloma lesions on the penis. The documentation stated 12 or more lesions were visible and treated during this session. The procedure was completed by laser technique. The patient received follow-up and post-procedure care instructions and was discharged in good condition. How should you report this procedure ?

A patient underwent an injection procedure for voiding urethrocystography with contrast. During the same investigative session, the physician completed all components of a urethral pressure profile study and a simple UFR including interpretation of the results. How should you report the professionial services for this procedure ?

Dr. Laura completed a vaginal delivery in the hospital for Stephanie, a 30-years-old patient. This is Stephanie’s first child and she delivered a healthy baby boy. Dr. Laura has taken care of Stephanie during the entire pregnancy and followed her through the postpartum period. Dr.Laura’s documentation stated that during the delivery admission, Stephanie required prophylactic antibiotics because she has mitral valve prolapse. How should Dr. Laura report the delivery care and diagnosis fort his patient?

An established patient required medical attention for removal of an impacted foreign body from the vaginal canal. Her physician documented a detailed history, detailed examination including enlargement of the vaginal opening with introduction of speculum, and identification of the foreign body as a tampon. The patient was asked to return to the office is she had any complications, fever, or abnormal discharge or heavy bleeding. How should you report the procedure ?

One week ago, Marion underwent a surgical laparoscopy with vaginal hysterectomy including removal of a 275-g uterus tube and ovaries due to cancer of the endometrium. Today she was admitted for a planned insertion of a vaginal radiation afterloading apparatus for clinical brachytherapy. During this procedure, the surgeon inserted the device and took x-rays to ensure placement. Once the device was in the proper location, it was fixed into position by tightening the applicator base plate and locking mechanism. Marion tolerated the procedure well and was sent to the recovery suite in satisfactory condition. How should today’s professional services be reported?

A 43-year-old patient who suffers from severe intermittent vertigo has been definitively diagnosed with Meniere’s disease. After a year of various treatments, medications, tests, and behavior/lifestyle changes that have failed to lessen the symptoms, she now presents for a transcanal chemical labyrinthotomy to the right ear. Dr. Miller visualizes the tympanic membrane with an operating microscope, cleans the ear canal and makes a small incision into the tympanic membrane. Gentamicin is delivered into the right ear. The ent is repositioned with the right ear up and monitored by the nurse. The perfusion is repeated to achieve the maximum result. The ear is suctioned, cleaned, and carefully examined for bleeding. The patient tolerated the procedure well and is returned to the recovery area in satisfactory condition. How would Dr. Miller report his professional services ?

What code(s) would be reported for the following case? Preoperative diagnosis : Bilateral impacted ventilating tube Postoperative diagnosis : Same Anesthesia : General Procedure performed : Removal and replacement of new tubes, bilaterally via tympanostomy. Procedure : Sammie, a 16-year-old patient, was admitted and taken to the operative suite and placed under general anesthesia by inhalation. When adequate sedation was achieved, a 3.8-mm speculum was inserted into the left ear, wax removed, and speculum removed. The impacted tube was then removed. A new site was achieved within the same tympanosderotic plaque and a new tube placed. The same procedure was repeated to the right ear. Sammie was sent to the recovery suite in stable condition.

Dr.Adams completed an anterior discectomy with decompression including osteophytectomy to levels C3-C5. During the same session, he stabilized C3-C5 with anterior cervical interbody fusion. For proper visualization, Dr. Adams used an operating microscope during all phases of the procedure. How should Dr. Adams report this procedure ?

Carl, a 28-year-old patient, has a history of epilepsy with recurrent seizures. His seizures are intolerable even with medication management. He does not experience non-epileptic seizures, which was confirmed by EEG recordings. Today he underwent an open procedure for implantation of cranial nerve neurostimulator electrode array, which was coiled around the vagus nerve. The pulse generator was connected to the neurostimulator array, tested, and repositioned to ensure maximum effectiveness. The pulse generator was placed and sutured into a created subcutaneous pocket. Again, the system is tested to ensure proper functionality. The subcutaneous tissues and skin are closed with deep sutures and skin staples. Carl tolerated the procedure well and was returned to the recovery suite in stable condition. Which code(s) should be reported for today’s services ?

What code(s) should be reported with the following case ? Preoperative diagnosis : Total retinal detachment, right eye Postoperative diagnosis : Same Procedure performed : Complex repair of retinal detachment with photocoagulation, scleral buckle, sclerotomy/vitrectomy. Anesthesia : Local Procedure : The patient was placed, prepped, and draped in the usual manner. Adequate local anesthesia was administered. The operating microscope was used to visualize the retina, which has fallen into the posterior cavity. The vitreous was extracted using a VISC to complete the posterior sclerotomy. Minimal scar tissue was removed to release tension from the choroids. The retina was repositioned and attached using photocoagulation laser, a gas bubble, and a suture placement of a scleral buckle around the eye. The positioning of the retina was checked during the procedure to ensure proper alignment. Antibiotic ointment was applied to the eye prior to placement of a pressure patch. The patient tolerated the procedure well and returned to the recovery suite in satisfactory condition

A patient had a bilateral strabismus surgery involving the medial and lateral rectus muscles. The surgeon explored and repaired a detached extraocular muscle in the right eye and placed bilateral posterior fixation sutures with muscle recession. How should you report this procedure ?

Dr. Mayer admitted Sally to observation status Monday afternoon related to minor changes to an EKG and a dizzy spell. His dictated note for initial observation status included a medically appropriate history, examination, and moderate decision-making. He started her on new medications and wanted to continue to observe her until he was sure her condition was stable. On Tuesday, Dr. Mayer saw Sally, who was still receiving observation services , and dictated a chart note related to her changes since his last visit. The note consisted of history, examination, and straightforward decision-making. How should Dr. Mayer report Tuesday’s visit ?

Dr. Peters is Tim’s family physician. During today’s visit with Dr. Peters, Tim complained of fatigue, light headedness, and intermediate chest pains, Dr. Peters called Dr. Counsel, a cardiologist, and asked for a work-in visit for Tim. Dr. Counsel saw Tim in the office later that afternoon, performed a comprehensive examination, and obtained an extended history of the present illness with complete past family, social, and personal history. Dr. Counsel’s decision-making was based on extensive data, the high risk of complications, and the problem encountered was noted as high intesity. Dr. Counsel sent a written report back to Dr. Peters outlining the visit and plans for insertion of a pacemaker in the next few days. How would Dr. Counsel report today’s visit

Dr. Mike asked Dr. Susan to conduct a follow-up consultation with Lou, a 15-year-old patient who had a tympanotomy three days ago. Dr. Susan consulted for Lou the day after surgery for a fever and mild seizures. The patient was stable until today when Lou’s fever returned and he suffered another mild seizure. Dr. Susan dictated a history, physical examination and high decision-making related to her findings. How would Dr. Susan report her services for today’s visit in the inpatient unit ?

A physician provided 185 minutes of critical care for an 82-year-old patient suffering from heart failure. The physician documented an additional 20 minutes, outside the critical care time, which was dedicated to insertion of a peripherally inserted venous access device. During this encounter, the physician obtained a fronted chest x-ray, pulse oximetry, and arterial puncture for blood gases. How should these services be reported?

Baby Jones is 26 days old and requires continued intensive care services but is not considered critically ill. Her present body weight is 1,400 grams. Dr. Rob initially admitted Baby Jones to her service on Monday. Dr. Rob completed a visit with Baby Jones and her parents on Tuesday and Wednesday. How would Dr. Rob report all three days of service ?

Today Dr. Miller completed an initial comprehensive service with Mary, an established patient. Mary has been admitted in the Nursing facility yesterday from hospital. Today’s documentation included an assessment of her overall condition, her continued need for 24-hours nursing assistance, and her decline in mental acuity. Dr. Miller dictated a medically appropriate history, examination and high decision-making, and notes related to discussions with her extended family. Additionally, he completed the required resident assessment instrument and protocols and Minimum Data Set paperwork. Which code(s) should Dr. Miller report for today’s visit ?

An anesthesiologist provided general anesthesia for open repair of a fractured pelvis column involving the acetabulum for a 74-year-old patient. Further documentation for this patient includes severe hypertension and uncontrolled diabetes. How should the anesthesiologist report her services ?

Dr. Burns, a surgeon, provided regional anesthesia and completed an exploration for postoperative hemorrhage in the neck on a 55-year-old patient with moderate cardiovascular disease. How would Dr. Burns report his services for this case ?

Dr. Will, an anesthesiologist, provided three days of hospital management for epidural continuous drug administration. These services were performed afte insertion of the epidural catheter. How should Dr. Will report these days of care ?

A patient with a third-degree burn of 54% of his body is being treated under anesthesia for excision, debridement, and extensive skin grafting. The patient’s condition is listed as severe, and he is not expected to survive without the operation. The operation is further complicated by the emergency condition of the patient, and delaying this procedure could lead to loss of body parts. How should the anesthesiologist report her services with this procedure?

A patient with a history of family breast cancer is now suffering from swelling in both arms and undergoes a bilateral lymphangiography. How should the professional services and diagnoses be reported for this procedure?

Angela, a 28-year-old patient, is pregnant with triplets. She is in her second trimester and is being evaluated by transabdominal ultrasound with real-time imaging for fetal sizes. This is her third follow-up ultrasound to ensure the adequacy of fetal growth, development, and weight. How would you report this service ?

A patient had an MRI of the face without contrast materials followed by contrast for six further sequences during the same scanning session. How should this professional service be reported ?

A therapeutic radiologist performed a comprehensive history, comprehensive examination and high complexity decision-making when admitting a patient. After admission, the same physician placed 12 interstitial ribbons for clinical brachytherapy. How would you report these services ?

Joann had a diagnostic mammography of her left breast with computer-aided detection. During the same session, two lesions were identified and mammographic guidance needle placements were completed. How should these services be reported ?

A patient completed three radiation treatment sessions for two separate treatment areas with use of multiple blocks. Each session consisted of 8 MeV of radiation being delivered. How should these technical services be reported?

Which code(s) should be reported for the following case ? Clinical history Mass in the body of stomach Gross description : Cavity effusion – two Diff-Quik four smears prepared with simple filter and interpretation. Specimen received : Stomach mass touch prep. Adequacy : Specimen satisfactory for cytological evaluation Diagnosis : Primary malignant neoplasm – body of the stomach Notes : Cytology completed on specimen. The malignant cells show subjective features suggestive of small – cell carcinoma, however, cell size is more attuned with non-small-cell carcinoma.

Dr. Ross, a pathologist, completed both gross and microscopic surgical pathology after a lung wedge biopsy. Dr. Miles, the surgeon, sent a single specimen to the laboratory after the completion of a limited biopsy by thoracotomy. How would Dr.Ross report her services ?

Robert was sent to a local laboratory for pre-employment alcohol screening. He provided a blood sample to the laboratory technologist. The technologist completed a qualitative screening, including one procedure for multiple drug classes using non-chromatographic methods with dipstick. The test was negative and results were sent back to the requesting employer. How should you report this laboratory service ?

Jane underwent a combined rapid anterior pituitary evaluation panel with multiple exposures and suppressions and had a hepatic function panel. How should these tests be reported ?

Dr. Thomas received a request for consultation that included records and specimens. Dr. Thomas did not see the patient, but documented the patient as inpatient status with a comprehensive family history of colon cancer. The patient takes multiple medications and is at high risk of complications due to weight loss, chronic diarrhea, and a continued fever. His confirmative opinion, based on the review of specimens and records, indicates positive small-cell cancer. Dr. Thomas sent his written report back to the requesting physician. How should Dr. Thomas report his services ?

A patient had the following blood tests completed as part of her primary care physician’s described metabolic panel : albumin, bilirubin total, calcium total, carbon dioxide, chloride, creainine, glucose, phosphatase alkaline, potassium, protein total, sodium, transferase (ALT SGPT), transferase aspartate (AST SGOT), urea nitrogen (BUN), bilirubin direct, and a hepatitis A lgM. How should these services be reported?

Mae’s physician asked her to wear a glucose monitoring device to obtain more accurate information about her blood sugars. She had sensors placed and was then hooked up to a calibrated wearable device. Once this was complete, the technician provided Mae with training for the noninvasive ambulatory continuous glucose monitoring device. After wearing the device for 72 hours, Mae’s physician’s office removed the device, printed recordings, and downloaded analyses reports to its computer system. Which code captures this service

A 19-year-old patient received immunizations at her health clinic. The immunizations were administered by a medical assistant at the same clinic. The patient was seen two weeks ago but was unable to complete the immunizations due to a stomach virus. Today, she is symptom free and receives an intramuscular H1N1 influenza pandemic formulation, preservative –free vaccine and an intramuscular hepatitis A immunization. Which codes capture these services ?

Which codes should be reported for the following case ? Preoperative diagnosis : Coronary arteriosclerosis of native arteries, chronic occlusion of coronary arteries. Postoperative diagnosis : Same Anesthesia : Conscious sedation by procedure physician with presence of trained observer. Procedure : The 64-year-old patient was prepped, draped, and positioned in the usual fashion. After adequate sedation was administered, an access site into the right femoral artery was achieved. The catheter devices were advanced into position. Extensive review of the current anatomy was completed along with review of the previous catheterization. The procedure continued as planned with placement of two drug-eluting stents in the left circumflex, PTCA to the right coronary artery and atherectomy for occlusion in the left anterior descending artery. Adequate flow was reviewed and confirmed via angiograms upon completion of the procedures. The guiding catheter was withdrawn after flow confirmation. Total intraservice time was noted at 1 hour 30 minutes. The sheath was secured to the groin with a suture and the patient was moved to recovery in good condition. Standing orders were given for sheath removal when the heparin effects are noted as normal through blood tests. Normal pressure is to be applied at the groin as needed with placement of a sandbag or ice bag.

A patient suffering from nystagmus completed a basic vestibular function evaluation with testing and recording in five different positions with gaze fixation; optokinetic, bidirectional, foveal, and peripheral stimulation ; and oscillation. An additional vertical electrode and vertical axis rotational testing was employed during testing. How should this procedure be reported ?

A patient underwent a left heart catheterization by transseptal puncture through an intact septum with image supervision and interpretation and intraprocedural injection for left ventriculography. During the procedure, pharmacologic agents were administrated and measured. An arm ergometry was employed for exercise study to assess hemodynamics before and after the procedure. How should this procedure be reported ?

A patient completed a diagnostic computerized ophthalmic scan of the retina on both eyes. The physician’s interpretation and report included changes to the retina in the right eye from a previous study. The left retina looked stable with no changes noted. The patient is scheduled for a follow-up study in three weeks to assess any new changes and treatment as needed. How should the physician report her services ?

What condition is caused by an accumulation of uric acid crystals in the basis joint of the large toe and other joints of the feet and legs ?

What term describes a muscle shortening its length in a resting state and then remaining in this position ?

Which of the following represents the correct pathway for electrical activity in the heart ?

Which joint movement is limited to flexion and extension in a single plane ?

What does the prefix “aniso-“ mean ?

The lymphatic system is sometimes referred to as which other system ?

Which term describes death of breast tissue resulting from interrupted blood flow to this area?

What does a corneal pachymetry determine ?

Six weeks ago, Terry underwent a biopsy procedure and was diagnosed with secondary metastatic liver carcinoma. His doctors are uncertain about the location of the primary site and have ordered further testing. Today, Terry is undergoing chemotherapy for the liver cancer. How should the diagnosis codes be reported for today’s service ?

Jodie is 28 weeks pregnant with her second child. During an office visit two weeks ago, she mentioned experiencing some edema and headaches. Dr. Smith noted a higher-than-usual blood pressure for Jodie and asked her to come in for continued blood pressure monitoring and a urine test. Her urine test came back positive for excessive protein. During her visit today, her blood pressure is 140/95, which is consistent with the past abnormal readings. She still has continued abnormal edema but no headache. Dr. Smith tells Jodie she has preeclampsia and wants her to schedule visits more often during the next two months for monitoring. What code(s) should be listed in Jodie’s record for today’s visit ?

Lynn is a 53-year-old patient who previously received treatment by external fixation for a Grade I right tibial fracture. She suffered the fracture falling from a ladder while cleaning the gutters on her home. Today she underwent an open reduction of the right proximal tibia with bone grafting for nonunion. What diagnosis codes would Dr. Rennin report for today’s encounter ?

Sara is being seen for a spontaneous pathologic fracture of her right hip with additional damage to the intertrochanteric section of the bone. The documentation indicates the patient also has symptomatic HIV disease. Sara has had previous pathologic fractures of the ulna and vertebral segments, which have since healed. How should the diagnosis codes be reported for this encounter ?

Jason was burned during a military scuba diving exercise when steam was released from a steam pipe. He suffered second and deep third-degree burns to the entire anterior side of his right leg, second-degree burns to part of the right palm, and a second-and third-degree burn to his right forearm. The documentation indicated 25% of the total body surface area (TBSA) was burned, of which 19% were third-degree burns. How would the diagnosis codes be reported for Jason’s burns ?

Mrs. Smith underwent a hemipelvectomy to remove a tumor in her uppermost right hip region. After healing from the operation, she was fitted with a prosthetic and started physical therapy. Which supply code(s) would be reported for her hemipelvectomy, Canadian type ; molded socket, hip joint, single-axis constant-friction knee, shin, SACH foot ?

Jane had her ostomy pouch replaced. Her new ostomy pouch is drainable, with extended wear barrier attached, with built-in convexity (1 piece). How should you report this supply ?

Sherry, a 5-year-old patient, was diagnosed with immune thrombocytopenic purpura and started on Privigen 1,000 mg. Which diagnosis and medication (drug) code should be reported for her injections ?

In the CPT Professional Edition, the same detailed definition for separate procedures can be located in which main section guidelines ?

What do the guidelines for Category II codes state about the use of these codes ?

Which of the following does the CPT Professional Edition indicate is always included in addition to the operation per se ?

How does the CPT Professional Edition describe concurrent care of a patient?

Which elements are listed to determine the complexity of decision-making for evaluation and management codes?

Which types of contrast administration alone do not qualify as a study “with contrast”

Why should the add-on code 99100 for qualifying circumstances not be reported with the following codes : 00326, 00561, 00834 and 00836 ?

What organization is responsible for updating CPT codes each year ?

What does the abbreviation PQRI refer to in relation to medical coding ?

Which two federal government agencies make up the ICD-10-CM Coordination and Maintenance Committee

How would the following case be coded ? Preoperative diagnosis : Lesion, buccal submucosa, right lower lip Postoperative diagnosis : Same Procedure performed : Excision of lesion, buccal submucosa, right lower lip. Anesthesia : Local Procedure : The patient was placed in the supine position. A measured 7x8 mm hard lesion is felt under the submucosa of the right lower lip. After application of 1% Xylocaine with 1:1000 epinephrine, the lesion was completely excised. The lesion does not extend into the muscle layer. The 8-cm wound was closed with complex mattress sutures to the submucosal level and dressed in typical sterile fashion. The patient tolerated the procedure well and returned to the recovery area in satisfactory condition.

Veronica, a 55-year-old patient, has left upper quadrant pain with a negative ultrasound. Veronica’s physician explains the need for a diagnostic and possible surgical procedure to determine the cause of this pain. She agrees to the procedure, completes overnight fast and prep, signs a consent for surgery, and is then taken to a procedure room. After nasal spray of 2% Xylocaine is administered, the tube is introduced through one nostril, down the back of the throat, and positioned into the stomach as the patient swallows. The diagnostic duodenal intubation and aspiration is completed. However, the physician decides to reposition the tube under fluoroscopic guidance and obtain multiple duodenal fluid specimens during the same operative session. The patient tolerates the procedure well and is moved to the recovery suite. How would you report the physician services ?

Chief Complaint: Patient presents today for paring of calluses that have formed on the fifth toes of each foot. Patient is an avid runner who averages 10-15 miles daily. Calluses continue to form as observed over previous visits. Patient is unable to effectively train for upcoming marathon due to increasing discomfort. Dermatologic Review of Systems: Positive for painful skin abnormality of the fifth toe of both the right and left foot. Physical Exam Vital Signs: BP 110/80 Integumentary: Visual examination revealed thick calluses on both the right and left foot. Raised, thickened, and extremely tender to touch. Area is pale yellow in color. Each callus measures 2 cm in size. Shape is round. Arrangement is isolated and has a well-demarcated distribution. Status is worsening due to continued vigorous physical activity. Procedures Lesion Excision/Shaving: Explanation of procedure given, and consent obtained. Lesion prepped and draped using sterile technique. Anesthetized using Lido 2% w/sodium bicarb 10:1 solution, less than 1 cc was administered to both left and right fifth toes. A 2.0 cm hyperkeratotic lesion including margins on the both the right and left fifth toe were removed via paring method. Assessment/Plan: Removal of hyperkeratotic lesion from the left and right fifth toes. Await pathology. Specimens sent to lab. Antibiotic ointment was applied and toes wrapped with sterile dressing. Patient advised to abstain from running for 2-3 days and to wear an additional pair of socks when running to prevent or slow callus formation in the future. Specimen for pathology. What CPT® and ICD-10-CM codes are reported?

At the patient’s bedside using Xylocaine local anesthesia, aseptic technique, and ultrasound guidance, a 21-gauge needle was used to aspirate the right cephalic vein of a 72-year-old patient. Ultrasound demonstrated vascular needle entry and vessel patency of the cephalic and subclavian veins. When blood was obtained, a 0.018 inch platinum tip guidewire was advanced to the central venous circulation. A 6 French dual lumen PICC was introduced through a 6 French peel-away sheath to the SVA RA junction. After removal of the sheath, the catheter was attached to the skin with a STAT-LOCK device and flushed with 500 units of Heparin in each lumen. Permanent ultrasound recordings were placed in the record. A sterile dressing was applied and the patient was discharged in improved condition. What CPT® code(s) is/are reported for the physician?

Operative Report Preoperative Diagnosis: Bilateral serous otitis media Postoperative Diagnosis: Bilateral serous otitis media Operative Technique: The patient has a history of persistent serous otitis media, unimproved with aggressive antibiotic therapy over the past six months, with recurrent acute otitis and failure on maintenance antibiotics. The patient was brought to the operating room and given a general anesthetic by mask. The ear canals were inspected. A tympanostomy incision was made in the anterior inferior quadrant in a radial incision. A small amount of serous fluid was found in the middle ear space on both sides. An Armstrong grommet ventilation tube was placed in both ears with alligator forceps and suctioned clear. TobraDex drops were placed through the PE tube in each ear.The patient was sent to the recovery room in good condition, discharged with TobraDex drop prescription for two days, and will follow up in the office in two weeks. What procedure code is reported?

An 83-year-old patient is admitted to the ASC for the following procedures: 1. Intraocular lens removal and new intraocular lens insertion, right eye 2. Suture-in intraocular lens, right eye 3. Partial vitrectomy, right eye Anesthesia: Local with MAC Operative Procedure: The operative eye was prepped and draped in a sterile ophthalmic fashion. A drop of betadine solution was placed on the eye. An eyelid speculum was placed. Conjunctival peritomies were made between 11, 2, and 8 o’clock. Two cornea paracentesis were made at 10 and 4 o’clock. A scleral tunnel was made superiorly into clear cornea with a crescent blade. A 3 mm keratome entered the scleral tunnel into the anterior chamber and enlarged it to 6 mm. The conjunctival flaps were repositioned with 10-0 nylon sutures, Xylocaine 1%, preservative free, and instilled subtenons superiorly. Any bleeding was controlled with diathermy. Viscoelastic was instilled into the anterior chamber. A Kuglen instrument was then used to dial out the lens implant from the capsular bag. It was removed from the eye with lens forceps. Viscoelastic deepened the capsular bag and anterior chamber. A posterior chamber lens made by Bausch & Lomb, model P366UV, with a power of +20.5 was inserted through the pupil and sutured into position using the lens eyelets with double armed 10-0 Prolene passing the needle from the posterior segment through the sclera at the 8 and 2 o’clock positions. The knots were rotated into the scleral grooves. The viscoelastic was removed with the irrigation-aspiration tip. The wound was noted to seal watertight. The conjunctival flap was laid back into position. The patient was taken back to the recovery room awake and alert. What anesthesia code(s) is/are reported?

Pathology Report Preoperative Diagnosis: Abdominal pain Tissues Submitted: Gallbladder, NOS Gross Description: The specimen is received in formalin in a container labeled “gallbladder.” The specimen consists of an unopened gallbladder measuring 6.0 cm in length by up to 2.5 cm in diameter at the tip. The light purple-tan serosal surface is glistening and the duct at the margin measures 0.2 cm. The gallbladder contains a small amount of thick, dark green-brown fluid. The dark pink-tan mucosa is velvety and free of ulceration, erosion, and cholesterolosis. The wall appears slightly thickened. No stones are noted within the gallbladder or loose within the container. Representative sections from the tip, mid portion, and neck region are submitted along with a section demonstrating the duct adjacent to the margin. Microscopic Description: A microscopic examination has been performed. Clinical Diagnosis: Gallbladder: mild chronic cholecystitis What code does the pathologist report?

Operative Report Preoperative Diagnosis: Atrial fibrillation Operation: Direct current cardioversion Procedure: After obtaining informed consent, a direct current cardioversion was performed. The patient was given sedation by a member of the anesthesia department. A 120 J of synchronized shock was delivered but atrial fibrillation appeared to persist after a few sinus beats. A 200 J of synchronized biphasic shock was delivered. Once again, sinus rhythm was restored but only for 50 seconds. Then, a second 200 J of synchronized biphasic shock was delivered, and this time sinus rhythm was restored and persisted. Conclusions: Successful direct current cardioversion after a few attempts with restoration of normal sinus rhythm. What are the diagnosis and procedure codes?

Operative Report Preoperative diagnosis: Benign prostatic hyperplasia Postoperative diagnosis: Benign prostatic hyperplasia Operation: Transurethral resection of the prostate History: This is a pleasant 72-year-old man who has a urinary obstruction. He opted for a transurethral resection of the prostate, having understood the risks and benefits of surgery. Description of Procedure: Patient was brought to the operating room and given spinal anesthesia. He was then dressed and draped in the usual sterile fashion in the lithotomy position. Pancystoscopy revealed the presence of orthotopic ureteral orifices, a very large median lobe and large kissing lateral lobes. The prostate itself was a short length. The veru was easily identified. The resectoscope sheath was then prepared and inserted with a visual obturator. Using our resectoscope and an electrocautery knife, we resected the lateral lobes and the floor of the prostate. We did this systematically, maintaining good hemostasis throughout. There was a small amount of tissue anteriorly which was also resected. Tissue was resected proximal to the veru until a nice clear channel was present. Meticulous hemostasis was maintained using coagulation. When meticulous hemostasis was confirmed, we rechecked the bladder again. The ureteral orifices were seen. There was no evidence of any bleeding and the channel was clear. Next, a 22 French three-way Foley catheter was placed, and a 30-cubic cm balloon was filled. The patient was then connected to continuous bladder irrigation. Patient was taken to the recovery room in a good condition. What CPT® and ICD-10-CM codes are reported?

Operative Report Preoperative Diagnosis: Possible basal cell carcinoma Postoperative Diagnosis: Basal cell carcinoma Procedure Performed: Excision lesion 4.3 cm x 2 cm left thigh; FTSG from calf to thigh Anesthesia: General by LMA Description of Procedure: After undergoing adequate general anesthesia and DuraPrep prepping, the left thigh and draping with cloth towels and drapes, 0.25 percent Marcaine with epinephrine, total of 30 cc, was used to anesthetize the skin. A lesion slightly over 4 cm was observed on the patient’s left thigh. A small portion was removed and sent for frozen section analysis. This returned basal cell carcinoma. Per prior consent, we removed the remaining lesion with a 0.75 surrounding margin. Due to size and location of this lesion, the decision was made to harvest a full thickness skin graft from his left lower leg. Lower leg was prepped and draped, and 0.25 percent Marcaine was injected. Excision of 5 cm x 5 cm full thickness graft was obtained and placed on back table for prep. We returned to the thigh area. All edges were trimmed, and the graft was placed into the defect and sewn with a running #3-0 Vicryl. The skin edges were approximated with a running subcuticular #4-0 Vicryl, and further sealed with Dermabond. Hemostasis was well controlled. The wound was irrigated with normal saline. What procedure and diagnosis codes are reported?

Newborn baby boy Martinez underwent a procedure to slit the prepuce to relieve constriction that prevented retraction of the foreskin over the head of the penis. The slit tissue was sutured at the divided skin to control bleeding. The patient tolerated the procedure well. How would Dr. David report his services for this procedure ?