30 year old female is having debridement performed on an infected ulcer with eschar on the right foot. Using sharp dissection, the ulcer and eschar infection was debrided all the way to down to the bone of the foot. The bone had to be minimally trimmed because of a sharp point at the end of the metatarsal. After debriding the area, there was minimal bleeding because of very poor circulation of the foot. It seems that the toes next to the ulcer may have some involvement and cultures were taken. The area was dressed with sterile saline and dressings and then wrapped. What CPT code should be reported?
64 year old female who has multiple sclerosis fell from her walker and landed on a glass table. She lacerated her forehead, cheek and chin and the total length of these lacerations was 6 cm. Her right arm and left leg had deep cuts measuring 5 cm on each extremity. Her right hand and right foot had a total of 3 cm lacerations. The ED physician repaired the lacerations as follows: The forehead, cheek, and chin had debridement and cleaning of glass debris with the lacerations being closed with 6-0 Prolene sutures. The arm and leg were repaired by 6-0 Vicryl subcutaneous sutures and prolene sutures on the skin. The hand and foot were closed with adhesive strips. Select the appropriate procedure codes for this visit
76-year-old has dermatochalasis on bilateral upper eyelids. A belpharoplasty will be performed on the eyelids. A lower incision line was marked at approximately 5 mm above the lid margin along the crease. Then using a pinch test with forceps the amount of skin to be resected was determined and marked. An elliptical incision was performed on the left eyelid and the skin was excised. In a similar fashion the same procedure was performed on the right eye. The wounds were closed with sutures. The correct CPT codes are?
Patient has basal cell carcinoma on his upper back. A map was prepared to correspond to the area of skin where the excisions of the tumor will be performed using Mohs micrographic surgery technique. There were three tissue blocks that were prepared for cryostat, sectioned, and removed in the first stage. Then a second stage had six tissue blocks which were also cut and stained for microscopic examination. The entire base and margins of the excised pieces of tissue were examined by the surgeon. No tumor was identified after the final stage of the microscopically controlled surgery. What procedure codes should be reported?
76-year-old female had a recent mammographic and ultrasound abnormality in the 6 o’clock position of the left breast. She underwent core biopsies which showed the presence of a papilloma. The plan now is for needle localization with excision to rule out occult malignancy. After undergoing preoperative needle localization with hookwire needle injection with methylene blue, the patient was brought to the operating room and was placed on the operating room table in the supine position where she underwent laryngeal mask airway (LMA) anesthesia. The left breast was prepped and draped in a sterile fashion. A radial incision was then made in the 6 o'clock position of the left breast corresponding to the tip of the needle localizing wire. Using blunt and sharp dissection, we performed a generous excisionaround the needle localizing wire including all of the methylene blue-stained tissues. The specimen was then submitted for radiologic confirmation followed by permanent section pathology. Once hemostasis was assured, digital palpation of the depths of the wound field failed to reveal any other palpable abnormalities. At this point, the wound was closed in 2 layers with 3-0 Vicryl and 5-0 Monocryl. Steri-Strips were applied. Local anesthetic was infiltrated for postoperative analgesia. What CPT and ICD-9-CM codes describe this procedure?
52 year old female has a mass growing on her right flank for several years. It has finally gotten significantly larger and is beginning to bother her. She is brought to the Operating Room for definitive excision. An incision was made directly overlying the mass. The mass was down into the subcutaneous tissue and the surgeon encountered a well encapsulated lipoma approximately 4 centimeters. This was excised primarily bluntly with a few attachments divided with electrocautery. What CPT should be reported?
An infant with genu valgum is brought to the operating room to have a bilateral medial distal femur hemiepiphysiodesis done. On each knee, the C-arm was used to localize the growth plate. With the growth plate localized, an incision was made medially on both sides. This was taken down to the fascia, which was opened. The periosteum was not opened. The Orthofix figure-of-eight plate was placed and checked with x-ray. We then irrigated and closed the medial fascia with 0 Vicryl suture. The skin was closed with 2-0 Vicryl and 3-0 Monocryl. What procedure code should be used?
42 year old male has a frozen left shoulder. An arthroscope was inserted in the posterior portal in the glenohumeral joint. The articular cartilage was normal except for some minimal grade III-IV changes, about 5% of the humerus just adjacent to the rotator cuff insertion of the supraspinatus. The biceps was inflamed, not torn at all. The superior labrum was not torn at all, the labrum was completely intact. The rotator cuff was completely intact. An anterior portal was established high in the rotator interval. The rotator interval was very thick and contracted and this was released with electrocautery and the Bovie including the superior glenohumeral ligament. After this was all released, the middle glenohumeral ligament was released as well as the tendinous portion of the subscapularis. After this was all done with a shaver and electrocautery, the arthroscope was placed anteriorly and the shaver and used to debride some of the posterior capsule and the posterior capsule was released in its posterosuperior and then posteroinferior aspect. After this was done, the arthroscope was then placed back posteriorly and used to release the anteroinferior capsule down to 6’oclock. This was done with electrocautery. The arthroscope was then placed anteriorly and used to release the posteroinferior capsule. The arthroscope was then placed anteriorly and used to release the posteroinferior capsule. The arthroscope was then placed back posteriorly and used to confirm that there was still one little strip of capsule around the biceps superiorly and there was one little strip from 6-7 o’clock posteroinferiorly that was only partially cut. The rest of the capsule was completely circumferentially released. What CPT code describes this procedure?
After adequate anesthesia was obtained the patient was turned prone in a kneeling position on the spinal table. A lower midline lumbar incision was made and the soft tissues divided down to the spinous processes. The soft tissues were stripped way from the lamina down to the facets and discectomies and laminectomies were then carried out at L3-4, L4-5 and L5-S1. Interbody fusions were set up for the lower three levels using the Danek allografts (morselized) and augmented with structural autogenous bone from the iliac crest. The posterior instrumentation of a 5.5 mm diameter titanium rod was then cut to the appropriate length and bent to confirm to the normal lordotic curve. It was then slid immediately onto the bone screws and at each level compression was carried out as each of the two bolts were tightened so that the interbody fusions would be snug and as tight as possible. Select the appropriate CPT code(s) for this visit?
PREOPERATIVE DIAGNOSIS: Displaced impacted Colles fracture, left distal radius and ulna. POSTOPERATIVE DIAGNOSIS: Displaced impacted Colles fracture, left distal radius and ulna. OPERATIVE PROCEDURE: Reduction with application external fixator, left wrist fracture FINDINGS: The patient is a 46-year-old right-hand-dominant female who fell off stairs 4 to 5 days ago sustaining an impacted distal radius fracture with possible intraarticular component and an associated ulnar styloid fracture. Today in surgery, fracture was reduced anatomically and an external fixator was applied. PROCEDURE: Under satisfactory general anesthesia, the fracture was manipulated and C-arm images were checked. The left upper extremity was prepped and draped in the usual sterile orthopedic fashion. Two small incisions were made over the second metacarpal and after removing soft tissues including tendinous structures out of the way, drawing was carried out and blunt-tipped pins were placed for the EBI external fixator. The frame was next placed and the site for the proximal pins was chosen. Small incision was made. Subcutaneous tissues were carried out of the way. The pin guide was placed and 2 holes were drilled and blunt-tipped pins placed. Fixator was assembled. C-arm images were checked. Fracture reduction appeared to be anatomic. Suturing was carried out where needed with 4-0 Vicryl interrupted subcutaneous and 4-0 nylon interrupted sutures. Sterile dressings were applied. Vascular supply was noted to be satisfactory. Final frame tightening was carried out. What CPT and ICD-9-CM codes should be reported?
46 year old female had a previous biopsy that indicated positive margins anteriorly on the right side of her neck. A 0.5 cm margin was drawn out and a 15 blade scalpel was used for full excision of an 8cm lesion. Light undermining of all margins was performed along with layered closure. The specimen was sent for permanent histopathologic examination. What are the code(s) for this procedure?
A 61 year-old gentleman with a history of a fall while intoxicated suffered a blow to the forehead and imaging revealed a posteriorly displaced odontoid fracture. The patient was taken into the Operating Room, and placed supine on the operating room table. Under mild sedation, the patient was placed in Gardner-Wells tongs and gentle axial traction under fluoroscopy was performed to gently try to reduce the fracture. It did reduce partially without any change in the neurologic examination. More manipulation would be necessary and it was decided to intubate and use fiberoptic technique. The anterior neck was prepped and draped and an incision was made in a skin crease overlying the C 4-C5 area. Using hand-held retractors, the ventral aspect of the spine was identified and the C2-C3 disk space was identified using lateral fluoroscopy. Using some pressure upon the ventral aspect of the C2 body, we were able to achieve a satisfactory reduction of the fracture. Under direct AP and lateral fluoroscopic guidance, a Kirschner wire was advanced into the C2 body through the fracture line and into the odontoid process. This was then drilled, and a 42 millimeter cannulated lag screw was advanced through the C2 body into the odontoid process. What procedure code should be used? 22505 22319 22315 22318correct Question was not answered 13. The patient is a 67 -year-old gentleman with metastatic colon cancer recently operated on for a brain metastasis, now for placement of an Infuse-A-Port for continued chemotherapy. The left subclavian vein was located with a needle and a guide wire placed. This was confirmed to be in the proper position fluoroscopically. A transverse incision was made just inferior to this and a subcutaneous pocket created just inferior to this. After tunneling, the introducer was placed over the guide wire and the power port line was placed with the introducer and the introducer was peeled away. The tip was placed in the appropriate position under fluoroscopic guidance and the catheter trimmed to the appropriate length and secured to the power port device. The locking mechanism was fully engaged. The port was placed in the subcutaneous pocket and everything sat very nicely fluoroscopically. It was secured to the underlying soft tissue with 2-0 silk stitch. What code should be used for this procedure?
The patient is a 59-year-old white male who underwent carotid endarterectomy for symptomatic left carotid stenosis a year ago. A carotid CT angiogram showed a recurrent 90% left internal carotid artery stenosis extending into the common carotid artery. He is taken to the operating room for re-do left carotid endarterectomy. The left neck was prepped and the previous incision was carefully reopened. Using sharp dissection, the common carotid artery and its branches were dissected free. The patient was systematically heparinized and after a few minutes clamps applied to the common carotid artery and its branches. A longitudinal arteriotomy was carried out with findings of extensive layering of intimal hyperplasia with no evidence of recurrent atherosclerosis. A silastic balloon-tip shunt was inserted first proximally and then distally, with restoration of flow. Several layers of intima were removed and the endarterectomized surfaces irrigated with heparinized saline. An oval Dacron patch was then sewn into place with running 6-0 Prolene. Which CPT code should be used?
79-year-old male with symptomatic bradycardia and syncope is taken to the Operating Suite where an insertion of a DDD pacemaker will be performed. A left subclavian venipuncture was carried out. A guide wire was passed through the needle, and the needle was withdrawn. A second subclavian venipuncture was performed, a second guide wire was passed and the second needle was withdrawn. An oblique incision in the deltopectoral area incorporating the wire exit sites. A subcutaneous pocket was created with the cautery on the pectoralis fascia. An introducer dilator was passed over the first wire and the wire and dilator were withdrawn. A ventricular lead was passed through the introducer, and the introducer was broken away in the routine fashion. A second introducer dilator was passed over the second guide wire and the wire and dilator were withdrawn. An atrial lead was passed through the introducer and the introducer was broken away in the routine fashion. Each of the leads were sutured down to the chest wall with two 2-0 silk sutures each, connected the leads to the generator, curled the leads, and the generator was placed in the pocket. We assured hemostasis. We assured good position with the fluoroscopy. What code should be used for this procedure?
The patient is a fifty-eight-year-old white male, one month status post pneumonectomy. He had a post pneumonectomy empyema treated with a tunneled cuffed pleural catheter which has been draining the cavity for one month with clear drainage. He has had no evidence of a block or pleural fistula. Therefore a planned return to surgery results in the removal of the catheter. The correct CPT code is:
This 67 year-old man presented with a history of progressive shortness of breath, mostly related to exercise. He has had a diagnosis of a secundum atrioseptal defect for several years, and has had atrial fibrillation intermittently over this period of time. He was in atrial fibrillation when he came to the operating room, and with the patient cannulated and on bypass, The right atrium was then opened. A large 3 x 5 cm defect was noted at fossa ovalis, and this also included a second hole in the same general area. Both of these holes were closed with a single pericardial patch. What CPT and ICD-9 codes should be reported?
The patient is a 77 year-old white female who has been having right temporal pain and headaches with some visual changes and has a sed rate of 51. She is scheduled for a temporal artery biopsy to rule out temporal arteritis. A Doppler probe was used to isolate the temporal artery and using a marking pen the path of the artery was drawn. Lidocaine 1% was used to infiltrate the skin, and using a 15 blade scalpel the skin was opened in the preauricular area and dissected down to the subcutaneous tissue where the temporal artery was identified in its bed. It was a medium size artery and we dissected it out for a length of approximately 4 cm with some branches. The ends were ligated with 4-0 Vicryl, and the artery was removed from its bed and sent to Pathology as specimen. What code should be used for this procedure?
A 52-year-old patient is admitted to the hospital for chronic cholecystitis for which a laparoscopic cholecystectomy will be performed. A transverse infraumbilical incision was made sharply dissecting to the subcutaneous tissue down to the fascia using access under direct vision with a Vesi-Port and a scope was placed into the abdomen. Three other ports were inserted under direct vision. The fundus of the gallbladder was grasped through the lateral port, where multiple adhesions to the gallbladder were taken down sharply and bluntly: The gallbladder appeared chronically inflamed. Dissection was carried out to the right of this identifying a small cystic duct and artery, was clipped twice proximally, once distally and transected. The gallbladder was then taken down from the bed using electrocautery, delivering it into an endo-bag and removing it from the abdominal cavity with the umbilical port. What CPT and ICD-9 codes should be reported?
A 70-year-old female who has a history of symptomatic ventral hernia was advised to undergo laparoscopic evaluation and repair. An incision was made in the epigastrium and dissection was carried down through the subcutaneous tissue. Two 5-mm trocars were placed, one in the left upper quadrant and one in the left lower quadrant and the laparoscope was inserted. Dissection was carried down to the area of the hernia where a defect of 12cm was clearly visualized. There was some omentum, which was adhered to the hernia and this was delivered back into the peritoneal cavity. The mesh was tacked on to cover the defect. What procedure code(s) should be used?
The patient is a 50-year-old gentleman who presented to the emergency room with signs and symptoms of acute appendicitis with possible rupture. He has been brought to the operating room. An infraumbilical incision was made which a 5-mm VersaStep trocar was inserted. A 5-mm 0- degree laparoscope was introduced. A second 5-mm trocar was placed suprapubically and a 12-mm trocar in the left lower quadrant. A window was made in the mesoappendix using blunt dissection with no rupture noted. The base of the appendix was then divided and placed into an Endo-catch bag and the 12-mm defect was brought out. Select the appropriate code for this visit:
An 82-year-old female had a CAT scan which revealed evidence of a proximal small bowel obstruction. She was taken to the Operating Room where an elliptical abdominal incision was made, excising the skin and subcutaneous tissue. There were extensive adhesions along the entire length of the small bowel: the omentum and bowel were stuck up to the anterior abdominal wall. Time- consuming tedious lysis of adhesions was performed to free up the entire length of the gastrointestinal tract from the ligament to Treitz to the ileocolic anastomosis. The correct CPT code is:
55-year-old patient was admitted with massive gastric dilation. The endoscope was inserted with a catheter placement. The endoscope is passed through the cricopharyngeal muscle area without difficulty. Esophagus is normal, some chronic reflux changes at the esophagogastric junction noted. Stomach significant distention with what appears to be multiple encapsulated tablets in the stomach at least 20 to 30 of these are noted. Some of these are partially dissolved. Endoscope could not be engaged due to high grade narrowing in the pyloric channel. It seems to be a high grade outlet obstruction with a superimposed volvulus. What code should be used for this procedure?
Patient is going into the OR for an appendectomy with a ruptured appendicitis. Right lower quadrant transverse incision was made upon entry to the abdomen. In the right lower quadrant there was a large amount of pus consistent with a right lower quadrant abscess. Intraoperative cultures anaerobic and aerobic were taken and sent to microbiology for evaluation. Irrigation of the pus was performed until clear. The base of the appendix right at the margin of the cecum was perforated. The mesoappendix was taken down and tied using 0-Vicryl ties and the appendix fell off completely since it was already ruptured with tissue paper thin membrane at the base. There was no appendiceal stump to close or to tie, just an opening into the cecum; therefore, the appendiceal opening area into the cecum was tied twice using figure of 8 vicryl sutures. Omentum was tacked over this area and anchored in place using interrupted 3-0 Vicryl sutures to secure the repair. What CPT and ICD-9-CM codes should be reported?
5-year-old female has a history of post void dribbling. She was found to have extensive labial adhesions, which have been unresponsive to topical medical management. She is brought to the operating suite in a supine position. Under general anesthesia the labia majora is retracted and the granulating chronic adhesions were incised midline both anteriorly and posteriorly. The adherent granulation tissue was excised on either side. What code should be used for this procedure?
The patient is a 22-year-old who was found to be 7-1/2 weeks pregnant. She has consented for a D&E .She was brought to the operating room where MAC anesthesia was given. She was then placed in the dorsal lithotomy position and a weighted speculum was placed into her posterior vaginal vault. Cervix was identified and dilated. A 6.5-cm suction catheter hooked up to a suction evacuator was placed and products of conception were evacuated. A medium size curette was then used to curette her endometrium. There was noted to be a small amount of remaining products of conception in her left cornua. Once again the suction evacuator was placed and the remaining products of conception were evacuated. At this point she had a good endometrial curetting with no further products of conception noted. Which CPT code should be used?
A 37-year-old female has menorrhagia and wants permanent sterilization. The patient was placed in Allen stirrups in the operating room. Under anesthesia the cervix was dilated and the hysteroscope was advanced to the endometrium into the uterine cavity. No polyps or fibroids were seen. The Novasure was used for endometrial ablation. A knife was then used to make an incision in the right lower quadrant and left lower quadrant with 5-mm trocars inserted under direct visualization with no injury to any abdominal contents. Laparoscopic findings revealed the uterus, ovaries and fallopian tubes to be normal. The appendix was normal as were the upper quadrants. Because of the patient's history of breast cancer and desire for no further children, it was decided to take out both the tubes and ovaries. This had been discussed with the patient prior to surgery. What are the codes for these procedures?
25-year-old female in the OR for ectopic pregnancy. Once the trocars were place a pneumoperitoneum was created and the laparoscope introduced. The left fallopian tube was dilated and was bleeding. The left ovary was normal. The uterus was of normal size, shape and contour. The right ovary and tube were normal. Due to the patient’s body habitus the adnexa could not be visualized to start the surgery. At this point the laparoscopic approach was terminated. The pneumoperitoneum was deflated, and trocar sites were sutured closed. The trocars and laparoscopic instruments had been removed. Open surgery was performed incising a previous transverse scar from a cesarean section. The gestation site was bleeding and all products of conception and clots were removed. The left tube was grasped, clamped and removed in its entirety and passed off to pathology. What code(s) should be used for this procedure?
23-year-old who is pregnant at 39 weeks and 3 days is presenting for a low transverse cesarean section. An abdominal incision is made and was extended superiorly and inferiorly with good visualization of the bladder. The bladder blade was then inserted and the lower uterine segment incised in a transverse fashion with the scalpel. The bladder blade was removed and the infant's head delivered atraumatically. The nose and mouth were suctioned with the bulb suction trap and the cord doubly clamped and cut. The placenta was then removed manually. What code should be reported for this procedure?
55-year-old female has a symptomatic rectocele. She had been admitted and taken to the main OR. An incision is made in the vagina into the perineal body (central tendon of the perineum). Dissection was carried underneath posterior vaginal epithelium all the way over to the rectocele. Fascial tissue was brought together with sutures creating a bridge and the rectocele had been reduced with good support between the vagina and rectum. What procedure code should be reported?
The patient is a 64-year-old female who is undergoing a removal of a previously implanted Medtronic pain pump and catheter due to a possible infection. The back was incised; dissection was carried down to the previously placed catheter. There was evidence of infection with some fat necrosis in which cultures were taken. The intrathecal portion of the catheter was removed. Next the pump pocket was opened with evidence of seroma. The pump was dissected from the anterior fascia. A 7-mm Blake drain was placed in the pump pocket through a stab incision and secured to the skin with interrupted Prolene. The pump pocket was copiously irrigated with saline and closed in two layers. What are the CPT and ICD-9-CM codes for this procedure?
2-year-old Hispanic male has a chalazion on both upper and lower lid of the right eye. He was placed under general anesthesia. With an #11 blade the chalazion was incised and a small curette was then used to retrieve any granulomatous material on both lids. What code should be used for this procedure?
MRI reveals patient has cervical stenosis. It was determined he should undergo bilateral cervical laminectomy at C3 through C6 and fusion. The edges of the laminectomy were then cleaned up with a Kerrison and foraminotomies were done at C4, C5, and,,C6. The stenosis is central: a facetectomy is performed by using a burr. Nerve root canals were freed by additional resection of the facet, and compression of the spinal cord was relieved by removal of a tissue overgrowth around the foramen. Which CPT codes should be used for this procedure?
An extracapsular cataract removal is performed on the right eye by manually using an iris expansion device to expand the pupil. A phacomulsicfication unit was used to remove the nucleus and irrigation and aspiration was used to remove the residual cortex allowing the insertion of the intraocular lens. What code should be used for this procedure?
An infant who has chronic otitis media was placed under general anesthesia and a radial incision was made in the posterior quadrant of the left tympanic membrane. A large amount of mucoid effusion was suctioned and then a ventilating tube was placed in both ears. What CPT and ICD-9-CM codes should be reported:
An entropian repair is performed on the left lower eyelid in which undermining was performed with scissors of the inferior lid and inferior temporal region. Deep sutures were used to separate the eyelid margin outwardly along with stripping the lateral tarsus to provide firm approximation of the lower lid to the globe. The correct CPT code is:
Patient was in the ER complaining of constipation with nausea and vomiting when taking Zovirax for his herpes zoster and Percocet for pain. His primary care physician came to the ER and directly admitted him to the hospital for intravenous therapy and management of this problem. His physician documented a detailed history, comprehensive examination and a medical decision making of moderate complexity. Which E/M service is reported?
20-day-old infant was seen in the ER by the neonatologist admitting the baby to NICU for cyanosis and rapid breathing. The neonatologist performed intubation, ventilation management and a complete echocardiogram in the NICU and provided a report for the echocardiography which did indicate congenital heart disease. Select the correct code(s) for the physician service
A patient was admitted yesterday to the hospital for possible gallstones. The following day the physician who admitted the patient performed a detailed history, a detailed exam and a medical decision making of low complexity. The physician tells her the test results have come back positive for gallstones and is recommending having a cholecystectomy. What code should be reported for this evaluation and management service?
A patient came in to the ER with wheezing and a rapid heart rate. The ER physician documents a comprehensive history, comprehensive exam and medical decision of moderate complexity. The patient has been given three nebulizer treatments. The ER physician has decided to place him in observation care for the acute asthma exacerbation. The ER physician will continue examining the patient and will order additional treatments until the wheezing subsides. Select the appropriate code(s) for this visit.
Two-year-old is brought to the ER by EMS for near drowning. EMS had gotten a pulse. The ER physician performs a moderate MDM, endotracheal intubation, blood gas, and a central venous catheter placement. The ER physician documents a total time of 30 minutes on this critical infant in which the physician already subtracted the time for the other billable services. Select the E/M service and procedures to report for the ER physician?
Patient is here to follow up on her atrial fibrillation. Her primary care physician is not in the office. She will be seen by the partner physician that is also in the same practice. No new problems. Blood pressure is 110/64. Pulse is regular at 72. Temp is 98.6F Chest is clear. Cardiac normal sinus rhythm. Medical making decision is straightforward. Diagnosis: Atrial fibrillation, currently stable. What CPT® code is reported for this service?
A 42-year-old with renal pelvis cancer receives general anesthesia for a laparoscopic radical nephrectomy. The patient has controlled type II diabetes otherwise no other co-morbidities. What is the correct CPT® and ICD-9-CM code for the anesthesia services?
A 6-month-old patient is administered general anesthesia to repair a cleft palate. What anesthesia code(s) should be used for this procedure?
A patient is having knee replacement surgery. The surgeon requests that in addition to the general anesthesia for the procedure that the anesthesiologist also insert a lumbar epidural for postoperative pain management. The anesthesiologist performs postoperative management for two postoperative days
A very large lipoma is removed from the chest measuring 8 sq cm and the defect is 12.2 cm requiring a layered closure with extensive undermining. MAC is performed by a medically directed Certified Registered Nurse Anesthetist (CRNA). Code the anesthesia service
56-year-old female is having a bilateral mammogram with computer aid detection conducted as a screening since the patient has had a previous cyst in the right breast. What radiological services are reported?
63 year-old patient with bilateral ureteral obstruction presents to an outpatient facility for placement of a right and left ureteral stent along with an interpretation of a retrograde pyelogram. What codes should be reported?
A patient came to the radiology department of the hospital on Monday morning for CT study of the abdomen and pelvis. An unenhanced CT of the abdomen and enhanced CT of the pelvis was done on the same session and interpretation was also provided.
A CT density study is performed on a post-menopausal female to screen for osteoporosis. Today’s visit the bone density study will be performed on the spine. Which CPT code should be used?
The patient is 15 weeks pregnant with twins coming back to her obstetrician to have a transabdominal ultrasound performed to reassess anatomic abnormalities of both fetuses that were previously demonstrated in the last ultrasound. What code(s) should be used for this procedure?
53-year-old woman with ascites consented to a procedure to withdraw fluid from the abdominal cavity. Ultrasonic guidance was used for guiding the needle placement for the aspiration. What CPT codes should be used?
Patient is coming in for a pathological examination for ischemia in the left leg. The first specimen is 1.5 cm of a single portion of arterial plaque taken from the left common femoral artery. The second specimen is 8.5 x 2.7 cm across x 1.5 cm in thickness of a cutaneous ulceration with fibropurulent material on the left leg. What surgical pathology codes should be reported for the pathologist?
During a craniectomy the surgeon performed a frozen section of a large piece of tumor and sent it to pathology. The pathologist received a rubbery pinkish tan tissue measuring in aggregate 3 x 0.8 x 0.8 cm. The entire specimen is submitted in one block and a microscope was used to examine the tissue. The frozen section and the pathology report are sent back to the surgeon indicating that the tumor was a medulloblastoma. What CPT® code(s) will the pathologist report?
Physician orders a comprehensive metabolic panel but also wants blood work on calcium ions and also orders a basic metabolic panel. Select the code(s) on how this is reported
18-year-old female with a history of depression comes into the ER in a coma. The ER physician orders a drug screen on antidepressants, phenothiazines, and benzodiazepines. The lab performs a screening for each single drug class using an immunoassay in a random access analyzer. Presence of antidepressants is found and a drug confirmation is performed to identify the particular antidepressant. What correct CPT® codes are reported?
Patient that is a borderline diabetic has been sent to the laboratory to have an oral glucose tolerance test. Patient drank the glucose and five blood specimens were taken every 30 to 60 minutes up to three hours to determine how quickly the glucose is cleared from the blood. What code(s) should be reported for this test?
A patient with severe asthma exacerbation has been admitted. The admitting physician orders a blood glass for oxygen saturation only. The admitting physician performs the arterial puncture drawing blood for a blood gas reading on oxygen saturation only. The physician draws it again in an hour to measure how much oxygen the blood is carrying. Select the codes for reporting this service.
4-year-old is getting over his cold and will be getting three immunizations in the pediatrician’s office by the nurse. The first vaccination administered is the Polio vaccine intramuscularly. The next one is the influenza (live) administered in the nose. The last vaccination is the Varicella (live) by subcutaneous route. What CPT® codes are reported for the administration and vaccines?
A patient with chronic renal failure is in the hospital being evaluated by his endocrinologist after just placing a catheter into the peritoneal cavity for dialysis. The physician is evaluating the dwell time and running fluid out of the cavity to make sure the volume of dialysate and the concentration of electrolytes and glucose are correctly prescribed for this patient. What code should be reported for this service?
An established patient had a comprehensive exam in which she has been diagnosed with dry eye syndrome in both eyes. The ophthalmologist measures the cornea and places the soft contact lens for treatment of this syndrome. What codes are reported by the ophthalmologist?
A patient who is a singer has been hoarse for a few months following an upper respiratory infection. She is in a voice laboratory to have a laryngeal function study performed by an otolaryngologist. She starts off with the acoustic testing first. Before she moves on to the aerodynamic testing she complains of throat pain and is rescheduled to come back to have the other test performed. What CPT® code(s) should be reported?
A new patient is having a cardiovascular stress test done in his cardiologist’s office. Before the test is started the physician documents a comprehensive history and exam and moderate complexity medical decision making. The physician will be supervising and interpreting the stress on the patient’s heart during the test. What procedure code should be documented for this encounter?
A cancer patient is coming in to have a chemotherapy infusion. The physician notes the patient is dehydrated and will first administer a hydration infusion. The infusion time was 1 hour and 30 minutes. Select the code(s) that should be reported for this encounter?
What is the difference between entropion and ectropion?
What type of graft is used when pigskin is applied to a burn wound?
Ventral, umbilical, spigelian and incisional are types of:
Fracturing the acetabulum involves what area?
When a patient is having a tenotomy performed on the abductor hallucis muscle, where is this muscle located?
The root word trich/o means:
A patient is having pyeloplasty performed to treat a uretero-pelvic junction obstruction. What is being performed?
When a person has labyrinthitis what has the inflammation?
Patient comes into see her primary care physician for a productive cough and shortness of breath. The physician takes a chest x-ray which indicates the patient has congestive pneumonia. Select the ICD-9-CM code(s) for this visit.
What is the correct way to code a patient having bradycardia due to Demerol that was correctly prescribed and properly administered?
What statement is true when reporting pregnancy codes
27-year-old was frying chicken when an explosion of the oil had occurred and she sustained second-degree burns on her face (3%), third degree burns on both hands (4%), and second degree burns on her lower left fore arm (3%). There was a total of 10 percent of the body surface that was burned. Select which ICD-9-CM codes should be used.
A patient that has cirrhosis of the liver just had an endoscopy performed showing hemorrhagic esophageal varices. The ICD-9-CM codes should be reported:
66-year-old Medicare patient, who has a history of ulcerative colitis, presents for a colorectal cancer screening. The screening is performed via barium enema. What HCPCS Level II code is reported for this procedure?
Patient with corneal degeneration is having a cornea transplant. The donor cornea had been previously prepared by punching a central corneal button with a guillotine punch. This had been stored in Optisol GS. It was gently rinsed with BSS Plus solution and was then transferred to the patient’s eye on a Paton spatula and sutured with 12 interrupted 10-0 nylon sutures. Select the HCPCS Level II code for the corneal tissue
The patient presents to the office for an injection. Joint prepped using sterile technique. Muscle group location: gluteus maximus. Sterilely injected with 1 cc Kenalog-40, 2 cc Marcaine and 2 cc lidocaine 2%. Sterile bandage applied. Choose the HCPCS Level II code for this treatment.
Which of the following is a BENEFIT of electronic claims submission?
Local coverage decisions are published to give providers information on which of the following?
Which statement is true about Z codes:
Which of the following is true regarding ICD-10-CM codes with the words “in diseases classified elsewhere” in their descriptions?
Which of the following statements is true regarding sequencing of External cause codes?
Which of the following is an example of a case in which a diabetes-related problem exists and the code for diabetes is never sequenced first?
53-year-old male for removal of 2 lesions located on his nose and lower lip. Lesions were identified and marked. Utilizing a 3-mm punch, a biopsy was taken of the left supratip nasal area. The lower lip lesion of 4mm in size was shaved to the level of the superficial dermis. What are the codes for these procedures?
This is a 32 year old female who presents today with sacroilitis. On the physical exam there was pain on palpation of the left sacroiliac joint and imaging confirmation was done for the needle positioning. Then 80 mg of Depo-Medrol and 1 mL of bupivacaine at 0.5% was injected into the left sacroiliac joint with a 22 gauge needle. The patient was able to walk from the exam room without difficulty. Follow up will be as needed. The correct CPT code is:
PREOPERATIVE DIAGNOSIS: Multivessel coronary artery disease. POSTOPERATIVE DIAGNOSIS: Multivessel coronary artery disease. NAME OF PROCEDURE: Coronary artery bypass graft x 3, left internal mammary artery to the LAD, saphenous vein graft to the obtuse marginal, saphenous vein graft to the diagonal. The patient is placed on heart and lung bypass during the procedure. Anesthesia time: 6:00 PM to 12:00 AM Surgical time: 6:15 PM to 11:30 PM What is the correct anesthesia code and anesthesia time?
The patient is a 67 -year-old gentleman with metastatic colon cancer recently operated on for a brain metastasis, now for placement of an Infuse-A-Port for continued chemotherapy. The left subclavian vein was located with a needle and a guide wire placed. This was confirmed to be in the proper position fluoroscopically. A transverse incision was made just inferior to this and a subcutaneous pocket created just inferior to this. After tunneling, the introducer was placed over the guide wire and the power port line was placed with the introducer and the introducer was peeled away. The tip was placed in the appropriate position under fluoroscopic guidance and the catheter trimmed to the appropriate length and secured to the power port device. The locking mechanism was fully engaged. The port was placed in the subcutaneous pocket and everything sat very nicely fluoroscopically. It was secured to the underlying soft tissue with 2-0 silk stitch. What code should be used for this procedure?
PRE OP DIAGNOSIS: Left Breast Abnormal MMX or Palpable Mass; Other Disorders Of Breast PROCEDURE: Automated Stereotactic Biopsy Left Breast FINDINGS: Lesion is located in the lateral region, just at or below the level of the nipple on the 90 degree lateral view. There is a subglandular implant in place. I discussed the procedure with the patient today including risks, benefits and alternatives. Specifically discussed was the fact that the implant would be displaced out of the way during this biopsy procedure. Possibility of injury to the implant was discussed with the patient. Patient has signed the consent form and wishes to proceed with the biopsy. The patient was placed prone on the stereotactic table; the left breast was then imaged from the inferior approach. The lesion of interest is in the anterior portion of the breast away from the implant which was displaced back toward the chest wall. After imaging was obtained and stereotactic guidance used to target coordinates for the biopsy, the left breast was prepped with Betadine. 1% lidocaine was injected subcutaneously for local anesthetic. Additional lidocaine with epinephrine was then injected through the indwelling needle. The SenoRx needle was then placed into the area of interest. Under stereotactic guidance we obtained 9 core biopsy samples using vacuum and cutting technique. The specimen radiograph confirmed representative sample of calcification was removed. The tissue marking clip was deployed into the biopsy cavity successfully. This was confirmed by final stereotactic digital image and confirmed by post core biopsy mammogram left breast. The clip is visualized projecting over the lateral anterior left breast in satisfactory position. No obvious calcium is visible on the final post core biopsy image in the area of interest. The patient tolerated the procedure well. There were no apparent complications. The biopsy site was dressed with Steri-Strips, bandage and ice pack in the usual manner. The patient did receive written and verbal post-biopsy instructions. The patient left our department in good condition. IMPRESSION: 1. SUCCESSFUL STEREOTACTIC CORE BIOPSY OF LEFT BREAST CALCIFICATIONS. 2. SUCCESSFUL DEPLOYMENT OF THE TISSUE MARKING CLIP INTO THE BIOPSY CAVITY 3. PATIENT LEFT OUR DEPARTMENT IN GOOD CONDITION TODAY WITH POST-BIOPSY INSTRUCTIONS. 4. PATHOLOGY REPORT IS PENDING; AN ADDENDUM WILL BE ISSUED AFTER WE RECEIVE THE PATHOLOGY REPORT. What are the codes for the procedures?
PREOPERATIVE DIAGNOSIS: Right scaphoid fracture. TYPE OF PROCEDURE: Open reduction and internal fixation of right scaphoid fracture. DESCRIPTION OF PROCEDURE: The patient was brought to the operating room, anesthesia having been administered. The right upper extremity was prepped and draped in a sterile manner. The limb was elevated, exsanguinated, and a pneumatic arm tourniquet was elevated. An incision was made over the dorsal radial aspect of the right wrist. Skin flaps were elevated. Cutaneous nerve branches were identified and very gently retracted. The interval between the second and third dorsal compartment tendons was identified and entered. The respective tendons were retracted. A dorsal capsulotomy incision was made, and the fracture was visualized. There did not appear to be any type of significant defect at the fracture site. A 0.045 Kirschner wire was then used as a guidewire, extending from the proximal pole of the scaphoid distalward. The guidewire was positioned appropriately and then measured. A 25-mm Acutrak drill bit was drilled to 25 mm. A 22.5-mm screw was selected and inserted and rigid internal fixation was accomplished in this fashion. This was visualized under the OEC imaging device in multiple projections. The wound was irrigated and closed in layers. Sterile dressings were then applied. The patient tolerated the procedure well and left the operating room in stable condition. What code should be used for this procedure?
50-year-old female has recurrent lymphoma in the axilla. Ultrasound was used to localize the lymph node in question for needle guidance. An 11 blade scalpel was used to perform a small dermatotomy. An 18 x 10 cm Biopence needle was advanced through the dermatotomy to the periphery of the lymph node. A total of 4 biopsy specimens were obtained. Two specimens were placed an RPMI and 2 were placed in formalin and sent to laboratory. The correct CPT code is:
PREOPERATIVE DIAGNOSIS: Diverticulitis, perforated diverticula POST OPERATIVE DIAGNOSIS: Diverticulitis, perforated diverticula PROCEDURE: Hartman procedure, which is a sigmoid resection with Hartman pouch and colostomy. DESCRIPTION OF THE PROCEDURE: Patient was prepped and draped in the supine position under general anesthesia. Prior to surgery patient was given 4.5 grams of Zosyn and Rocephin IV piggyback. A lower midline incision was made, abdomen was entered. Upon entry into the abdomen, there was an inflammatory mass in the pelvis and there was a large abscessed cavity, but no feces. The abscess cavity was drained and irrigated out. The left colon was immobilized, taken down the lateral perineal attachments. The sigmoid colon was mobilized. There was an inflammatory mass right at the area of the sigmoid colon consistent with a divertiliculitis or perforation with infection. Proximal to this in the distal left colon, the colon was divided using a GIA stapler with 3.5 mm staples. The sigmoid colon was then mobilized using blunt dissection. The proximal rectum just distal to the inflammatory mass was divided using a GIA stapler with 3.5 mm staples. The mesentary of the sigmoid colon was then taken down and tied using two 0 Vicryl ties. Irrigation was again performed and the sigmoid colon was removed with inflammatory mass. The wall of the abscessed cavity that was next to the sigmoid colon where the inflammatory mass was, showed no leakage of stool, no gross perforation, most likely there is a small perforation in one of the diverticula in this region. Irrigation was again performed throughout the abdomen until totally clear. All excess fluid was removed. The distal descending colon was then brought out through a separate incision in the lower left quadrant area and a large 10 mm 10 French JP drain was placed into the abscessed cavity. The sigmoid colon or the colostomy site was sutured on the inside using interrupted 3-0 Vicryl to the peritoneum and then two sheets of film were placed into the intra- abdominal cavity. The fascia was closed using a running #1 double loop PDS suture and intermittently a #2 nylon retention suture was placed. The colostomy was matured using interrupted 3-0 chromic sutures. I palpated the colostomy; it was completely patent with no obstructions. Dressings were applied. Colostomy bag was applied. Which CPT code should be used?
5-year-old male with a history of prematurity was found to have penile curvature, congenital hypospadias. He presents for surgical management for straightening the curvature. Under general anesthesia, bands were placed around the base of the penis and incisions were made degloving the penis circumferentially. The foreskin was divided in Byers flaps and the penile skin was reapproximated at the 12 o’clock position. Two Byers flaps were reapproximated, recreating a mucosal collar which was then criss- crossed and trimmed in the midline in order to accommodate median raphe reconstruction. This was reconstructed with use of a horizontal mattress suture. The shaft skin was then approximated to the mucosal collar with sutures correcting the defect. Which CPT code should be used?
Under fluoroscopic guidance an injection of a combination of steroid and analgesic agent is performed on T2-T3, T4-T5, T6-T7 and T8-T9 on the left side into the paravertebral facet joints. The procedure was performed for pain due to thoracic root lesions. What are the procedure codes?
A catheter is placed in the left common femoral artery in retrograde fashion which was directed into the right iliac system advancing it to the external iliac. Dye was injected and a select right lower extremity angiogram was performed which revealed patency of the common femoral and profunda femoris. The catheter was then manipulated into the femoral artery in which a select lower extremity angiogram was performed which revealed occlusion from the popliteal to the peroneal artery. What are the procedure codes that describe this procedure?
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?
Emily, 23-months-old, has severe diarrhea and vomiting according to her mom. She is extremely dehydrated. She is brought to the outpatient clinic to see her pediatrician. The mom provides the history. The patient’s pediatrician performs a medically appropriate history and examination. The physician orders labs to be performed in the office including carbon dioxide, chloride, potassium, and sodium. The nurse performs venipuncture to obtain the blood sample. The physician diagnoses the patient with dehydration and instructs the mother to increase fluid intake to hydrate the baby. What procedure and diagnosis codes are reported for this encounter?
Preoperative Diagnoses: Severe multi-vessel coronary artery occlusive disease with increasing angina Non-Q wave myocardial infarction Hypertension Hypercholesterolemia Non-insulin dependent diabetes mellitus Postoperative Diagnoses: Same Name of Procedure: Coronary artery bypass graft times three (left internal mammary artery to mid LAD, saphenous vein graft to intermediate and saphenous vein graft to distal right coronary artery). Anesthesia: General endotracheal History: This patient is a 72-year-old female with known coronary artery occlusive disease treated medically. She has had increasing angina. She has multiple risk factors. Repeat catheterization showed rather significant progression of disease and recommendation was made for bypass grafting. Ventricular function was well-preserved and was normal. Description of Operative Procedure: The patient was brought to the operating room. After having induced adequate general endotracheal anesthesia, she was prepared and draped in sterile fashion. The segment of saphenous vein was taken from the left thigh through multiple skin incisions. Adequate length of good quality vein was obtained. The thigh was closed in layers with 2-0 and 3-0 Dexon over a tubular Jackson-Pratt drain. The chest was entered through a standard median sternotomy and systemic heparin administered. She was cannulated for bypass with a catheter placed in the distal ascending aorta for perfusion and a venous return catheter in the right atrial appendage. Cardiopulmonary bypass was instituted. After achieving a systemic temperature of 30 degrees, the aorta was cross clamped. Cold potassium cardioplegia was instilled in the aortic root and topical ice saline placed on the heart. We bypassed the intermediate branch first. This was an intramyocardial 2.5 to 3 mm vessel. A segment of reverse vein was sewn end-to-side with 7-0 Prolene and then more cardioplegia instilled down the graft. Next, we bypassed the distal right coronary artery. This was a diffusely diseased vessel with a distal plaque. The distal plaque was bridged. A segment of vein was sewn end-to-side with 7-0 Prolene and again more cardioplegia instilled down the graft. We then sewed a nice size left internal mammary artery to the mid LAD with 7-0 Prolene. The cross clamp was removed, and a partial occlusion clamp was placed on the base of the aorta. Two aortotomies were made. The veins were cut to the appropriate length and sewn to the aorta end-to-side with 5-0 Prolene. Vein graft to the right was placed superiorly and the vein graft to the intermediate inferiorly on the aorta. Cardiac action returned promptly in sinus rhythm. She was fully rewarmed, weaned from bypass and decannulated. Cannulation sites were reinforced with 3-0 Prolene. Protamine was administered. Hemostasis was assured. A temporary pacing wire was placed on the right ventricular surface. Two chest tubes were placed in the midline and secured to the skin with -0- Tevdek. The sternum was closed with multiple interrupted wires, linea alba with #1 Tevdek, presternal fascia with -0- Dexon, the skin with 4-0 subcuticular Dexon and Dermabond. She tolerated this procedure well and was returned to the CVR in stable condition. What CPT® codes are reported?
