A 10-year-old boy presents for injuries caused by failing off his bike. All wounds were superficial. He has a 2-cm would to his nose and a 1-cm wound to his cheek. He also has a 2,5-cm would to his elbow. All injuries were simple repair by means of suture. Assign the repair code for the physician’s services.

Dr. Smith performed a bilateral radical mastectomy, including the pectoral muscles and axillary lymph nodes, on a 63-year-old female with breast cancer located on the upper inner quadrant of both the breasts.

What CPT and ICD-9-CM codes would you use to report chemosurgery, first stage Mohs’ micrographic technique, with five tissue blocks, of the skin of female genitalia, stated as uncertain behavior ?

A 40-year-old male is in for intermediate closure of wounds due to a car accident. The patient sustained injuries to the forehead, 1.5 cm, and a 1-cm wound to the eyebrow when his head hit the steering wheel. Patient was the driver.

Which CPT code would the surgeon use to report the shaving of an epidermal lesion of the upper arm when a lesion diameter is greater than 2 cm? The post-procedure diagnosis was a benign growth.

Richard, a 34-year-old male, fell from a 4-foot scaffolding and hit his heel on the bottom rung of the support, fracturing his calcaneus in several locations. The orthopedic surgeon manipulated the bone pieces back into position and secured the fracture sites by means of percutaneous fixation.

Sammy, a 5-year-old male, tumbled down the stairs at daycare, striking and fracturing his coccygeal bone. The physician manually manipulated the bone into proper alignment and told Sammy’s mother to have the child sit on a rubber ring to alleviate the pain.

Alice, a 42-year-old female, is a carpenter at the local college. While on a ladder repairing a window frame, the weld on the rung of the metal ladder loosened and she fell backward and down a distance of 8 feet. She landed on her right hip, resulting in a dislocation. With the patient under general anesthesia, the Allis maneuver is used to repair an anterior dislocation of the right hip. The pelvis is stabilized and pressure applied to the thigh to reduce the hip and bring it into proper alignment.

A 13-year-old female sustained multiple tibial tuberosity fractures of the left knee while playing soccer at her local track meet. The physician extended the left leg and manipulated several fragments back into place. The knee was then aspirated. A long leg knee brace was then placed on the knee. Assign code for the physician service only.

Under general anesthesia, 5-year-old Michael’s tarsal dislocation was reduced by means of manipulation. Two-view intraoperative x-rays demonstrated that the tarsus was in correct alignment, and a short leg cast was then applied. (Code only the reduction service.)

Dr. Clark applied a cranial halo to Gordon to stabilize the cervical spine in preparation for x-rays and subsequent surgery. The scalp was sterilized and local anesthesia injected over the pin insertion sites. Posterior and anterior cranial pins are inserted and the halo device attached. Assign code(s) for the physician service only.

PREOPERATIVE DIAGNOSIS : Deviated septum. PROCEDURE PERFORMED : Septoplasty Reduction of inferior turbinates. The patient was taken to the operating room and placed under general anesthesia. The fracture of the inferior turbinates was first performed to do the septoplasty. Once this was done, the septoplasty was completed and the turbinates were placed back in their original position. The patient was taken to recover in satisfactory condition. Code the physician’s procedure(s) and the diagnosis.

A 24-year-old female is seen in the office for a chronic candidal paronychia nail abscess that needs to be incised and drained. Assign code for physician services only.

The patient is seen in the clinic for chronic sinusitis. The physician decides to schedule an endoscopic sinus surgery for the next day. The patient arrives to same day surgery, and the physician performs an endoscopic total ethmoidectomy with an endoscopic maxillary antrostomy with removal of maxillary tissue. Postoperative diagnosis includes chronic ethmoidal and maxillary sinusitis. Code the procedure(s) and diagnosis

Faye, an 88-year-old female, is taken to same-day surgery for a possible small chicken bone stuck in her larynx. The physician does a direct laryngoscopy to check the larynx. On inspection, a small bone fragment is een obstructing the larynx. The physician using an operating microscope removes the bone fragment. The patient is sent home in satisfactory condition

OPERATIVE REPORT PREOPERATIVE DIAGNOSIS : Ventilator dependency, aspiration pneumonia PROCEDURE PERFORMED : Tracheostomy DESCRIPTION OF PROCEDURE : After consent was obtained, the patient was taken to the operating room and placed on the operating room table in the supine position. After an adequate level of general endotracheal anesthesia was obtained, the patient was positioned for tracheostomy. The patient’s neck was prepped with Betadine and then draped in a sterile manner. A curvilinear incision was marked approximately a fingerbreadth above the sternal notch in the area just below the cricoid cartilage. This area was then infiltrated with 1% Xylocaine with 1:100,000 units of epinephrine. After several minutes, sharp dissection was carried down through the skin and subcutaneous tissue. The subcutaneous fat was removed down to the strap muscles. Strap muscles were divided in the midline and retracted laterally. The cricoid cartilage was then identified. The thyroid gland was divided in the midline with the Bovie, and then the two lobes were retracted laterally, exposing the anterior wall of the trachea. The space between the second and third tracheal rings was then identified. This was infiltrated with local solution. A cut was then made through the anterior wall. The endotracheal tube was then advanced superiorly. An inferior cut into the third tracheal ring was then done to make a flap. This was secured to the skin with 4-0 Vicryl suture. A no. 6 Shiley cuffed tracheostomy tube was then placed and secured to the skin with ties as well as the tracheostomy strap. The patient tolerated the procedure well and was taken to the critical care unit in stable condition. Report the procedure(s).

Carl, a 58-year-old male, is taken to the operating room to remove his permanent pacemaker after successfully getting his heart back to normal sinus rhythm.

This 70-year-old male is admitted for coronary ASHD. A prior cardiac catheterization showed numerous native vessels to be 70% blocked. The patients was taken to the operating room. After opening the chest and separating the rib cage, a coronary artery bypass was performed using five venous grafts and four coronary arterial grafts. Code the graft procedure(s) and the diagnosis.

OPERATIVE REPORT PROCEDURE : Excision of parotid tumor or gland or both. Once the patient was successfully under general anesthesia, Dr. Green, assisted by Dr. Smith, opened the area in which the parotid gland is located. After carefully inspecting the gland, the decision was made to excise the total gland because of the size of the tumor (5 cm). With careful dissection and preservation of the facial nerve, the parotid gland was removed. The wound was cleaned and closed, and the patient was brought to recovery in satisfactory condition. The diagnosis on the pathology report listed a primary cancer of the gland. Report only Dr. Smith’s service.

A 9-year-old boy is in for a tonsillectomy because of chronic tonsillitis and possible adenoidectomy. On inspection of the adenoids, they were found not to be inflamed; then we did a tonsillectomy only.

What code would you use to report a rigid proctosigmoidoscopy with guidewire?

A 62-year-old female presents to Acute Surgical Care for a sigmoidoscopy. The physician inserts a flexible scope into the patient’s rectum and determines the rectum is clear of any polyps. The scope is advanced to the sigmoid colon, and a total of three polyps are found. Using the snare technique, the polyps are removed. The remainder of the colon is free of polyps. The flexible scope is withdrawn. The polyps were benign.

OPERATIVE REPORT PREOPERATIVE DIAGNOSIS : Barrett’s esophagus with severe dysplasia, possible carcinoma. POSTOPERATIVE DIAGNOSIS : Same PROCEDURE PERFORMED : Exploratory laparotomy, needle biopsy of liver lesion, immobilization of stomach with pyloroplasty and placement of feeding tube. OPERATIVE NOTE : With the patient under general anesthesia, the abdomen was prepped and draped in a sterile manner. Midline incision was made from the xiphoid to below the pubis. Sharp dissection was carried down into the peritoneal cavity, and hemostasis was maintained with electrocautery. We began by exploring the abdominal cavity. The liver was carefully palpated. The area that had been identified on CT was at the very apex of the right lobe of the liver. We could fell this area, and it did not have a thickened feel to it but was more consistent with an area of hemangioma. There was a small secondary lesion on the undersurface of the right lobe. A biopsy was taken, and it did return a diagnosis of hemangioma. The rest of the liver appeared normal, and in my opinion we did not need to proceed with anything further. We thus began with mobilization of the stomach, taking down the greater curvature vessels, preserving the gastroepiploica. We carried our dissection all the way up into the hiatal hernia, preserving the blood supply to the spleen and not injuring it. We were then able to detach the left gastric artery such that the stomach was tetchered on its other vasculature but appeared completely viable. All these vessels were taken down with clamps and ligatures of 2-0 silk. We then circumferentially went around the esophagus and carried our dissection all the way back toward the pylorus. We then had the entire stomach freed up from the pylorus all the way up to the diaphragm. The stomach appeared viable with reasonable circulation. A Heineke-Mikulicz pyloroplasty then was performed to open the pylorus in one direction and close it in another using interrupted 3-0 silk sutures to complete the pyloroplasty. With this accomplished, we then picked up the jejunum approximately 40 or 50 cm beyond the ligament of Treitz and placed a red rubber feeding tube using a Witzel technique; this was a number 18-2. This was attached to the skin and brought out through a separate stab incision. The abdominal cavity was then checked for hemostasis, and everything appeared to be intact. We then closed the incision using running 0 loop nylon. We closed the skin with staples. A sterile dressing was applied. Code the biopsy of the liver lesion and pyloroplasty only.

OPERATIVE REPORT PROCEDURE : Upper gastrointestinal endoscopy PREOPERATIVE DIAGNOSIS : Upper gastrointestinal bleeding POSTOPERATIVE DIAGNOSIS : Multiple serpiginous ulcers in the gastric antrum and body, not bleeding. FINDINGS : The video therapeutic double-channel endoscope was passed without difficulty into the oropharynx. The gastroesophageal junction was seen at 42 cm. Inspetio of the esophagus revealed no erythema, ulceration, exudates, stricture, or other mucosal abnormalities. The stomach proper was entered. The endoscope was advanced to the second duodenum. Inspection of the second duodenum, first duodenum, duodenal bulb, and pylorus revealed no abnormalities. Retroflexion revealed no lesion along the cardia or lesser curvature. Inspection of the antrum, body, and fundus of the stomach revealed no abnormality, except there are multiple serpiginous ulcerations in the gastric antrum and body. They were not bleeding. They had no recent stigmata of bleeding. Photographs and biopsies were obtained. The patient tolerated the procedure well.

What CPT code would you use to report a biopsy of the bladder by means of a scope inserted through the urethra and into the bladder ?

OPERATIVE REPORT DIAGNOSIS : Large bladder neck obstruction. PROCEDURE PERFORMED : Cystoscopy and electrosurgical transurethral resection of the prostate. The patient is a 78-year-old male with obstructive symptoms and subsequent urinary retention. The patient underwent the usual spinal anesthetic, was put in the dorsolithotomy position, prepped, and draped in the usual fashion. Cystoscopic visualization showed a marked high-riding bladder. Median lobe enlargement was such that it was difficult even to get the cystoscope over. Inside the bladder, marked trabeculation was noted. No stones were present. The urethra was well lubricated and dilated. The resectoscopic sheath was passed with the aid of an obturator with some difficulty because of the median lobe. Electrosurgical TURP of the median lobe was performed, getting several big loops of tissue, which helped to improve visualization. Anterior resection of the roof was carried out from the bladder neck. Bladder-wall resection was taken from the 10 to 8 o’clock position. This eliminated the rest of the median lobe tissue as well. The patient tolerated the procedure well. Code the procedure(s) performed and the diagnosis.

What codes would you use to code reconstruction of the penis for straightening of chordee ?

Clamp circumcision with regional dorsal penile block.

Jim is a 42-year-old male in for a bilateral vasectomy that will include three postoperative semen examinations.

Patient is seen for a Bartholin’s gland abscess. The physician performed an I&D of the abscess.

OPERATIVE REPORT DIAGNOSIS Malignant tumor, thyroid PROCEDURE : Thyroidectomy, for tumor excision. The patient was prepped and draped. The neck area was opened. With careful radical dissection of the neck completed, one could visualize the size of the tumor. The decision was made to remove the entire thyroid.

What code would you use to report burr hole(s) to drain an abscess of the brain?

The patient was brought to the operating room to repair an aneurysm of the intracranial artery by balloon catheter.

OPERATIVE REPORT REOPERATIVE DIAGNOSIS : Obstructed ventriculoperitoneal shunt in patient with obstructive hydrocephalus. PROCEDURE PERFORMED : Revision of shunt. Replacement of ventricular valve and peritoneal end. Entire shunt replacement. PROCEDURE : Under general anesthesia, the patient’s head, neck, and abdomen were prepped and draped in the usual manner. An incision was made over the previous site where the shunt had been inserted in the posterior right occipital area. This shunt was found to be nonfunctioning and was removed. The problem was that we could not get the ventricular catheter out without probably producing bleeding, so it was left inside. The peritoneal end of the shunt was then pulled out through the same incision. Having done this, I placed a new ventricular catheter into the ventricle. I then attached this to a medium pressure bulb valve and secured this with 3-0 silk to the subcutaneous tissue. We then went to the abdomen and made an incision below the previous site, and we were able to trocar the peritoneal end of the shunt by making a stab wound in the neck and then connecting it up to the shunt. This was then connected to the shunt. Pumping on the shunt, we got fluid coming out the other end. I then inserted this end of the shunt into the abdomen by dividing the rectus fascia, splitting the muscle, and dividing the peritoneum and placing the shunt into the abdomen. One 2-0 chromic suture was used around the peritoneum. The wound was then closed with 2.0 Vicryl, 2-0 plain in the subcutaneous tissue, and surgical staples on the skin. The stab wound on the neck was closed with surgical staples. The head wound was closed with 2-0 Vicryl on the galea and surgical staples on the skin. A dressing was applied. The patient was discharged to the recovery room.

OPERATIVE REPORT DIAGNOSIS : Herniated disc. PROCEDURE : Hemilaminectomy L4-5 and L5-S1. The patient was taken to the operating room prepped and draped in the usual fashion. Once the lower back area was opened, after decompression of the nerve roots, the interspace at L4-5 was entered and the disc fragment was excised. Next, the interspace at L5-S1 was entered and disc fragments were excised as well. The patient tolerated the procedure well.

Delores, a 67-year-old female, is seen today for destruction of a ulcer of her cornea. The lesion is removed by thermocauterization. Assign codes for the professional service only.

A consultation is requested for a 90-year-old patient whose ophthalmologist recently diagnosed her with bilateral senile cataracts. The service was provided in the consultant’s office. Her regular ophthalmologist has recommended surgical removal of the cataracts and implantation of lenses. Her ophthalmologist has referred her for presurgical clearance. The patient has benign hypertension and requires clearance prior to surgery. During the history, the patient states that she has had decreasing vision in both eyes over the last year or two but has always had excellent vision. She began wearing glasses in the past year, with minimal improvement in vision. She cannot recall any eye trauma in the past. Patient denies any headaches, blurry vision, diplopia, or unusual tearing or drainage from the eyes. Patient notes that a brother also had cataracts some years back. There is a family history of hypertension. The internal medicine physician conducted a detailed history and physical exam, including vision, and confirmed the diagnosis of the patient’s ophthalmologist. The physician noted stable hypertension no risk for anesthesia/surgery. The medical decision making was of low complexity. Assign codes for the physician services only.

The attending physician requests a consultation for an inpatient from an interventional radiologist for an opinion about a 63-year-old male with abnormal areas within the liver. The patient reported right upper quadrant sharp pain for almost two weeks. He has also had some bouts of nausea and feeling fatigued. Patient denies any unexplained weight loss, shortness of breath, palpitations or rashes ; admits to periodic indigestion ; remainder of 10-system review is negative. Patient states no previous surgical history ; he denies tobacco use and admits to 1-2 beers per week ; family history is negative for liver disorders to his knowledge. His liver enzymes were elevated. Previous liver scan revealed multiple low attenuation areas within the liver (infection versus tumor). The laboratory studies were creatinine, 0.9; hemoglobin, 9.5; PT and PTT, 13.0/31.5 with an INR of 1.2. The comprehensive physical examination showed that the lungs were clear to auscultation and the heart had regular rate and rhythm. The mental status was oriented times three. Organ systems examined included: GI, lymphatic, GU, ENMT, musculoskeletal, skin and temperature noted as intermittent low-grade fever, up to 101 F, usually occurred at night. The CT-guided biopsy was considered appropriate and recommended for this patient. The medical decision making was of high complexity. Assign codes for the physician services.

A cardiology consultation is requested by Dr. Attending for a 71-year-old inpatient for recent onset of dyspnea on exertion and chest pain. The history reveals that the patient cannot walk three blocks without exhibiting retrosternal squeezing sensation with shortness of breath. She relates that she had the first episode 3 months ago, which she attributed to indigestion. Upon questioning, patient denies any weight loss, visual disturbances, hearing loss, nausea, vomiting or diarrhea. States that prior to current complaint had no episodes of palpitations or chest pain and no breathing difficulties. Admits to some nocturia. Has no problems with headaches, bruising, excessive thirst or intolerance to temperatures. Admits to some joint pain, with no specific diagnosis. Her medical history is negative for stroke, tuberculosis, cancer, or rheumatic fever but includes seborrheic keratosis and benign positional vertigo. History of immature cataracts, OU. She has no known allergies. She lives alone and indicates one sibling, a sister now deceased, did have some kind of heart problems. A comprehensive physical examination reveals a pleasant, elderly female in no apparent distress. She has a blood pressure of 150/70 with a heart rate of 76. Weight is 131 pounds, and she is 5 foot 4 inches. Head and neck reveal JBP less than 5 cm. Normal carotid volume and upstroke without bruit. Chest examination shows clear to auscultation with no rales, crackles, crepitations, or wheezing. The complete cardiovascular single system examination was documented and revealed a normal PMI without RV lift. Normal S1 and S2 with an S3, without murmur, are noted. The medical decision making complexity is high based on the various diagnosis options. Assign codes for the physician services.

A new patient presents to the emergency department with an ankle sprain received when he fell while inline skating. The patient is in apparent pain, and the ankle has begun to swell. He is unable to flex the ankle. The patient reports that he did strike his head on the sidewalk as a result of the fall. The physician completes and expanded problem focused history and examination. The medical decision making complexity is low. Assign codes for the physician services.

An 89-year-old female patient is admitted to the skilled nursing facility after being seen in the office earlier today. The daughter brought the patient to the office. As a part of the history, conducted with the patient’s daughter, it is found that the patient was diagnosed with dementia last year. The patient was moved to this city from Anytown so that the daughter could care for her mother. The patient is noncontributory, and the physician relies on medical record documentation brought in by the daughter from he mother’s previous physician. Due to patient’s state, unable to obtain review of systems and PFSH limited to information from daughter and records. Of late, the patient has become more and more withdrawn and noncommunicative. She has wandered away from the daughter’s home twice in the last week and on the last occasion was found walking on the street. After a comprehensive examination, it was decided that the patient would be admitted to the nursing facility today. The physician spent 45 minutes with the patient and in preparation of the medical documentation for admittance to the nursing facility. The medical decision making was of moderate complexity.

The physician provides a service to a new patient in a custodial care center. The patient is a paraplegic who has pneumonia of moderate severity. Patient has no other complaints aside from cough related to pneumonia. After taking the patient’s history, the physician performed an expanded problem-focused examination. The examination focused on the respiratory and cardiovascular systems, based on the patient’s current complaint and past history of tachycardia. The medical decision making was of low complexity

When reporting anesthesia services for two procedures performed on the same patient during the same operative procedure, you would do the following to calculate the unit value of the services :

Anesthesia provided for an anterior cervical discectomy with decompression of a single interspace of the spinal cord and nerve roots and including osteophytectomy (63075).

The anesthesiologist personally performed the anesthesia service. An 11-month-old with bilateral cleft lip and palate has shown slow growth but is generally in good health. She underwent attempted preliminary closure with bilateral lip adhesions, which dehisced. She subsequently underwent unilateral lip adhesion, which also dehisced. She presents now for definitive repair.

The Anesthesia service was performed by the CRNA with an anesthesiologist medically directing 3 concurrent cases. Report both the anesthesiologist service and the CRNA service. The patient’s physical status was –P2. This young child who has developmental delay was noted to have a decreased level of consciousness

A 62-year-old male comes into the clinic complaining of shortness of breath. The physician orders a chest x-ray, frontal and lateral. The x-ray results were inconclusive

A patient is in for an MRI (magnetic resonance imaging) of the pelvis with contrast material(s). Assign code for the physician service only.

What code(s) would you use for an endoscopic catheterization of the biliary ductal system for the professional radiology component ?

Jennier is a 29-year-old pregnant female in for a follow-up ultrasound with image documentation of the uterus. Assign code service only.

What codes would you use for complex brachytherapy isodose calculation for a patient with prostate cancer ?

Therapeutic radiology treatment planning is the “prescription” for a patient who will start radiation therapy for a cancerous neoplasm of the adrenal gland. What CPT code would you use for a complex treatment planning ?

A patient presents to the laboratory at the clinic for the following tests : thyroid- stimulating hormone, comprehensive metabolic panel, and an automated hemogram with manual differential WBC count (CBC). How would you code this lab ?

An 80-year-old female patient presented to the laboratory for a lipid panel that includes measurement of total serum cholesterol, lipoprotein (direct measurement, HDL and LDL), and triglycerides.

Surgical pathology, gross examination, or microscopic examination is most often required when a sample of an organ, tissue, or body fluid is taken from the body. What CPT codes would you use to report biopsy of the colon, hematoma, pancreas, and a tumor of the testis?

The patient presented to the laboratory at the clinic for the following blood tests ordered by her physician : albumin (serum), bilirubin (total) and BUN (quantitative). Assign code(s) for the service only

A 70-year-old male who suffers from atrial fibrillation has been on long-term use of digoxin. He comes into the lab today to check his serum digoxin level.

This 68-year-old female suffers from chronic liver disease and needs a hepatic function panel performed every 6 months. Tests include total bilirubin (82247), direct bilirubin (82248), total protein (84155), alanine aminotransferases (ALT and SGPT) (84460), aspartate aminotransferases (AST and SGOT) (84450), and what other lab tests? Also choose the correct ICD-9-CM code to support the medical necessity of this lab test.

A 64-year-old male comes in for his flu (split virus, IM) and pneumonia (23-valent, IM) vaccines. Code only the immunization administration and diagnoses for the vaccines.

Katie is back for a 2-year follow-up comprehensive ophthalmologic exam. The physician provides a gas-permeable, extended-wear contact lens for the right eye. She is to follow up in 1 week to see how her contact is working. Code the exam and the supply of a contact lens.

This 70-year-old male is taken to the emergency room with severe chest pain. The physician provided an expanded problem-focused history and examination. While the physician is examining the patient, his pressure drops and he goes into cardiac arrest. Cardiopulmonary resuscitation is given to the patient, and his pressure returns to normal; he is transferred to the intensive care unit in critical condition. Code the cardiopulmonary resuscitation and the diagnosis. The medical decision making was of low complexity.,ij

Dr. Green orders a sleep study for Dan, a 51-year-old male who has been diagnosed with obstructive sleep apnea. The sleep study was done with C-PAP (continuous positive airway pressure), included 6 parameters, and was attended by the technologist.

Ann is a 58-year-old female with end-stage renal failure. She receives dialysis Tuesdays. Thursdays and Saturdays each week. Code a full month of dialysis for the month of December of 8 encounters.

OPERATIVE REPORT PROCEDURE PERFORMED : Primary stenting of 70% proximal posterior descending artery stenosis. INDICATIONS : Atherosclerotic heart disease. DESCRIPTION OF PROCEDURE Please see the computer report. Please note that a 2.5 x 13-mm pixel stent was deployed. COMPLICATIONS : None RESULTS : Successful primary stenting of 70% proximal posterior descending artery stenosis with no residual stenosis at the end of the procedure.

The term means to divert or make an artificial passage :

This term means to identify the presence of and the amount of :

The term that means the expansion of :

This term means to turn downward :

This gland is located at the base of the brain in a depression in the skull :

Which of the following is not part of the kidney ?

This is located in the middle ear :

This is another name for the bulbourethral gland :

HOLTER REPORT LOCATION : Outpatient CHOLTER REPORT LOCATION : Outpatient Clinic INDICATION : Patient with atrial fibrillation on Lanoxin. Patient with known cardiomyopathy. BASELINE DATA : An 86-year-old man with congestive heart failure on Elavil, Vasotec, Lanoxin, and Lasix. The patient was monitored for the 24 hours in which the analysis was performed. INTERPRETATION : 1. The predominant rhythm is atrial fibrillation. The average ventricular rate is 74 beats per minute, minimum 49 beats per minute, and maximum 114 beats per minute. 2. A total of 4948 ventricular ectopic beats were detected. There were four forms. There were 146 couplets with one triplet and five runs of bigeminy. There were two runs of ventricular tachycardia, the longest for 5 beats at a rate of 150 beats per minute. There was no ventricular fibrillation. 3. There were no prolonged pauses. CONCLUSION : 1. Predominant rhythm is atrial fibrillation with well-controlled ventricular rate. 2. There are no prolonged pauses. Asymptomatic, nonsustained, ventricular tachycardialinic INDICATION : Patient with atrial fibrillation on Lanoxin. Patient with known cardiomyopathy. BASELINE DATA : An 86-year-old man with congestive heart failure on Elavil, Vasotec, Lanoxin, and Lasix. The patient was monitored for the 24 hours in which the analysis was performed. INTERPRETATION : 1. The predominant rhythm is atrial fibrillation. The average ventricular rate is 74 beats per minute, minimum 49 beats per minute, and maximum 114 beats per minute. 2. A total of 4948 ventricular ectopic beats were detected. There were four forms. There were 146 couplets with one triplet and five runs of bigeminy. There were two runs of ventricular tachycardia, the longest for 5 beats at a rate of 150 beats per minute. There was no ventricular fibrillation. 3. There were no prolonged pauses. CONCLUSION : 1.Predominant rhythm is atrial fibrillation with well-controlled ventricular rate. 2.There are no prolonged pauses. Asymptomatic, nonsustained, ventricular tachycardia

A 51-year-old male patient had surgery to remove two separate carbuncles of the left axilla. Pathology report indicated staphylococcal infection.

Jim suffers from paralysis of his upper right arm. He is left handed. ______

Unspecified closed fracture of the right upper end of the right ulna initial encounter. ______

A patient is treated for three pressure ulcers: bilateral buttock ulcers, stage 3 on the right and stage 2 on the left; and a stage 4 on the sacral area.

A 65-year-old male Medicare patient presents for a digital rectal examination and a total prostate-specific antigen (PSA) screening test. His father and brother had prostate cancer.

An 82-year-old female Medicare patient has a single energy x-ray absorptiometry (SEXA) bone density study of two sites of the wrist. The patient has osteopenia and is complaining of wrist pain.

A 72-year-old male Medicare patient receives 30 minutes of individual diabetes outpatient self-management training session. The patient is a newly diagnosed type II diabetic.

The term OIG stands for the Office of the :

This part of Medicare helps to cover medically necessary physician services, outpatient care, and some other medical services such as physical and occupational therapy, and some home health care :

This provider receives reimbursements for Medicare directly from the fiscal intermediary :

According to the E/M Guidelines, this is a chronological description of the development of the patient’s present illness from the first sign and/or symptom to the present

This type of code is exempt from the use of modifier-51 :

Which of the following is NOT an example of a method of contrast that qualifies as “with contrast” and, if not included in the code description, can be reported separately ?

A service that is rarely provided, unusual, variable, or new may require this type of report to assist in the determination of the medical appropriateness of a service and indicates the nature, extent, need, time, effort, and equipment necessary.

Anesthesia time begins when the anesthesiologist begins to prepare the patient for the induction of anesthesia and ends when

If a distinct, separately identifiable procedure is provided in addition to an E/M service, you would add this modifier to the E/M code.

All third-party payers require the use of HCPCS codes in submissions for service provided to any patient

Two malignant lesions on the scalp measuring 1.1 cm and 2.0 cm, and one malignant lesion on the neck measuring 2.2 cm were destroyed. Electrocautery was used for the first two lesions and laser was used for the third lesion. What procedure code(s) is/are reported?

Operative Report: Diagnosis: Idiopathic gout, left knee. Procedure: Aspiration, left knee Procedure: The knee was prepped and draped in the usual sterile fashion. After the skin was infiltrated with lidocaine, a needle was inserted through the skin into the joint and 10 mL of slightly cloudy yellow fluid was aspirated from the knee. A sterile dressing was applied. There was good apposition and hemostasis, no complications, and the patient tolerated the procedure well. The patient was advised to keep the dressing clean and dry. Instructions were given for signs and symptoms of infection (such as increased pain, swelling, redness, puss, heat, or fever). Patient was told to return immediately if any of these developed. Ace bandage was placed. Fluid showed glucose 156, WBC 100. These findings did not seem to indicate septic joint. The patient will be treated with Keflex and Vicodin. She is to ice, rest, and elevate the left knee. She is to contact her doctor on Monday and follow up. She is to return for any fever, redness of the left knee. She understands these instructions and agrees to follow up. What CPT® and ICD-10-CM codes are reported?

Preoperative Diagnosis: Painful varicose veins, right lower extremity. Postoperative Diagnosis: Painful varicose veins, right lower extremity with history of DVT. Procedure: Sclerotherapy Anesthesia: Moderate conscious sedation provided. Operative Procedure: This 38-year-old patient was brought to the ASC operating room and placed under moderate conscious sedation. The right lower extremity was prepped and draped in a sterile manner. Varicose veins were identified. Utilizing a 21-gage butterfly needle, multiple varicose veins along the posterior and anterior right lower extremity were injected with polidocanol foam. Symmetrical Class III reticular vessels of 2-3 mm diameter were injected with equal amounts (0.5 cc) of sclerosing solutions: 0.5% POL in the right leg. Distance of vessel sclerosing effect was calibrated from the inferior patellar tendon employing a calibrated measuring window. Patient tolerated the procedure well. A compression stocking was applied, which will need to remain in place for the next 72 hours. The patient was monitored until complete consciousness returned. Total intra-services sedation time: 28 min. The patient was then taken to the recovery room in stable condition. No specimens were sent to lab. What CPT® and ICD-10-CM codes are reported?

Patient presents with complaints of blood per rectum for the past three months. He has not been experiencing significant abdominal pain, but his bowels have been alternating between constipation and diarrhea. The blood is ribbon-like in appearance. Abdominal exam reveals mild tenderness throughout all quadrants. Proctoscopy is performed with 8 cm of interference. Multiple biopsies are taken, unable to pass regular scope; stricture size scope was advanced past the lesion and visualized the distal rectal mucosa. Digital exam reveals internal hemorrhoids prolapsing. Biopsies sent to lab. Patient scheduled for follow-up visit pending pathology report. What CPT® and ICD-10-CM codes are reported?

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 diagnoses: Cervical stenosis C3-C4, cervical spondylosis with myelopathy, and C3-C4 cervical instability. Procedures: Laminectomies at C3 and C4 with bilateral foraminotomies. Description of Procedure: The patient was taken to the operating room. In the supine position, general anesthesia was induced, intravenous antibiotics administered, a Foley catheter placed, and neurophysiological monitoring leads applied. Mayfield head tongs were applied in the standard surgical fashion. The patient was then transferred into the prone position with all pressure points padded and the Mayfield head tongs attached to the bed firmly. The shoulders were very gently taped down to allow better visualization with fluoroscopy, and then the posterior cervical region was prepped and draped in the usual sterile fashion. The head of the bed was elevated about 30 degrees. An incision was made from approximately the level of C2 to C6 to allow dissection down to the C3 to C4 region. We took care to preserve the ligamentum nuchae and interspinous ligaments outside the level of decompression. Dissection was carried down with Bovie electrocautery through subcutaneous tissues in the midline directly onto the spinous processes. Subperiosteal dissection was then carried out over the C3 and C4 lamina out to the lateral border of the lateral masses. We then closed over a deep drain with #1 Vicryl sutures in the deep fascia, followed by 2-0 Vicryl sutures in the subcutaneous tissues, followed by 3-0 nylon interrupted horizontal mattress sutures. A sterile dressing was applied, the patient was transferred into the supine position, and a cervical collar applied. The drain was hooked up to bulb suction. The Mayfield head tongs were removed. The patient was awakened and extubated. He was able to flex and extend across the ankles and toes, flex and extend across the elbows and wrists bilaterally, and was following commands. The patient was taken to the post-anesthesia care unit in good condition. He tolerated the procedure well and there were no complications. What CPT® code(s) is/are reported?

An MRI is taken to confirm the diagnosis of a subperiosteal abscess (SPA) between the orbital bones and left periorbital caused by a Staphylococcus infection. The MRI is performed first without contrast material and then followed by contrast materials and further sections. An independent radiologist reads the MRI confirming the diagnosis. What are the CPT® and ICD-10-CM codes reported for the radiologist’s services?

The physician inserted a ventriculoperitoneal shunt for the purpose of draining a cerebrospinal fluid shunt in a 10-year-old male patient with secondary hydrocephalus resulting from bacterial meningitis. Anesthesia was started at 11 AM and ended at 11:50 AM. The procedure was performed from 11:05 AM to 11:45 AM. What CPT® code is reported for the anesthesia and what anesthesia time is reported?

A 10-year-old is brought in to see an allergist for generalized urticaria. The family just recently visited a family member that had a cat and dog. The mother wants to know if her daughter is allergic to cats and dogs. The child’s skin was scratched with two different allergens. The physician waited 15 minutes to check the results. There was a flare-up reaction to the cat allergen, but there was no flare-up to the dog allergen. The physician included the test interpretation and report in the record.What CPT® coding is reported?