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A patient suffering from idiopathic dystonia is seen today and receives the following Botulinum injections: three muscle injections in both upper extremities and seven injections in six paraspinal muscles.
How are these injections reported according to the CPT® guidelines?
The gynecologist performs a colposcopy of the cervix including biopsy and endocervical curettage.
What CPT® code is reported?
A Medicare patient is scheduled for a screening colonoscopy.
What code is reported for Medicare?
A patient with Parkinson's has sialorrhea. The physician administers an injection of atropine bilaterally into a total of four submandibular salivary glands.
What CPT® coding is reported?
A patient presents to the labor and delivery department for a planned cesarean section for triplets. She is at 37 weeks gestation. She is given a continuous epidural for the delivery.
What anesthesia coding is reported?
A witness of a traffic accident called 911. An ambulance with emergency basic life support arrived at the scene of the accident. The injured party was stabilized and taken to the hospital. What HCPCS Level II coding is reported for the ambulance's service?
View MR 007400
MR 007400
Radiology Report
Patient: J. Lowe Date of Service: 06/10/XX
Age: 45
MR#: 4589799
Account #: 3216770
Location: ABC Imaging Center
Study: Mammogram bilateral screening, all views, producing direct digital image
Reason: Screen
Bilateral digital mammography with computer-aided detection (CAD)
No previous mammograms are available for comparison.
Clinical history: The patient has a positive family history (mother and sister) of breast cancer.
Mammogram was read with the assistance of GE iCAD (computerized diagnostic) system.
Findings: No dominant speculated mass or suspicious area of clustered pleomorphic microcalcifications is apparent Skin and nipples are seen to be normal. The axilla are unremarkable.
What CPT® coding is reported for this case?
A patient is taken to the radiology department for a radiological cardiac catheterization. An acute MI of the left anterior descending coronary artery is found. The cardiologist performs a suction thrombectomy, followed by atherectomy and a stent to the artery. A CRNA provides MAC for this patient, who is status P5.
What code/modifier combination would you report for the services of the CRNA?
A patient with a history of chronic venous embolism in the inferior vena cava has a radiographic study to visualize any abnormalities. In outpatient surgery the physician accesses the subclavian vein and the catheter is advanced to the inferior vena cava for injection and imaging. The supervision and interpretation of the images is performed by the physician.
What codes are reported for this procedure?
A 47-year-old female presents to the operating room for a partial corpectomy on one upper thoracic vertebral body, T3. Two surgeons are performing the surgery. One surgeon performs the transthoracic approach and excises the damaged portion of the vertebral body. The second surgeon inserts a bone graft into the vertebral gap, closing the gap, and inserts a metal plate. Both surgeons work together, each as a primary surgeon.
How does each surgeon report their portion of the surgery?
A woman at 36-weeks gestation goes into labor with twins. Fetus 1 is an oblique position, and the decision is made to perform a cesarean section to deliver the twins. The obstetrician who delivered the twins, provided the antepartum care, and will provide the postpartum care.
What CPT® coding is reported for the twin delivery?
The gastroenterologist performs a simple excision of three external hemorrhoids and one internal hemorrhoid, each lying along the left lateral column. The operative report indicates that the internal hemorrhoid is not prolapsed and is outside of the anal canal.
What CPT® and ICD-10CM codes are reported?
A diagnostic mammogram is performed on the left and right breasts. Computer-aided detection is also used to further analyze the image for possible lesions.
What CPT® coding is reported for this radiology service?
A 6-French sheath and catheter is placed into the coronary artery and is advanced to the left side of the heart into the ventricle. Ventriculography is performed using power injection of contrast agent. Pressures in the left heart are obtained. The coronary arteries are also selected and imaged.
What CPT® code is reported?
View MR 005398
MR 005398
Operative Report
Preoperative Diagnosis: Nonfunctioning right kidney with ureteral stricture.
Postoperative Diagnosis: Nonfunctioning right kidney with ureteral stricture.
Procedure: Right nephrectomy with partial ureterectomy.
Findings and Procedure: Under satisfactory general anesthesia, the patient was placed in the right flank position. Right flank and abdomen were prepared and draped out of the sterile field. Skin incision was made between the 11th and 12th ribs laterally. The incision was carried down through the underlying subcutaneous tissues, muscles, and fascia. The right retroperitoneal space was entered. Using blunt and sharp dissection, the right kidney was freed circumferentially. The right artery, vein, and ureter were identified. The ureter was dissected downward where it is completely obstructed in its distal extent. The ureter was clipped and divided distally. The right renal artery was then isolated and divided between 0 silk suture ligatures. The right renal vein was also ligated with suture ligatures and 0 silk ties. The right kidney and ureter were then submitted for pathologic evaluation. The operative field was inspected, and there was no residual bleeding noted, and then it was carefully irrigated with sterile water. Wound closure was then undertaken using 0 Vicryl for the fascial layers, 0 Vicryl for the muscular layers, 2-0 chromic for subcutaneous tissue, and clips for the skin. A Penrose drain was brought out through the dependent aspect of the incision. The patient lost minimal blood and tolerated the procedure well.
What CPT® coding is reported for this case?
Patient has undergone open surgery for a left total knee arthroplasty. While in the recovery room, he continued to have severe postoperative pain. The surgeon ordered a femoral block for postoperative pain. The anesthesiologist evaluated the patient and performed a left femoral block, which provided significant post-operative pain relief.
What CPT® coding is reported?
View MR 003396
MR 003396
Operative Report
Preoperative Diagnosis: Acute MI, severe left main arteriosclerotic coronary artery disease
Postoperative Diagnosis: Acute MI, severe left main arteriosclerotic coronary artery disease
Procedure Performed: Placement of an intra-aortic balloon pump (IABP) right common femoral artery
Description of Procedure: Patient's right groin was prepped and draped in the usual sterile fashion. Right common femoral artery is found, and an incision is made over the artery exposing it. The artery is opened transversely, and the tip of the balloon catheter was placed in the right common femoral artery. The balloon pump had good waveform. The balloon pump catheter is secured to his skin after local anesthesia of 2 cc of 1% Xylocaine is used to numb the area. The balloon pump is secured with a 0-silk suture. The patient has sterile dressing placed. The patient tolerated the procedure. There were no complications.
What CPT® coding is reported for this case?
A patient complains of tarry, black stool, and epigastric tightness. An esophagogastroduodenoscopy is recommended to evaluate the source of the bleeding. The endoscope is inserted orally. The esophagus appears normal on scope insertion. No evidence of bleeding in the stomach. The scope is then passed into the duodenum, where a polyp is found and removed with hot biopsy forceps. No evidence of bleeding post procedure.
What CPT® code is reported?
A patient is diagnosed with diabetic polyneuropathy.
Using ICD-10-CM coding guidelines, what ICD-10-CM coding is reported?
A 60-year-old male suffering from degenerative disc disease at the L3-L4 and L5-S1 levels was placed under general anesthesia. Using an anterior approach, the L3-L4 disc space was exposed. Using blunt dissection, the disc space was cleaned. The disc space was then sized and trialed. Excellent placement and insertion of the artificial disc at L3-L4 was noted. The area was inspected and there was no compression of any nerve roots. Same procedure was performed on L5-S1 level. Peritoneum was then allowed to return to normal anatomic position and entire area was copiously irrigated. The wound was closed in a layered fashion. The patient tolerated the discectomy and arthroplasty well and was returned to recovery in good condition. What CPT® coding is reported for this procedure?
Mr. Roland has difficulty breathing and congestion with a productive cough. The physician takes frontal and lateral view chest X-rays in the office (the equipment is owned by the physician group). The physician reads the X-rays and determines a diagnosis of walking pneumonia. The physician’s interpretation is placed in the patient’s chart.
How does the physician bill for the chest X-ray?
A 60-year-old male has three-vessel disease and supraventricular tachycardia which has been refractory to other management. He previously had pacemaker placement and stenting of LAD coronary artery stenosis, which has failed to solve the problem. He will undergo CABG with autologous saphenous vein and an extensive modified MAZE procedure to treat the tachycardia.
He is brought to the cardiac OR and placed in the supine position on the OR table. He is prepped and draped, and adequate endotracheal anesthesia is assured. A median sternotomy incision is made and cardiopulmonary bypass is initiated. The endoscope is used to harvest an adequate length of saphenous vein from his left leg. This is uneventful and bleeding is easily controlled. The vein graft is prepared and cut to the appropriate lengths for anastomosis. Two bypasses are performed: one to the circumflex and another to the obtuse marginal. The left internal mammary is then freed up and it is anastomosed to the ramus, the first diagonal, and the LAD. An extensive maze procedure is then performed and the patient is weaned from bypass. At this point, the sternum is closed with wires and the skin is reapproximated with staples. The patient tolerated the procedure without difficulty and was taken to the PACU.
Choose the procedure codes for this surgery.
A 45-year-old female presents to the ED with chest pain. The provider has an Albumin Cobalt Binding Test to determine if the chest pain is ischemic in nature.
That lab test is reported?
View MR 001394
MR 001394
Operative Report
Procedure: Excision of 11 cm back lesion with rotation flap repair.
Preoperative Diagnosis: Basal cell carcinoma
Postoperative Diagnosis: Same
Anesthesia: 1% Xylocaine solution with epinephrine warmed and buffered and injected slowly through a 30-gauge needle for the patient's comfort.
Location: Back
Size of Excision: 11 cm
Estimated Blood Loss: Minimal
Complications: None
Specimen: Sent to the lab in saline for frozen section margin control.
Procedure: The patient was taken to our surgical suite, placed in a comfortable position, prepped and draped, and locally anesthetized in the usual sterile fashion. A #15 scalpel blade was used to excise the basal cell carcinoma plus a margin of normal skin in a circular fashion in the natural relaxed skin tension lines as much as possible The lesion was removed full thickness including epidermis, dermis, and partial thickness subcutaneous tissues. The wound was then spot electro desiccated for hemorrhage control. The specimen was sent to the lab on saline for frozen section.
Rotation flap repair of defect created by foil thickness frozen section excision of basal cell carcinoma of the back. We were able to devise a 12 sq cm flap and advance it using rotation flap closure technique. This will prevent infection, dehiscence, and help reconstruct the area to approximate the situation as it was prior to surgical excision diminishing the risk of significant pain and distortion of the anatomy in the area. This was advanced medially to close the defect with 5 0 Vicryl and 6-0 Prolene stitches.
What CPT® coding is reported for this case?
A cardiologist uses the hospital's equipment for a cardiac stress test as he doesn't own equipment for the test. He supervises the test and provides the interpretation and report of the test.
What CPT® codes are reported?
TESTED 21 Nov 2024