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Author Archives: Anonymous

A physician states he performed a comprehensive EP study wit…

A physician states he performed a comprehensive EP study with induction of arrhythmia in the hospital. The report shows bundle of His recording, pacing and recording of the right atrium, and induction of arrhythmia by electrical pacing. What CPT® coding is reported?

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A patient has partial removal of his lung which is sent in f…

A patient has partial removal of his lung which is sent in for gross and microscopic examination. The pathologist also did gross and microscopic exam on biopsies for several lymph nodes in the patient’s chest which are placed in one container. A consultation is performed on a tissue block of a single specimen intraoperatively by frozen section. The pathologist also performs a trichrome stain. What CPT® codes are reported for the lab tests performed?

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A new patient visits the internal medicine clinic today for…

A new patient visits the internal medicine clinic today for diabetes, hypertension, arthritis, and a history of cardiac disease. The provider performs a medically appropriate history and exam. Blood pressure is high. All other conditions are stable. Labs ordered are HbA1c and complete blood count (CBC). The dosage for the blood pressure medication is reviewed and changed. The patient will follow up in three months. What CPT® code is reported?

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Patient undergoes a mitral valve repair with a ring insertio…

Patient undergoes a mitral valve repair with a ring insertion and an aortic valve replacement, on cardiopulmonary bypass. Which CPT® codes are reported?

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A patient is seen by Dr. B who is covering on call services…

A patient is seen by Dr. B who is covering on call services for Dr. A. The patient is an established patient with Dr. A., but she has not been seen by Dr. B. before. Which E/M subcategory is appropriate to report the services provided by Dr. B?

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What are the layers of the skin?

What are the layers of the skin?

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A 47-year-old male presents with chronic back pain and lower…

A 47-year-old male presents with chronic back pain and lower left leg radiculitis. A laminectomy is performed on the inferior end of L5. The microscope is used to perform microdissection. There was a large extradural cystic structure on the right side underneath the nerve root as well as the left. The entire intraspinal lesion was evacuated. What CPT® code(s) is/are reported for this procedure?

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A patient is having a decompression of the nerve root involv…

A patient is having a decompression of the nerve root involving two segments of the lumbar spine via transpedicular approach. What CPT® code(s) is/are reported?

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A 32-year-old male is in a diagnostic center to have an ultr…

A 32-year-old male is in a diagnostic center to have an ultrasound of his neck due to difficulty swallowing. The patient’s father had esophageal cancer. What is/are the appropriate code(s) to report for the diagnostic service?

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A 49-year-old female had two previous rotator cuff procedure…

A 49-year-old female had two previous rotator cuff procedures and now has difficulty with shoulder function, deltoid muscle function and axillary nerve function. An arthrogram is scheduled. After preparation, the shoulder is anesthetized with 1% lidocaine, 8 cc without epinephrine. The needle was placed into the shoulder area posteriorly under image intensification. It appeared as if the dye was in the shoulder joint. A good return of flow was obtained. The shoulder was then mobilized and there was no evidence of any cuff tear from the posterior arthrogram. What CPT® codes are reported?

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