An ED physician treats a 30-year-old patient who was a victi…
An ED physician treats a 30-year-old patient who was a victim of a rape. She has bruises and other trauma as well as a laceration of the vaginal wall, which is repaired with sutures (colporrhaphy) by the ED physician. What are the CPT® and ICD-10-CM codes reported for this procedure?
Read DetailsA patient presents to the hospital for a cardiovascular SPEC…
A patient presents to the hospital for a cardiovascular SPECT study. A single study is performed under stress, but without quantification, with a wall motion study, and ejection fraction. Select the CPT® code(s) for this procedure.
Read DetailsThe patient is seen in follow-up for excision of the basal c…
The patient is seen in follow-up for excision of the basal cell carcinoma of his nose. I examined his nose noting the wound has healed well. His pathology showed the margins were clear. He has a mass on his forehead; he says it is from a fragment of sheet metal from an injury to his forehead. He has an X-ray showing a foreign body, and we have offered to remove it. After obtaining consent we proceeded. The area was infiltrated with local anesthetic. I had drawn for him how I would incise over the foreign body. He observed this in the mirror so he could understand the surgery and agree on the location. I incised a thin ellipse over the mass to give better access to it; the mass was removed. There was a granuloma capsule around this, containing what appeared to be a black-colored piece of stained metal; I felt it could potentially cause a permanent black mark on his forehead. I offered to excise the metal. He wanted me to, and so I went ahead and removed the capsule with the stain and removed all the black stain. I consider this to be a complicated procedure. Hemostasis was achieved with light pressure. The wound was closed in layers using 4-0 Monocryl and 6-0 Prolene.What CPT® and ICD-10-CM codes are reported?
Read DetailsPreoperative Diagnosis: Aortic valve stenosis with coronary…
Preoperative Diagnosis: Aortic valve stenosis with coronary artery disease associated with congestive heart failurePostoperative Diagnosis: Same Procedure: Aortic valve replacement, coronary artery bypass graft with harvesting of the saphenous vein and the radial artery.Anesthesia: General endotrachealIncision: Median sternotomyDescription of Procedure: The patient was brought to the operating room and placed in supine position. After the patient was prepared, median sternotomy incision was carried out and conduits were taken from the left arm as well as the right thigh. She was cannulated after the aorta and atrium were exposed and after full heparinization.She went on cardiopulmonary bypass, and the aortic cross-clamp was applied. Cardioplegia was delivered through the coronary sinuses in a retrograde manner. The patient was cooled to 32 degrees. Iced slush was applied to the heart. The aortic valve was then exposed through the aortic root by transverse incision. The valve leaflets were removed, and the 23 St. Jude mechanical valve was secured into position by circumferential pledgeted sutures. At this point, aortotomy was closed.Attention was turned to the coronary arteries. The first obtuse marginal artery was a very large target and the saphenous vein graft to this target indeed produced an excellent amount of flow. Proximal anastomosis was then carried out to the foot of the aorta. The radial artery was anastomosed to the left anterior descending artery target in an end-to-side manner. The proximal anastomosis was then carried out to the root of the aorta.The patient came off cardiopulmonary bypass after aortic cross-clamp was released. She was adequately warmed. Protamine was given without adverse effect. Sternal closure was then done using wires. The subcutaneous layers were closed using Vicryl suture. The skin was approximated using staples. What CPT® codes are reported?
Read DetailsA 26-year-old female with a one-year history of a left tympa…
A 26-year-old female with a one-year history of a left tympanic membrane perforation has consented to have it repaired. A postauricular incision was made under general anesthesia. Dissection was carried down to the temporalis fascia and a 3 x 3 cm segment of fascia was harvested and satisfactorily desiccated. The tympanic membrane was excised. Using a high speed drill a canaloplasty was performed until the entire annulus could be seen. The ossicular chain was examined, it was found to be freely mobile. The previously harvested skin was trimmed and placed in the anterior canal angle with a slight overlapping over the temporalis fascia. Packing is placed in the ear canal, external incisions are closed, and dressings are applied. What CPT® code is reported?
Read DetailsA patient reports to the hospital radiology department for a…
A patient reports to the hospital radiology department for a functional MRI of the brain. The technologist asks the patient to perform small tasks. He takes the images of the patient at rest and while performing the tasks. What CPT® code is reported?
Read DetailsA 37-year-old has multilevel lumbar degenerative disc diseas…
A 37-year-old has multilevel lumbar degenerative disc disease and is coming in for an epidural injection. Localizing the skin over the area of L5-S1, the provider uses the transforaminal approach with fluoroscopy. The spinal needle is inserted and the patient experienced paresthesia in her left lower extremities. The anesthetic drug is injected into the epidural space. What CPT® code(s) is/are reported for this procedure?
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