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Author Archives: Anonymous

A patient with a status post (after or following) lumbar pun…

A patient with a status post (after or following) lumbar puncture headache receives an epidural blood patch. The patient’s venous blood is injected into the lumbar epidural space; this blood forms a clot sealing the leak of CSF from the lumbar puncture. What CPT® and ICD-10-CM codes are reported?

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A couple has been trying to conceive for nine months without…

A couple has been trying to conceive for nine months without success. Preliminary studies show the woman ovulates and the husband’s sperm count is good. A sperm sample is submitted for both a post coital Huhner test and a hamster penetration test. Report the codes.

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A provider is performing an experimental cervical sympathect…

A provider is performing an experimental cervical sympathectomy on a patient with Raynaud’s Syndrome. What CPT® and ICD-10-CM codes are reported?

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What is the correct CPT® code for the wedge excision of a na…

What is the correct CPT® code for the wedge excision of a nail fold of an ingrown toenail?

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Operative ReportPREOPERATIVE DIAGNOSIS: Squamous cell carcin…

Operative ReportPREOPERATIVE DIAGNOSIS: Squamous cell carcinoma, scalp.POSTOPERATIVE DIAGNOSIS: Squamous carcinoma, scalp.PROCEDURE PERFORMED: Excision of Squamous cell carcinoma, scalp with Yin-Yang flap repairANESTHESIA: Local, using 4 cc of 1% lidocaine with epinephrine.COMPLICATIONS: None.ESTIMATED BLOOD LOSS: Less than 5 cc.SPECIMENS: Squamous cell carcinoma, scalp sutured at 12 o’clock, anterior tipINDICATIONS FOR SURGERY: The patient is a 43-year-old male patient with a biopsy proven squamous cell carcinoma of his scalp measuring 2.1 cm. I marked the area for excision with gross normal margins of 4 mm and I drew my planned Yin-Yang flap closure. The patient observed these markings in two mirrors, to understand the surgery and he agreed on the location. We proceeded with the procedure.DESCRIPTION OF PROCEDURE: The area was infiltrated with local anesthetic. The patient was placed prone, his scalp and face were prepped and draped in sterile fashion. I excised the lesion as drawn to include the galea. Hemostasis was achieved with the Bovie cautery. Pathologic analysis showed the margins to be clear. I incised the Yin-Yang flaps and elevated them with the underlying galea. Hemostasis was achieved in the donor site using Bovie cautery. The flap rotated into the defect with total measurements of 2.9 cm x 3.2 cm. The donor sites were closed and the flaps inset in layers using 4-0 Monocryl and the skin stapler. Loupe magnification was used. The patient tolerated the procedure well.What CPT® and ICD-10-CM codes are reported?

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What type of insurance is Medicare Part D?

What type of insurance is Medicare Part D?

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What do brackets [] indicate in the ICD-10-CM Alphabetic Ind…

What do brackets [] indicate in the ICD-10-CM Alphabetic Index?

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A 32-year-old male was seen in the ambulatory surgery center…

A 32-year-old male was seen in the ambulatory surgery center (ASC) for removal of two lipomas. One was located on his back and the other was located on the right forearm. Both involved subcutaneous tissue. What ICD-10-CM code(s) is/are reported?

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The splenic (left colic) flexure lies in the upper left quad…

The splenic (left colic) flexure lies in the upper left quadrant, between what two portions of the large intestine?

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A 47-year-old patient was previously treated with external f…

A 47-year-old patient was previously treated with external fixation for a Type IIIA left lateral condyle tibial fracture. There is now nonunion of the left proximal tibia, and he is admitted for open reduction of tibia with bone grafting. Approximately 30 grams of cancellous bone was harvested from the iliac crest. The fracture site was exposed and the area of nonunion was osteotomized, cleaned and repositioned. Intrafragmentary compression was applied with three screws. The harvested bone graft was packed into the fracture site. What CPT® and ICD-10-CM codes are reported?

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