The provider saw an established patient in his office and decided to admit an 18-month-old infant to the hospital from his office to rule out sepsis. The infant is crying inconsolably. He has a large amount of gas in his bowel, no hematochezia associated with it. The provider documented two distinct notes and saw the patient in the office and in the hospital. A medically appropriate history and exam were documented in both settings. In the hospital, the provider ordered a CBC, EKG and chest x-ray and started the patient on antibiotics. If cultures are negative and the patient remains afebrile for 48 hours, the infant will be discharged home. According to the CPT® E/M guidelines, what CPT® code is reported for this visit?

Tomographic axial images (CT or CAT scan) through the abdomen were obtained without administration of intravenous contrast. This showed a 3 cm diameter mass in the upper pole of the right kidney abutting the liver. Cryoablation of the lesion was performed utilizing two freezing cycles with good cosmetic results. What CPT® codes are reported?

An elderly male patient presents to the ED complaining of a high fever the day prior to the encounter and of extreme lethargy. He has a history of benign hypertension which has been elevated. On arrival he was examined by his primary care physician and admitted, with possible urinary tract infection and concern for his elevated blood pressure. He was noted to have hematuria and a urine culture is performed. Positive UTI and pseudomonas showed in the urine culture and IV antibiotics were administered. During the course of the day, his fever decreased, and his lethargy improved.  As the IV fluids were decreased, he resumed a benign hypertensive state. On the next hospital day, his primary care physician noted the urine was clear and he was discharged on oral antibiotics. What ICD-10-CM codes should be reported?

The physician is on the hospital floor for the medical management of a 56-year-old patient who he admitted one day ago with chest pain due to aspiration pneumonia. Patient indicates no chest pain at present, but still SOB and some swelling in his lower extremities. Patient was tachypneic yesterday; examination of the lungs reveals course crackles in both bases, right worse than left. The physician writes instructions to continue with intravenous antibiotic treatment and respiratory support with ventilator management. He reviewed chest X-ray and labs that were ordered yesterday. Patient is improving and a pulmonary consultation has been requested. What CPT® code is reported?

A patient is given Xylocaine, a local anesthetic, by injection in the thigh above the site to be biopsied. A small bore needle is then introduced into the muscle, about 3 inches deep, and a muscle biopsy is taken. What CPT® code is reported for this service?

A patient sustained a neck strain as a driver in an automobile accident, losing control, hydroplaning and hitting a tree off the highway which caused the car to overturn. He has continued to have neck pain and stiffness. He sees a chiropractor who assesses the patient and manipulates his neck. The diagnosis is neck strain. What CPT® and ICD-10-CM codes are reported for the chiropractor?

Myocardial Perfusion Imaging (MPI)—Office Based TestIndications: Chest pain.Procedure: Resting tomographic myocardial perfusion images were obtained following injection of 10 mCi of intravenous Cardiolite. At peak exercise, 30 mCi of intravenous Cardiolite was injected, and post-stress tomographic myocardial perfusion images were obtained. Post stress gated images of the left ventricle were also acquired. Myocardial perfusion images were compared in the standard fashion.Findings: This is a technically fair study. There was no stress induced electrocardiographic changes noted. There were no significant reversible or fixed perfusion defects noted. Gated images of the left ventricle reveal normal left ventricular volumes, normal left ventricular wall motion, and an estimated left ventricular ejection fraction of 50%.Impression: No evidence of myocardial ischemia or infarction. Normal left ventricular ejection fraction. What CPT® code(s) is/are reported?

A 27-year-old woman’s regular obstetrician delivers her twins. The first is delivered vaginally but the second is delivered by cesarean delivery. Both are delivered without complications. Patient will return in two weeks for a postpartum visit. What is/are the CPT® code(s) reported for this service?

What is the ICD-10-CM code for swine flu?

A 45-year-old female with malignant Müllerian duct cancer is receiving her first treatment of chemotherapy. What diagnosis codes are reported?