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?

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?

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?

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?

What is the ICD-10-CM code for a patient with postoperative anemia due to acute blood loss during the surgery who needs a blood transfusion?

A patient sees his primary care provider for chest pain and regurgitation. The provider’s diagnosis for the patient is gastroesophageal reflux. What diagnosis code(s) should be reported?

A 25-year-old male is brought by EMS to the Emergency Department for nausea and vomiting. Patient has elevated blood sugars and the ED provider is unable to get a history due to patient’s altered mental status. A medically appropriate exam is performed and the MDM is high. The patient was stabilized and transferred to ICU under a different provider. The ED provider documents total critical care time 25 minutes. What CPT® coding is reported?

A patient presents with a 2 cm benign lip lesion. The provider decides to remove the lesion along with a portion of the lip by performing a wedge excision. Single-layer suture repair is performed. What CPT® code(s) is/are reported for this service?

Patient with coronary arteriosclerosis disease (CAD) sees his cardiologist to discuss a coronary artery bypass graft (CABG). This will be the patient’s first CABG. What ICD-10-CM code is reported?

Most of the codes in ICD-10-CM Chapter 13 Diseases of the Musculoskeletal System and Connective Tissue have site and laterality designations. According to ICD-10-CM guidelines what is considered the site?