A patient is brought to the operating suite when she experie…
A patient is brought to the operating suite when she experiences a large output of blood in her chest tubes post CABG. The physician performing the original CABG yesterday is concerned about the post-operative bleeding. He explores the chest and finds a leaking anastomosis site and he resutured. What CPT® code is reported?
Read DetailsMrs. Smith is visiting her mother and is 150 miles away from…
Mrs. Smith is visiting her mother and is 150 miles away from home. She is in the 26th week of pregnancy. In the late afternoon she suddenly feels a gush of fluids followed by strong uterine contractions. She is rushed to the hospital but the baby is born before they arrive. In the ED she and the baby are examined and the retained placenta is delivered. The baby is in the neonatal nursery doing okay. Mrs. Smith has a 2nd degree perineal laceration secondary to precipitous delivery which was repaired by the ED physician. She will return home for her postpartum care. What ICD-10-CM and CPT® codes are reported by the ED physician?
Read DetailsA patient with congestive heart failure and chronic respirat…
A patient with congestive heart failure and chronic respiratory failure with hypoxia is placed on home oxygen. Prescribed treatment is 2L nasal cannula oxygen at all times. A home care nurse visited the patient to assist with his oxygen management. What CPT® and ICD-10-CM codes are reported?
Read DetailsOperative ReportDiagnosis: Basal Cell CarcinomaProcedure: Mo…
Operative ReportDiagnosis: Basal Cell CarcinomaProcedure: Mohs micrographic excision of skin cancer.Site: Face left lateral upper canthus eyelidPre-operative size: 0.8 cmIndications for surgery: Area of high recurrence, area of functional and/or cosmetic importance. Discussed procedure including alternative therapy, expectations, complications, and the possibility of a larger or deeper defect than expected requiring significant reconstruction. Patient’s questions were answered. Local anesthesia 1:1 Marcaine and 1% Lidocaine with Epinephrine. Sterile prep and drape.Stage 1: The clinically apparent lesion was marked out with a small rim of normal appearing tissue and excised down to subcutaneous fat level with a defect size of 1.2 cm. Hemostasis was obtained and a pressure bandage placed. The tissue was sent for slide preparation. Review of the slides show clear margins for the site.Repair: Complex repair. Repair of Mohs micrographic surgical defect. Wound margins were extensively undermined in order to mobilize tissue for closure. Hemostasis was achieved. Repair length 3.4 cm. A layered closure was performed. Multiple buried absorbable sutures were placed to re-oppose deep fat. The epidermis and dermis were re-opposed using monofilament sutures. There were no complications; the patient tolerated the procedure well. Post-procedure expectations (including discomfort management), wound care and activity restrictions were reviewed. Written Instructions with urgent contact numbers given, follow-up visit and suture removal in 3-5 daysWhat CPT® and ICD-10-CM codes are reported?
Read DetailsA 45-year-old woman suffers with chronic migraines that have…
A 45-year-old woman suffers with chronic migraines that have been unresponsive to traditional medication. She is referred to have acupuncture as an alternative treatment method. During the first session, the provider uses five needle insertions without electrical stimulation in an attempt to alleviate the patient’s migraine symptoms. The session lasts for 15 minutes. What CPT® code is reported?
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