Operative Report:Pre-Operative Diagnoses:        Basal Cell Carcinoma, forehead Basal Cell Carcinoma, right cheekSuspicious lesion, left noseSuspicious lesion, left forehead Post-Operative Diagnoses:        Basal Cell Carcinoma, forehead with clear margins Basal Cell Carcinoma, right cheek with clear marginsCompound nevus, left nose with clear marginsEpidermal nevus, left forehead with clear margins INDICATIONS FOR SURGERY: The patient is a 47-year-old white man with a biopsy proven basal cell carcinoma of his forehead and a biopsy proven basal cell carcinoma of his right cheek. We were not quite sure of the patient’s location of the basal cell carcinoma of the forehead whether it was a midline lesion or lesion to the left. We felt stronger about the midline lesion, so we marked the area for elliptical excision in relaxed skin tension lines of his forehead with gross normal margins of 1-2 mm and I marked the lesion of the left forehead for biopsy. He also had a lesion of his left alar crease we marked for biopsy and a large basal cell carcinoma of his right cheek, which was more obvious. This was marked for elliptical excision with gross normal margins of 2-3 mm in the relaxed skin tension lines of his face. I also drew a possible rhomboid flap that we would use if the wound became larger. He observed all these margins in the mirror, so he could understand the surgery and agree on the locations, and we proceeded.DESCRIPTION OF PROCEDURE: All four areas were infiltrated with local anesthetic. The face was prepped and draped in sterile fashion. I excised the lesion of the forehead measuring 6 mm and right cheek measuring 1.3 cm as I had drawn them and sent in for frozen section. The biopsies were taken of the left forehead and left nose using a 2-mm punch, and these wounds were closed with 6-0 Prolene. Meticulous hemostasis was achieved of those wounds using Bovie cautery. I closed the cheek wound first. Defects were created at each end of the wound to facilitate primary closure and because of this I considered a complex repair and the wound was closed in layers using 4-0 Monocryl, 5-0 Monocryl and 6-0 Prolene, with total measurement of 2.1 cm. The forehead wound was closed in layers using 5-0 Monocryl and 6-0 Prolene, with total measurement of 1.0 cm. Loupe magnification was used and the patient tolerated the procedure well.What ICD-10-CM codes are reported?

Preoperative Diagnosis: Coronary artery disease associated with congestive heart failure. In addition, the patient has diabetes and massive obesity.Postoperative Diagnosis: SameAnesthesia: General endotracheal Incision: Median sternotomy Indications: The patient had presented with severe congestive heart failure associated with her severe diabetes. She had significant coronary artery disease, consisting of a chronically occluded right coronary artery but a very important large obtuse marginal artery coming off as the main circumflex system. She also has a left anterior descending artery which has moderate disease and this supplies quite a bit of collateral to her right system. The decision was therefore made to perform a coronary artery bypass grafting procedure particularly because she is so symptomatic. The patient was brought to the operating room.Description of Procedure: The patient was brought to the operating room and placed in supine position. Myself, the operating surgeon was scrubbed throughout the entire operation. 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. The patient weighs almost three hundred pounds and with her obesity there was some concern as to taking down the left internal mammary artery. Because the radial artery appeared to be a good conduit, she should have an arterial graft to the left anterior descending artery territory. She was cannulated after the aorta and atrium were exposed and after full heparinization.Attention was turned to the coronary arteries. The first obtuse marginal artery was a very large target and the 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 left anterior descending artery does not have severe disease but is also a very good target, and the radial artery was anastomosed to this target, and the proximal anastomosis was then carried out to the root of the aorta.Sternal closure was then done using wires. The subcutaneous layers were closed using Vicryl suture. The skin was approximated using staples. What CPT® coding is reported?

A 33-year-old male was admitted to the hospital on 12/17/XX from the ER following a motor vehicle accident. His spleen was severely damaged and a splenectomy was performed. The patient is being discharged from the hospital on 12/20/XX. During his hospitalization the patient experienced pain and shortness of breath, but with an antibiotic regimen of Levaquin, he improved. The attending provider performed a final examination and reviewed the chest X-ray revealing possible infiltrates and a CT of the abdomen ruled out any abscess. He was given a prescription of Zosyn. The patient was told to follow up with his PCP or return to the ER for any pain or bleeding. The provider spent 20 minutes on the date of discharge. What CPT® code is reported for the 12/20 visit?

A 49-year-old female was brought to the emergency department. She was lethargic, but awake. She is four years post liver transplant. Neurology was consulted who determined the patient was encephalopathic with altered mental status. There was some question whether she had a seizure. An EEG and WADA test were performed. What CPT® and ICD-10-CM codes are reported?

The patient presents with a recurrent infection of the Bartholin’s gland which has previously been treated with antibiotics and I&D. At this visit her gynecologist incises the cyst, draining the material from it and tacks the edges of the cyst open creating an open pouch to prevent recurrence. How is this procedure coded?

The provider performs an iridotomy using laser on both eyes for chronic angle closure glaucoma that is moderate; procedure includes local anesthesia. What CPT® and ICD-10-CM codes are reported?

A patient mangled his left hand in machinery requiring amputation at the wrist. The wound has healed and the patient is fitted with an artificial hand. The device has a molded socket, flexible elbow hinges and triceps pad. A total of 30 minutes was spent training the patient to use the prosthesis. What codes are reported for the prosthesis, training and diagnosis?

What external cause code(s) are reported for a passenger involved in an MVA that lost control on the highway and hit a guardrail?

A 55-year-old female smoker presents with cough, hemoptysis, slurred speech and weight loss. Chest X-ray done today demonstrates a large, unresectable right upper lobe mass, and brain scan is suspicious for metastasis. Under fluoroscopic guidance in an outpatient facility, a percutaneous needle biopsy of the right lung lesion is performed for histopathology and tumor markers. A diagnosis of small cell carcinoma is made and chemoradiotherapy is planned. What CPT® and ICD-10-CM codes are reported?

What ICD-10-CM code is reported for suppurative otitis media in the right ear?