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Dr. Howitzer sees Mrs. Jones in Clinic Eight for sudden loss…

Dr. Howitzer sees Mrs. Jones in Clinic Eight for sudden loss of consciousness while watching the Olympic Torch go by. He is a new provider to the neurology department. Dr. Drake Rinaldi, a prominent member of the neurology faculty at the university saw Mrs. Jones last month. Dr. Howitzer performs a medically appropriate history and exam. Medical decision making is of high complexity. The final diagnosis given is transient loss of consciousness. The patient makes a follow-up appointment to see Dr. Rinaldi in one week. What is the appropriate diagnosis and E/M code for this visit?

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Patient is a 53-year-old female who yesterday underwent Mohs…

Patient is a 53-year-old female who yesterday underwent Mohs surgery with Dr. Smith to remove a basal cell carcinoma of her scalp. Due to the size of the defect Dr. Smith requested a Plastic Surgeon to reconstruct the site. Dr. Jones discussed with the patient his planned closure, which was a Ying-Yang type flap. The patient agreed and we proceeded. The area was prepped and draped in a sterile fashion being careful to keep betadine solution out of the open wound. Wound preparation was done by excising an additional 1 mm margin to freshen the wound and excising the wound deeper. Starting on the right, Dr. Jones incised his planned flap, elevating the flap with full-thickness and subcutaneous fat, staying superior to the galea. Then Dr. Jones incised his planned flap on the left elevating the flap with full-thickness and subcutaneous fat. Both flaps were rotated together and the wound was temporarily closed using the skin stapler. Once it was determined there was minimal tension on the wound, the galea was approximated using 4.0 Monocryl. The wound was then closed in layers using 5-0 Monocryl and a 35R skin stapler. Meticulous hemostasis was achieved through-out the procedure with the Bovie cautery. Final measurements of the wound were 36.25 cm2. What CPT® code(s) is/are reported?

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What part of the cardiovascular system is responsible for th…

What part of the cardiovascular system is responsible for the one-way flow of blood through the chambers of the heart?

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Which anatomic position has the patient lying at an angle in…

Which anatomic position has the patient lying at an angle instead of lying flat or directly on their side?

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What CPT® code(s) would best describe treatment of 9 plantar…

What CPT® code(s) would best describe treatment of 9 plantar warts removed and 6 flat warts all destroyed with cryosurgery during the same office visit?

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Tests in the Chemistry section of CPT® are what types of tes…

Tests in the Chemistry section of CPT® are what types of tests unless specified otherwise?

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A 6-year-old patient is seen in the office for acute otitis…

A 6-year-old patient is seen in the office for acute otitis media, coded as H66.90. This is an example of what ICD-10-CM convention?

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What ICD-10-CM code is reported for pyopneumothorax with fis…

What ICD-10-CM code is reported for pyopneumothorax with fistula?

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A 32-year-old patient sees Dr. Smith for a consult at the re…

A 32-year-old patient sees Dr. Smith for a consult at the request of his PCP, Dr. Long, for an ongoing problem with allergies. The patient has failed Claritin and Alavert and feels his symptoms continue to worsen. Dr. Smith performs medically appropriate history and exam and discusses options with the patient on allergy management. The patient agrees he would like to be tested to possibly gain better control of his allergies. Dr. Smith sends a report to Dr. Long thanking him for the referral and includes the date the patient is scheduled for allergy testing. Dr. Smith also includes his findings from the encounter. What E/M code is reported?

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A 35-year-old patient presented to the outpatient hospital f…

A 35-year-old patient presented to the outpatient hospital for PTA of an obstructed hemodialysis AV graft in the venous anastomosis and the immediate venous outflow. The procedure was performed under moderate sedation administered by the physician performing the PTA. The physician performed all aspects of the procedure, including radiological supervision and interpretation. Code for all services performed.

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