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?

Which of the following choices is NOT a benefit of an active compliance plan?

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?

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?

What does the abbreviation MAC stand for?

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?

A 52-year-old female is sent to radiology for a lymphangiography of both arms. The patient has swelling in both arms which is suspected to be lymphangitis. She also has a history of breast cancer having had a double mastectomy 5 years ago. What CPT® and ICD-10-CM codes are reported?

A male patient is seen by his primary care provider for rectal bleeding and persistent intestinal cramps. After a colonoscopy with biopsy, the results come back and the provider documents that the patient has malignant neoplasm in his sigmoid colon. What ICD-10-CM code(s) is/are reported?

A patient is diagnosed with actinic keratosis of the chest and arms. She presents to her physician’s office for destruction of these lesions. Using cryosurgery, the physician destroys 4 lesions on the right arm, 4 lesions on the left forearm and 4 lesions on the chest. What CPT® and ICD-10-CM codes are reported?

A 35-year-old woman is experiencing dizziness with nausea and vomiting. The provider documents auditory vertigo of both ears, possible Meniere’s disease. What ICD-10-CM code(s) is/are reported?