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A patient has a history of MRSA. She has just been diagnosed…

A patient has a history of MRSA. She has just been diagnosed with pneumonia due to possible staphylococcus aureus. What ICD-10-CM code(s) is/are reported?

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If a non-Medicare patient has an age and gender appropriate…

If a non-Medicare patient has an age and gender appropriate preventive medicine exam (i.e., a breast and pelvic exam) this is coded with the age appropriate Preventive Medicine codes from the E/M chapter of CPT®. If a Medicare patient has a breast and pelvic exam, how is this coded?

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A patient with AIDS presents for follow up care. The total T…

A patient with AIDS presents for follow up care. The total T-cell count is ordered to evaluate any progression of the disease. What CPT® code(s) is/are reported?

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A patient presents for extremity venous study. Complete noni…

A patient presents for extremity venous study. Complete noninvasive physiologic studies of both lower extremities were performed. Which CPT® code is reported?

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Splenorrhaphy is:

Splenorrhaphy is:

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A patient has benign prostatic hyperplasia with urinary rete…

A patient has benign prostatic hyperplasia with urinary retention. What ICD-10-CM code(s) is/are reported?

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The skin over the left groin was prepped and draped in a ste…

The skin over the left groin was prepped and draped in a sterile fashion and anesthetized with 1% Xylocaine. Through a right femoral artery access, a 5 French pigtail catheter was placed in the abdominal aorta and a run-off was performed following injection of 80cc of contrast. Oblique DSA images of the iliac circulation were performed following two injections, each 15cc.Findings: Abdominal aorta: no signs of renal artery stenosis. There is mild atheromatous change involving the lower abdominal aorta. There are two eccentric plaques arising from the distal aorta just above the iliac bifurcation. There are high-grade stenoses involving both proximal iliacs, the right far more pronounced than the left.The right superficial femoral, profunda femoral, popliteal arteries are normal. The trifurcation vessels are unremarkable.On the left, there is an eccentric plaque in the common femoral artery just below the catheter entrance site. This creates approximately 40-50% stenosis at this site. The remainder of the proximal femoral artery is normal. The trifurcation vessels and popliteal artery are normal. What CPT® codes are reported?

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Procedure: Colectomy with a take-down of splenic flexure.Th…

Procedure: Colectomy with a take-down of splenic flexure.The patient was taken to the operating room, placed in the dorsal lithotomy position, and then prepped and draped in the usual sterile fashion. A vertical paramedian incision was made along the left side of the umbilicus from the symphysis and taken up to above the umbilicus. This incision was carried down to the rectus muscles, which were separated in the midline. The peritoneal cavity was entered with findings as described. The ascitic fluid was removed and hand-held retractors were used to assist in surgical exposure. The malignant intra-abdominal tumor was resected from the hepatic flexure into the mid transverse colon. The resection was extended into the left upper quadrant and the attachments were also clamped, cut and suture ligated with 2-0 silk sutures in a stepwise fashion until mobilization of the tumor mass could be brought medial and hemostasis was obtained. Attempts to find a dissection plane between the malignant tumor mass and the transverse colon were unsuccessful as it appeared the tumor mass was invading into the wall of the bowel with extrinsic compression and distortion of the bowel lumen.Given the mass could not be resected without removal of bowel, attention was directed to mobilization of the splenic flexure. Retroperitoneal dissection was started in the pelvis and continued along the left paracolic gutter. The ligamentous and peritoneal attachments were taken down with Bovie cautery in a stepwise fashion around the splenic flexure of the colon until the entire left colon was mobilized medially. Similar steps were then carried on the right side as the right colon and hepatic flexure were mobilized. The peritoneal and ligamentous attachments were taken down with Bovie cautery. Vascular attachments were clamped, cut, and suture ligated with 2-0 silk until the right colon was mobilized satisfactorily. The GIA stapler was introduced and fired at both ends to dissect the tumorous bowel free. The bowel was delivered off the operative field. Attention was then directed towards re-anastomosis of the colon. Linen-shod clamps were used to gently clamp the proximal and distal segments of the large bowel. The staple line was removed with Metzenbaum scissors and the colon lumen was irrigated. The silk sutures were used to divide the circumference of the bowel into equal thirds, and the proximal and distal edges of the bowel were reapproximated with silk sutures. The posterior segment of the bowel was then retracted and secured with a TA stapler, ensuring a full thickness bowel wall insertion into the staple line. The additional two-thirds were also isolated and, with the TA stapler, clamped, ensuring that all layers of the bowel wall were incorporated into the anastomosis. A third staple line was fired and the integrity of the anastomosis was checked. First, complete hemostasis was noted. There was well beyond a finger width lumen within the large bowel. The linen-shod clamps were released and gas and bowel fluid were moved through the anastomosis aggressively with intact staple line; no leakage of gas or fluid. The abdomen was then irrigated and water was left over the anastomosis. The anastomosis was manipulated with no extravasation of air. The abdomen and pelvis were then irrigated aggressively. The Mesenteric trap was then re-approximated with interrupted 3-0 silk suture ligatures. All sites were inspected and noted to be hemostatic. Attention was directed towards closing.Pathology report showed intra-abdominal cancer. Transverse colon and hepatic flexure cancer were also indicated. The origin of the cancer could not be determined from the specimen given.What is the correct CPT® and ICD-10-CM coding for this report?

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The patient is a 53-year-old male with benign prostatic hype…

The patient is a 53-year-old male with benign prostatic hypertrophy causing urinary obstruction and requires the placement of a temporary urethral stent. What CPT® code is reported for this service?

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In ICD-10-CM, what classification system is used to report o…

In ICD-10-CM, what classification system is used to report open fracture classifications?

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