Patient is a sweet 2 1/2-year-old boy with meatal stenosis. Patient is brought to the operating room and placed supine on the operating room table. After adequate general endotracheal anesthesia was accomplished, he was prepped and draped in the usual sterile fashion. A clamp was placed just inferior ventrally to his stenotic meatus after the dorsal penile block had been administered. We then cut the clamped area to allow for a widely spatulated urethral meatus. Skin edges were approximated and patient was sent to the recovery room in good condition. What CPT® code is reported for this service?

A patient has a fine needle aspiration with the specimen sent to cytopathology for examination. Once the specimen is reviewed, it is found to be inadequate to perform the test. A new specimen must be obtained which is then examined and a diagnosis is confirmed. What modifier is appropriate to indicate that two specimens were examined?

What ICD-10-CM code is reported for personal history of transitional cell carcinoma of the bladder?

A female patient was taken to the emergency room for severe abdominal pain, nausea and vomiting. A WBC (white blood cell count) was taken and the results showed an elevated WBC count. The general surgeon suspected appendicitis and performed an emergency appendectomy. The patient had extensive adhesions secondary to two previous Cesarean deliveries. Dissection of this altered the anatomical field and required the surgeon to spend 40 additional intraoperative minutes. The surgeon discovered the appendix was not ruptured nor was it hot. Extra time was documented in order to thoroughly irrigate the peritoneum. What CPT® and ICD-10-CM codes are reported?

A 27-year-old girl has been on the lung transplant list for months and today she will be receiving a LT and RT lung from an individual involved in an MVA. This person was DOA at the hospital and is an organ donor. The donor pneumonectomy was performed by physician A, the backbench work by physician B and the transplant of both lungs into the prepped and waiting patient by physician C. What is the correct coding for the removal (physician A), preparation (physician B) and insertion (physician C) of the lungs?

A post-MI (myocardial infarction) patient has been receiving cardiac rehabilitation. At this session the provider evaluates the patient, determines he shows satisfactory progress and may increase his normal daily activities. Continuous EKG is not used at this session. What CPT® code is reported?

In the cardiac suite, an electrophysiologist performs an EP study. With programmed electrical stimulation, the heart is stimulated to induce arrhythmia. Observed is right atrial and ventricular pacing, recording of the bundle of His, right atrial and ventricular recording and left atrial and ventricular pacing and recording from the left atrium. What CPT® coding is reported?

What is a dime sized opening in the skull to access the brain called?

The patient was taken to the operating room. The provider everts the upper eyelid and places clamps across the everted undersurface of the upper lid. The tissue distal to the clamps is excised or resected. This tissue includes conjunctiva, tarsus, Muller’s muscle and the distal insertion of the levator aponeurosis. The remaining tissue is reattached and sutured. What CPT® code is reported?

A pregnant female is Rh negative and at 28 weeks gestation. The child’s father is Rh positive. The mother is given an injection of a high-titer Rho (D) immune globulin, 300 mcg, IM. What CPT® and ICD-10-CM codes are reported?