A patient with AML (Acute Myelogenous Leukemia) has just lea…
A patient with AML (Acute Myelogenous Leukemia) has just learned his sister is an HLA (Human Leukocyte Antigen) match for him. Stem cells taken from the donor (the patient’s sister) will be transplanted into the patient to help with his treatment. What CPT® code is used to report the harvesting of the stem cells from the donor (his sister)?
Read DetailsPatient presents with no menses and positive pregnancy test…
Patient presents with no menses and positive pregnancy test but ultrasound finds no uterine contents. Embryo has implanted on left ovary and this is treated with laparoscopic oophorectomy. What are the CPT® and ICD-10-CM codes reported for this procedure? Do not code the ultrasound.
Read DetailsOperative Report PREOPERATIVE DIAGNOSIS: Prolapsed vitreo…
Operative Report PREOPERATIVE DIAGNOSIS: Prolapsed vitreous in anterior chamber with corneal edema POSTOPERATIVE DIAGNOSIS: Same OPERATION PERFORMED: Anterior vitrectomy The patient is a 72-year-old woman who approximately 10 months ago underwent cataract surgery with a YAG laser capsulotomy, developed corneal edema and required a corneal transplant. The patient has done well. Over the last few weeks, she developed posterior vitreous detachment with vitreous prolapse to the opening in the posterior capsule with vitreous into the anterior chamber with corneal touch and adhesion to the graft host junction and early corneal edema. The patient is admitted for anterior vitrectomy.PROCEDURE: The patient was prepped and draped in the usual manner after first undergoing retrobulbar anesthetic. A lid speculum was inserted. An incision was made at approximately the 10 o’clock meridian 3 mm in length, 2 mm posterior to the limbus, and grooved forward into clear cornea with a 3.2 mm anterior chamber. An anterior vitrectomy was carried out, placing a visco-elastic substance in the anterior chamber to maintain it. A Sinskey hook was used to sweep vitreous away from the corneal wound and this was removed with the disposable vitrectomy instrument. The patient’s pupil is noted to be round. There was no vitreous to the wound. The wound self-sealed without aqueous leak. Cautery was used to close the conjunctiva. Subconjunctival Decadron and Gentamicin was given. The patient tolerated the procedure well and was discharged to the recovery room in good condition. What CPT® code(s) is/are reported?
Read DetailsA 47-year-old female presents to the OR for a partial corpec…
A 47-year-old female presents to the OR for a partial corpectomy to three thoracic vertebrae. One surgeon performs the transthoracic approach while another surgeon performs the three vertebral nerve root decompressions necessary. How should each provider involved code their portion of the surgery?
Read DetailsA 36-year-old male suffered back pain after heavy lifting an…
A 36-year-old male suffered back pain after heavy lifting and was found to have bilateral disc herniation. The patient was placed prone and general anesthesia given. Incision was then made with a 10-blade knife and dissection was carried downward through the thick adipose tissue to the fascia in a subperiosteal plane. The paraspinous muscles were reflected off L5 and S1. A laminotomy was drilled with the Midas Tex AMB on the inferior end of L5. The thecal sac was retracted medially. The microscope was brought in, direct with microdissection there was a massive disk herniation on the right side underneath the nerve root as well as the left. The disc was incised with an 11-blade knife and was cleaned out with a series of straight and angled curettes and rongeurs. The disc was intertwined with the posterior longitudinal ligament. The space was cleaned out, the foramina were checked and no further compression was found on any of the neural elements. What CPT® codes are reported for this procedure?
Read DetailsA soccer player hits his head during an indoor game and is a…
A soccer player hits his head during an indoor game and is admitted to observation to watch for head trauma. Admit date/time: 01/21/20XX 8:12 PMMedically appropriate history and exam Low MDMDischarge date/time: 01/22/20XX 8:15 AMDischarge time: 20 minutesWhat CPT® coding is reported for the admission and discharge in Observation Care?
Read DetailsA 64-year-old patient came to the emergency department compl…
A 64-year-old patient came to the emergency department complaining of chest pressure. The provider evaluated the patient. Appropriate initial management was continued by the ED provider who contacted the cardiologist on call in the hospital. Admission to the cardiac unit was ordered. No beds were available in the cardiac unit and the patient was held in the ED. The cardiologist left the ED after completing the evaluation of the patient and had interpreted the findings of an EKG that indicated signs of acute cardiac damage. Several hours passed and the patient was still in the ED. During an 80-minute period, the patient experienced acute breathing difficulty, increased chest pain, arrhythmias, and cardiac arrest. The patient was managed by the ED provider during this 80-minute period. Included in the ED provider management were endotracheal intubation and CPR to restore the patient’s breathing and circulation for 20 minutes. CPR was unsuccessful, the patient was pronounced dead after a total of 44 minutes critical care time, exclusive of other separately billable services. What CPT® codes are reported by the ED provider?
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