A provider performed an aspiration via thoracentesis on a pa…
A provider performed an aspiration via thoracentesis on a patient in observation status in the hospital. The patient has advanced right lung cancer that has metastasized to the pleura with malignant pleural effusion. Later the same day, due to continued accumulation of fluid, the patient was returned to the procedure room and the same provider performed a repeat thoracentesis. What ICD-10-CM codes are reported?
Read DetailsA 49-year-old female presented with chronic de Quervain’s di…
A 49-year-old female presented with chronic de Quervain’s disease and has been unresponsive to physical therapy, bracing or cortisone injection. She has opted for more definitive treatment. After induction of anesthesia, the patient’s left arm was prepared and draped in the normal sterile fashion. Local anesthetic was injected using a combination 2% lidocaine and 0.25% Marcaine. A transverse incision was made over the central area of the first dorsal compartment. The subcutaneous tissues were gently spread to protect the neural and venous structures. The retractors were placed. The fascial sheath of the first dorsal compartment was then incised and opened carefully. The underlying thumb abductor and extensor tendons were identified. The tissues were dissected and the extensor retinaculum of the first extensor compartment was incised. The fibrotic tissue was incised and the tendons gently released. The tendons were freely moving. Subcutaneous tissues were closed with a 3-0 Vicryl and the skin with 3-0 Prolene subcuticular closure. Steri-strips, Xeroform and dry sterile dressings were applied. What CPT® code is reported?
Read DetailsA 14-year-old boy was thrown against the window of the car o…
A 14-year-old boy was thrown against the window of the car on impact. The resulting injury was a star-shaped pattern cut to the top of his head. In the ED, the MD on call for plastic surgery was asked to evaluate the injury and repair it. The total length of the intermediate repair was 5+4+4+5 cm (18 cm total). The star-like shape allowed the surgeon to pull the wound edges together nicely in a natural W-plasty in two spots. What CPT® code is reported for the repair?
Read DetailsA patient with a long history of endometriosis has an open s…
A patient with a long history of endometriosis has an open surgical approach to perform an exploratory laparotomy for an enlarged right ovary seen on ultrasound with other possible masses on the uterus and in the peritoneum. Exploration reveals these masses to be endometriosis of the right ovary, right fallopian tube, and peritoneum. The cysts are all small, and laser is used to ablate them, except the ovarian cyst, which is excised. The total sum of the cysts is 6 cm. During the procedure the patient also has a tubal ligation. What are the CPT® and ICD-10-CM codes reported for this service?
Read DetailsA young male was brought to the clinic by his mom. He has ha…
A young male was brought to the clinic by his mom. He has had periods of major depression for many years and is on Lithium. His provider also manages his migraine headaches and epilepsy. During the past week, he became psychotic, hearing voices to kill himself and intense feelings of worthlessness. On the day of the clinic visit, he had an epileptic seizure that could not be controlled by medication. He was admitted for Lithium adjustment. Final diagnoses are: Severe depression with psychotic behavior and epileptic seizure poorly controlled with medication. What ICD-10-CM codes should be reported?
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