This patient presented with internal derangement of the left…
This patient presented with internal derangement of the left knee. After satisfactory anesthesia was administered for the arthroscopic procedure, the left lower extremity was prepped and draped in a sterile fashion. Routine portals were made in the knee. We first looked at the medial compartment which showed a complex small tear of the posterior horn of the medial meniscus. This was debrided using a 4.0 meniscal shaver. There was an area of grade 4 chondromalacia on the proximal medial distal femur and this was all the way down to bone. There was also evidence of chondromalacia over the patellofemoral joint of grade 4. This area was drilled with a 0.45 K-wire. Multiple drill holes were placed in an attempt to get some scar tissue to form. The notch area was normal and lateral compartment normal. Following microfracture technique, the knee was irrigated, each portal was closed with 4-0 nylon and the patient was taken to recovery. What CPT® codes are reported?
Read DetailsA 72-year-old female sustained a left radius fracture, resul…
A 72-year-old female sustained a left radius fracture, resulting in volar angulation, radial shortening and loss of radioulnar inclination. A general anesthetic was administered. A standard dorsal central approach to the wrist was made. The capsule was opened in a T fashion and the malunion site was identified. A series of osteotomes was utilized to open the fracture site and the normal distal radial architecture was restored. The pie-plate was placed on the distal radius utilizing a combination of 2.0 and 1.8 screws and threaded pins for the distal segment and 2.7 screws proximally. Fragments were secured, and Norian SRS was packed into the defect and allowed to harden. With this completed, the wounds were copiously irrigated with normal saline. Soft tissue was closed over the plate and distal radius and secured with 2-0 Vicryl. What CPT® code is reported?
Read DetailsA 5-year-old is brought to the Emergency Department by ambul…
A 5-year-old is brought to the Emergency Department by ambulance, He had been found floating in a pool for an unknown amount of time. EMS started CPR which was continued by the ED provider along with endotracheal intubation and placement of a CVC. The ER provider spent 1 hour with the critically ill patient. The ED provider makes a notation the 1 hour does not include the time for the other separate billable services. What CPT® codes are reported?
Read DetailsA 33-year-old patient visits his primary care provider to di…
A 33-year-old patient visits his primary care provider to discuss a lap band procedure for his morbid obesity. His caloric intake is in excess of 4,000 calories per day and his BMI is currently 45. What ICD-10-CM code(s) is/are reported?
Read DetailsA 70-year-old female patient presents with a complaint of le…
A 70-year-old female patient presents with a complaint of left knee pain with weight bearing activities. She is also developing pain at rest. She denies any recent injury. There is pain with stair climbing and start up pain. AP, lateral and sunrise views of the left knee are ordered and interpreted. The diagnosis is left knee pain secondary to underlying primary degenerative arthritis. What ICD-10-CM code(s) is/are reported?
Read DetailsThe provider sees a 70-year-old patient with a documented hi…
The provider sees a 70-year-old patient with a documented history in the past few months of being combative and agitated in the nursing home. The provider diagnoses the patient with dementia and refers the patient to a neurologist for further evaluation on her combative and agitated behavior. What ICD-10-CM code(s) is/are reported?
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