A patient receives 200 mg IM Depo-Testosterone.
What HCPCS Level II coding is reported?
Preoperative diagnosis: Right thigh benign congenital hairy nevus. *1
Postoperative diagnosis: Right thigh benign congenital hairy 0 nevus.
Operation performed: Excision of right thigh benign congenital>1
nevus, excision size with margins 4.5 cm and closure size 5 cm.
Anesthesia: General.0
Intraoperative antibiotics: Ancef.0
Indications: The patient is a 5-year-old girl who presented with her parents for evaluation of her right thigh congenital nevus. It has been followed by pediatrics and thought to have changed over the past year. Family requested excision. They understood the risks involved, which included but were not limited to risks of general
anesthesia, infection, bleeding, wound dehiscence, and poor scar formation. They understood the scar would likely widen as the child grows because of the location of it and because of the age of the patient. They consented to proceed.
Description of procedure: The patient was seen preoperatively in > I the holding area, identified, and then brought to the operating room. Once adequate general anesthesia had been induced, the patient's right thigh was prepped and draped in standard surgical fashion. An elliptical excision measuring 6 x 1.8 cm had been marked. This was injected with Lidocaine with epinephrine, total of 6 cc of 1% with 1:100,000. After an adequate amount of time, a #15 blade was used to sharply excise this full thickness.
This was passed to pathology for review. The wound required □ limited undermining in the deep subcutaneous plane on both sides for approximately 1.5 cm in order to allow mobilization of the skin for closure. The skin was then closed in a layered fashion using 3-0 Vicryl on the dermis and then 4-0 Monocryl running subcuticular in the skin, the wound was cleaned and dressed with Dermabond and Steri-Strips.
The patient was then cleaned and turned over to anesthesia for S extubation.
She was extubated successfully in the operating room and taken S to the recovery room in stable condition. There were no complications.
Which CPT® and ICD-10-CM codes are reported for this procedure?
A diagnostic mammogram is performed on the left and right breasts. Computer-aided detection is also used to further analyze the image for possible lesions.
What CPT® coding is reported for this radiology service?
A patient is diagnosed with a pressure ulcer on her right heel that is currently being treated.
What ICD-10-CM code is reported?
A patient is taken to the radiology department for a radiological cardiac catheterization. An acute MI of the left anterior descending coronary artery is found. The cardiologist performs a suction thrombectomy, followed by atherectomy and a stent to the artery. A CRNA provides MAC for this patient, who is status P5.
What code/modifier combination would you report for the services of the CRNA?
A patient has a 5 cm tumor in the left lower quadrant abdominal wall, excised through dermis and subcutaneous tissue. Pathology is pending to rule out cancer.
What CPT® and ICD-10-CM codes are reported?
A patient has five biopsies performed on the duodenum.
What CPT® coding is reported?
Dr. Meredith sees Mr. Hollis (new patient) for the first time In the Community Rest Home. She documents a visit with medical decision making of moderate complexity. She spends 20 minutes of additional time discussing physical therapy and going over medications. Dr. Meredith spends a total of 90 minutes on that patient that day.
What CPT® coding does Dr. Meredith report?
A patient undergoes CABG using the right internal mammary artery anastomosed to three coronary arteries.
What CPT® coding is reported?
A 44-year-old female patient with chest pains had a CT of her chest that identified a mass in her left lower lung. The patient currently has ovarian cancer with metastases to the liver. The radiologist suspects the cancer has spread to her lungs. The physician performed an outpatient bronchoscopic biopsy and the pathology report documents the mass as a tumor of uncertain behavior.
What ICD-10-CM codes are reported for this patient?
