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A patient arrived at the emergency department experiencing pain in both legs. The ED physician ordered a comprehensive duplex scan of the arteries in both lower extremities to rule out arteriosclerosis.
What CPT® and ICD-10-CM codes are reported?
A 25-year-old woman underwent percutaneous breast biopsy on the right breast with placement of a Gelmark clip. The procedure was performed using stereotactic imaging.
What CPT® codes will be reported?
A 45-year-old patient presents with right shoulder pain. The provider administers three trigger point injections in the trapezius muscle and two in the pectoralis muscle.
What CPT® coding is reported?
A patient was in a car accident as the driver and suffered a concussion with brief loss of consciousness (15 minutes). What ICD-10-CM codes are 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 â–¡ 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.
What CPT® codes are reported?
A 65-year-old gentleman presents for refill of medications and follow-up for his chronic conditions. The patient indicates good medicine compliance. No new symptoms or complaints.
Appropriate history and exam are obtained. Labs that were ordered from previous visit were reviewed and discussed with patient. The following are the diagnoses and treatment:
Hypokalemia - stable. Refill Potassium 20 MEQ
Hypertension - blood pressure remaining stable. Patient states home readings have been in line with goals. Refill prescription Lisinopril.
Esophageal Reflux - Patient denies any new symptoms. Stable condition. Continue taking over the counter Prevacid oral capsules, 1 every day.
Patient is instructed to follow up in 3 months. Labs will be obtained prior to visit.
What CPT® code is reported?
A patient undergoes a percutaneous liver biopsy with ultrasound guidance for primary biliary cirrhosis.
What CPT® and ICD-10-CM codes are reported?
Ms. C is diagnosed with a supratentorial intracerebral hematoma, and the neurologist performs a craniectomy to access the hematoma. The hematoma is accessed, and a suction device is
used to remove it.
What CPT@ code is reported?