CPC Exam Dumps - Certified Professional Coder (CPC) Exam

A patient has chronic cholesteatoma in the right middle ear. The otolaryngologist performed a tympanoplasty with a radical mastoidectomy, removing the middle ear cholesteatoma. Grafting technique was used to repair the eardrum without ossicular chain reconstruction.

What CPT® code is reported for this surgery?

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® coding is reported?

56-year-old female is postmenopausal with abnormal vaginal bleeding. Ob-gyn provider performs a hysteroscopy to examine the uterine cavity.

What CPT® code is reported?

View MR 002395

MR 002395

Operative Report

Pre-operative Diagnosis: Acute rotator cuff tear

Post-operative Diagnosis: Acute rotator cuff tear, synovitis

Procedures:

1) Rotator cuff repair

2) Biceps Tenodesis

3) Claviculectomy

4) Coracoacromial ligament release

Indication: Rotator cuff injury of a 32-year-old male, sustained while playing soccer.

Findings: Complete tear of the right rotator cuff, synovitis, impingement.

Procedure: The patient was prepared for surgery and placed in left lateral decubitus position. Standard posterior arthroscopy portals were made followed by an anterior-superior portal. Diagnostic arthroscopy was performed. Significant synovitis was carefully debrided. There was a full-thickness upper 3rd subscapularis tear, which was repaired. The lesser tuberosity was debrided back to bleeding healthy bone and a Mitek 4.5 mm helix anchor was placed in the lesser tuberosity. Sutures were passed through the subcapulans in a combination of horizontal mattress and simple interrupted fashion and then tied. There was a partial-thickness tearing of the long head of the biceps. The biceps were released and then anchored in the intertubercular groove with a screw. There was a large anterior acromial spur with subacromial impingement. A CA ligament was released and acromioplasty was performed. Attention was then directed to the

supraspinatus tendon tear. The tear was V-shaped and measured approximately 2.5 cm from anterior to posterior. Two Smith & Nephew PEEK anchors were used for the medial row utilizing Healicoil anchors. Side-to-side stitches were placed. One set of suture tape from each of the medial anchors was then placed through a laterally placed Mitek helix PEEK knotless anchor which was fully inserted after tensioning the tapes. A solid repair was obtained. Next there were severe degenerative changes at the AC joint of approximately 8 to 10 mm. The distal clavicle was resected taking care to preserve the superior AC joint capsule. The shoulder was thoroughly lavaged. The instruments were removed and the incisions were closed in routine fashion. Sterile dressing was applied. The patient was transferred to recovery in stable condition.

What CPT® coding is reported for this case?

A patient is seen at the doctor's office for nausea, vomiting, and sharp right lower abdominal pain. CT scan of the abdomen is ordered. Labs come back indicating an increased WBC count with

review of the abdominal CT scan. The physician determines the patient has chronic appendicitis. The physician schedules an appendectomy and takes the patient to the operating room. The

appendix is severed from the intestines and removed via scope inserted through an umbilical incision. What CPT® and diagnosis codes are reported?

A 43-year-old female with a history of joint pain and fatigue presents to the office with swollen salivary glands. Patient agrees to have a labial gland biopsy performed in office. Patient is

numbed with a local anesthetic. Then an incision is made on the lower labial mucosa and tissue samples from the salivary gland are removed with tweezers. The incision is sutured. Pathology

report findings are consistent with Sjogren's syndrome.

What CPT® code 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 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® and ICD-10-CM code is reported?

Refer to the supplemental information when answering this question:

View MR 874276

What E/M code is reported?