Which place of service code is submitted on the claim for a service that is performed in an outpatient surgical floor?
A 47-year-old female presents to the operating room for a partial corpectomy on one upper thoracic vertebral body, T3. Two surgeons are performing the surgery. One surgeon performs the transthoracic approach and excises the damaged portion of the vertebral body. The second surgeon inserts a bone graft into the vertebral gap, closing the gap, and inserts a metal plate. Both surgeons work together, each as a primary surgeon.
How does each surgeon report their portion of the surgery?
Which one of the following is an example of a case in which a diabetes-related problem exists and the code for diabetes is never sequenced first?
(Full Case:Established patient office visit.CC:Bilateral thyroid nodules.HPI:54-year-old evaluated for bilateral thyroid nodules; thyroid ultrasound last week showed multiple thyroid masses likely multinodular goiter; patient can “feel” left-sided nodules; denies dysphagia; denies unexplained weight loss/gain; family history thyroid cancer (maternal grandmother); otherwise no problems except palpable right-sided thyroid mass.ROS:Constitutional negative (chills/fever/weight change). ENT negative (hearing loss/trouble swallowing/voice change). GI negative (distention/pain/bleeding/bowel changes/N/V). Endocrine negative (cold/heat intolerance).PE:Vitals BP 140/72, P 96, R 16, T 97.6, SpO2 97%, wt 89.8 kg, ht 165.1 cm. General alert/cooperative/no distress. Head normocephalic. Throat moist/no lesions/no thrush. Neck: no adenopathy, supple, trachea midline,thyromegaly present, no carotid bruit, no JVD. Lungs clear. Heart regular rhythm/rate, normal S1/S2, no murmur/gallop/rub/click. Lymph nodes no palpable adenopathy.Assessment/Plan:Multinodular goiter; patient will have apercutaneous biopsy (minor procedure).Question:What E/M code is reported?)
Which one of the following is a commercial or private payer?
A pathologist performs fluorescent microscopy for chromosomal abnormalities, but no specific CPT® code exists.
Which unlisted 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 □ 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?
The pulmonologist performs a bronchoscopy with fluoroscopic guidance. The scope is introduced into the right nostril and advanced to the vocal cords and into the trachea. The scope is advanced to the right upper lobe and a lung nodule is noted. An endobronchial biopsy is performed.
What CPT® code is reported for the procedure?
An anesthesiologist medically directs two cases during EGD and colonoscopy in a PS III patient with severe bleeding risk.
What CPT® codes are reported?
A 42-year-old male is diagnosed with a left renal mass. An abdominal incision along with rib resection is made to expose and access the kidney. The left kidney is removed, along with surrounding fat, adrenal gland, lymph nodes in the area, and the incision site is sutured. What CPT ® code is reported for this procedure?
