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1. Procedure and CPT® Code Selection:

The procedure described is a craniectomy to access and remove a supratentorial intracerebral hematoma using a suction device.

CPT® Code 61314 is specific for a craniectomy or craniotomy for evacuation of a hematoma, supratentorial (within the upper portion of the brain), and includes any required dural repair and closure. This code precisely describes the procedure performed to remove the hematoma.

2. Rationale for Excluding Other Options:

Code 61154 is used for a burr hole procedure for the evacuation of a hematoma, which is a less invasive approach and does not involve a craniectomy.

Code 61313 is for a craniectomy or craniotomy to evacuate an infratentorial hematoma, which is located in the lower portion of the brain (posterior fossa) and is not applicable here.

Code 61312 is for evacuation of an epidural or subdural hematoma and does not apply to an intracerebral hematoma as described in this case.

3. AAPC and CPT® Coding Guidelines:

According to AAPC guidelines, 61314 is the appropriate code for craniectomy procedures aimed at removing supratentorial intracerebral hematomas, as it covers the full scope of the documented procedure.

Thus, the correct answer is A. 61314.

Cesarean Delivery with Antepartum and Postpartum Care: The procedure involved the cesarean section delivery of twins, including antepartum and postpartum care.

CPT Code 59510: This code is used for routine obstetric care including antepartum care, cesarean delivery, and postpartum care. The code is not reported per fetus but per delivery, even when delivering multiples.

The patient is an established patient presenting with bilateral thyroid nodules and has a detailed history and examination performed.

Procedure Description:

Detailed history and examination of bilateral thyroid nodules.

Review of systems and physical examination.

Assessment and plan for a percutaneous biopsy.

CPT® Coding:

99214: Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and moderate medical decision making.

AMA's CPT® Professional Edition (current year).

CPT® Assistant for detailed coding guidelines on evaluation and management services.

Procedure: Cardiac stress test performed using hospital's equipment with the cardiologist providing supervision, interpretation, and report.

CPT® Codes:

93016: This code is for supervision only without provision of the equipment.

93018: This code is for interpretation and report only.

Code Selection Justification: Since the cardiologist does not own the equipment, codes 93016 and 93018 correctly represent the supervision, interpretation, and report of the test.

AMA CPT® Professional Edition (current year)

The CPT code 10005 is for fine needle aspiration biopsy, including ultrasound guidance, for the first lesion. CPT code 10006 is for each additional lesion with ultrasound guidance. Since the provider aspirated tissue from three nodules, the coding should be 10005 for the first nodule and 10006 x 2 for the additional two nodules.

AMA's CPT® Professional Edition (current year)

Dacryocystitis is the inflammation of the lacrimal sac, which is part of the tear drainage system located in the inner corner of the eye. The lacrimal sac is connected to the nasolacrimal duct, which drains tears into the nasal cavity. Inflammation in this area can cause pain, redness, and swelling near the inner corner of the eye.

ICD-10-CM, medical dictionaries

Modifier 53 is used to report a discontinued procedure. It indicates that a procedure was started but terminated due to the patient's well-being being at risk. In this scenario, the percutaneous transluminal coronary angioplasty was attempted but stopped because of an anatomical problem that created a risk for the patient, preventing the completion of the procedure.

AMA's CPT® Professional Edition, coding guidelines on the use of modifiers.

20552 = Injection(s); single or multiple trigger points, 1–2 muscles

Total muscles injected = 2 (trapezius + pectoralis)

Number of injections does not determine code selection—number of muscles does

In coding burns, ICD-10-CM guidelines indicate that each burn site is coded separately, specifying the degree, location, and extent of the burn. Additionally, a code for total body surface area (TBSA) burned is included when burns cover more than 10% of the body. Here’s the breakdown:

1. T24.311A: Represents a third-degree burn on the left thigh, initial encounter.

2. T24.312A: Represents a third-degree burn on the right thigh, initial encounter.

3. T21.21XA: Represents a second-degree burn on the anterior chest wall, initial encounter.

4. T21.23XA: Represents a second-degree burn on the upper back, initial encounter.

5. T31.21: Represents burns with 20–29% TBSA involvement, with third-degree burns covering 10–19% of the TBSA.

Explanation of incorrect answers:

A includes an incorrect TBSA code (T31.21).

B has the correct codes but lists an incorrect TBSA code for third-degree burns.

C uses incorrect burn site codes for the areas involved and incorrect TBSA percentages.

Therefore, the correct answer is D. T24.311A, T24.312A, T21.21XA, T21.23XA, T31.21, which accurately captures the burns' degrees, locations, and TBSA.

Brackets [ ] in the ICD-10-CM Alphabetic Index are used to identify manifestation codes.

These codes cannot be reported as the principal diagnosis and must be sequenced after the underlying condition.

This is a frequently tested ICD-10-CM guideline concept.