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?
A patient who is 37 weeks' gestation is admitted to labor and delivery for a cesarean delivery. An external cephalic version was performed successfully several days ago and she now presents in labor, fully dilated, and the fetus has returned to a footling presentation.
What anesthesia code is reported?
(A patient presents to the urgent care facility with multiple burns acquired while burning debris in his backyard. After examination the physician determines the patient hasthird-degree burns of the left and right posterior thighs (10%). He also hassecond-degree burnsof theanterior portion of the right side of his chest wall (8%)andupper back (6%).TBSA is 24%withthird-degree burns totaling 10%. What ICD-10-CM codes are reported, according to ICD-10-CM coding guidelines?)
A patient is sent to the hospital by his family care provider for admission due to a high fever and neck pain The patient is admitted to the hospital to rule out bacterial meningitis. The hospitalist admits the patient and orders a CBC. CMR Blood culture, CT of the head and chest, and a lumbar puncture (spinal tap). After review of the results, he determines the patient has bacterial meningitis and starts the patient on IV antibiotics.
What CPT® and ICD-10-CM codes are reported for the admission?
A 5-year-old is brought to the QuickCare in the ED to repair two lacerations: a 3 cm laceration on her right arm and 2 cm laceration on her nose. Her arm is repaired with a simple one-layer closure with sutures. Her nose is repaired with a simple repair using tissue adhesive, 2-cyanoacrylate.
How are the repairs reported?
A patient presents with keratosis lesions on her left cheek, above the left eyebrow, and on the chin area. The dermatologist treats those areas by lightly sanding the surface of a total of 5 lesions.
What CPT® coding is reported?
(Procedure date:01/12/20XX
Surgeon:MD |Assistant:PA
Preoperative diagnosis:Dry gangrene of the left foot in the setting of peripheral vascular disease. Non-pressure chronic ulcer on toe.
Postoperative diagnosis:Dry gangrene of the left foot in the setting of peripheral vascular disease. Non-pressure chronic ulcer on toe.
Procedure:Amputation at the metatarsophalangeal joint of the left third toe
Indication:63-year-old female with peripheral vascular disease; vascular workup determined no further interventions to improve vascularity; third toe became progressively dusky; wound formed distally with chronic ulcer; amputation necessary; risks/benefits discussed.
Description:Left foot and third toe marked; 1 g Ancef given; general anesthesia; supine; calf tourniquet; timeout; tourniquet inflated (no Esmarch); total tourniquet time 5 minutes; tennis racquet incision with longitudinal arm over third metatarsal encircling joint proximal to closure; extensor/flexor tendons and collateral ligaments excised sharply; toe removed; tourniquet released; superficial bleeders cauterized; washed out; skin closed with 3-0 nylon; dry dressing; to PACU in good condition; signed 01/19/20XX 09:41.
Question:What CPT® and ICD-10-CM coding is reported?)
Which statement is TRUE for an Excludes2 note that is under a code in the Tabular List for ICD-10-CM?
(Day 1: Provider admits patient toobservation carefor type 2 diabetes with hyperglycemia, orders labs, consults endocrinologist, starts IV insulin drip, keeps overnight. Day 2: orders glucose test, dietitian, documents total time 25 minutes. Day 3: glucose normal, documents 15 minutes, discharges patient. What E/M coding is reported by the physician for the patient in observation care?)
A cardiologist performs remote monitoring for a 30-day period via a previously implanted hemodynamic pulmonary artery pressure monitor for a patient with congestive heart failure with resulting pulmonary edema. The first month of monitoring includes weekly downloads, interpretations, trend analysis, and subsequent reports.
What CPT® code is reported?
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