A patient had surgery a year ago to repair two extensor tendons in his wrist. He is in surgery for a secondary repair for the same two tendons with free graft. What CPT® coding is reported?
(An 8-day-old newborn, weighing 3 kilograms, is seen for a circumcision. A numbing cream is applied. A circumferential incision is made and the foreskin is excised with a scalpel. What CPT® coding is reported?)
A patient undergoes a laparoscopic appendectomy for chronic appendicitis.
What CPT® and diagnosis codes are reported?
A patient who has HIV disease presents with loin pain in the clinic today. The patient reports he is having trouble sleeping due to the pain. What ICD-10-CM coding is reported?
A patient underwent a cystourethroscopy with a pyeloscopy using lithotripsy to break up the ureteral calculus. An indwelling stent was also inserted during the same operative session on the same side. This service was performed in the outpatient hospital surgery center.
What CPT® coding reported?
A patient presents to the ER with a large sacral pressure ulcer measuring 7 cm. The provider excised the ulcer with 3 mm margins, removed muscle and segmental bone, and performed a layered skin flap closure.
What CPT® and ICD-10-CM coding 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® and ICD-10-CM codes are reported?
A physician conducts a 15-minute phone call discussing medication management.
How is this reported?
A cystic lesion on the chest is excised with margins totaling 2.5 cm. Simple closure performed.
What CPT® coding is reported?
(A patient is diagnosed with agangrenous ulceron theright thighwith thefat layer exposedand is currently being treated. What ICD-10-CM coding is reported?)
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