7 year-old riding his bike struck a tree stump throwing him off his bike. He received multiple lacerations. He had a 3 cm dermis laceration on his scalp with two 0.5 cm lacerations on his face. His right arm had a 5 cm laceration and right leg has a 5 cm laceration. The physician stapled the laceration for the scalp. Physician used steri-strips (adhesive strips) to close the wounds on the face. The legs and arms were cleaned by heavily irrigating them with normal saline and removal of embedded debris performed on both wounds, followed with a single-layer closure. Select the repair codes to report.

A 55 year-old male presents in the office with an ingrown toenail on the right and left foot. The procedure was discussed in detail and the patient elected to have it performed. The right foot was prepped and draped in sterile fashion. The right great toe was anesthetized with 50/50 solution of 2 percent lidocaine and .05 percent Marcaine. A mini-tourniquet was placed around the toe for hemostasis in which part of the nail plate and matrixectomy were performed. Phenol was then applied, the toe was then flushed. Tourniquet was released and dressing applied. At this time the patient elected to only have one performed and will return in two weeks for the left foot. Code the procedure.

OPERATIVE REPORT POSTOPERATIVE DIAGNOSIS: Full thickness burn wound to anterior left lower leg. Operation: Split- thickness graft, approximately 35 centimeters; preparation of the wound. Procedure: Left lower leg was prepped and draped in the usual sterile fashion. The ulcer, which measured approximately 8 x 4 to 4.5 cm, was debrided sharply with Goulian knife until healthy bleeding was seen. The bleeding was controlled with epinephrine-soaked lap pads. Split-thickness skin graft was harvested from the left lateral buttock area approximately 4.5 to 5 cm x 8 cm at the depth of 14/1000 of an inch. The graft was meshed to 1 to 1.5 fashion and placed over the prepared wound, stabilized with staples and then Xeroform dressings and dry dressings, wrapped with Kerlix and finally immobilized in a posterior splint. The donor site was covered with Xeroform and dry dressings. What are the correct procedure codes reported by the physician for this procedure performed in the hospital outpatient surgical suite?

OPERATIVE REPORT PROCEDURE PERFORMED: Primary stenting of 70% proximal posterior descending artery stenosis. INDICATIONS: Atherosclerotic heart disease DESCRIPTION OF PROCEDURE: Stents inserted via percutaneous transcatheter placement. A 2.5 x 13 mm pixel stent was deployed. COMPLICATIONS: None RESULTS: Successful primary stenting of 70% proximal posterior descending artery stenosis with no residual stenosis at the end of the procedure.

The physician removes a tumor from the patient’s neck using the Mohs micrographic surgery technique. During the first stage, the physician takes four tissue blocks and reviews them under a microscope. The exam of the tissue blocks reveals a second stage is necessary to remove areas where the tumor is still present. The physician examines two additional tissue blocks. What are the appropriate CPT® codes for reporting the procedure?

This 45 year-old male presents to the operating room with a painful mass of the right upper arm. General anesthesia was induced. Soft tissue dissection was carried down thru the proximal aspect of the teres minor muscle. Upon further dissection a large mass was noted just distal of the IGHL(inferior glenohumeral ligament), which appeared to be benign in nature. With blunt dissection and electrocautery, the 4.5 cm mass was removed en bloc and sent to pathology. The wound was irrigated, and repair of the teres minor with subcutaneous tissue was then closed with triple-0 Vicryl. Skin was closed with double-0 Prolene in a subcuticular fashion. What is the correct CPT® code for this service?

Postoperative Diagnosis: 1. Impingement syndrome left shoulder. 2. AC synovitis left shoulder Procedure: Arthroscopy with subacromial decompression and AC resection left shoulder. The patient was placed supine on the operating table and prepped and draped in usual sterile fashion. The scope was introduced from a posterior portal and the joint was inspected. The rotator cuff looked in good condition. The articular surfaces looked good. The bicep also was in good condition. We went subacromially and there was a fair amount of bursal inflammation encountered. We did a thorough bursectomy. A ligament chisel was used to take down the coracoacromial ligament. A high-speed bur was used to do a subacromial decompression going from lateral to medial. We took off about 2 cm of bone anteriorly. Part of the acromion is surgically corrected. Next we opened the AC joint through an anterosuperior portal. High-speed bur was used to grind off about 10 mm of distal clavicle because there was a large subchondral cyst and we wanted to get this totally ground out, which we did. Then the wounds were irrigated out, Nylon suture was placed in our portals. The patient was placed in a bulky dressing and an arm sling and sent to the recovery room in stable condition. Code the procedure.v

A 90-year-old patient asks for a second opinion when he was recently diagnosed with bilateral senile cataracts. His regular ophthalmologist has recommended implantation of lenses after surgical removal of the cataracts. The patient presents to the clinic stating that he is concerned about the necessity of the procedure. During the detailed history, the patient states that he has had decreasing vision over the last year or two but has always had excellent vision. He cannot recall a trauma to the eye in the past. The physician conducted a detailed visual examination and confirmed the diagnosis of the patient's ophthalmologist. The medical decision-making was of low complexity.

The attending physician requests a confirmatory consultation from an interventional radiologist for a second opinion about a 60-year-old male with abnormal areas within the liver. The recommendation for a CT guided biopsy is requested, which the attending has recommended be performed. During the comprehensive history, the patient reported right upper quadrant pain. His liver enzymes were elevated. Previous CT study revealed multiple low attenuation areas within the liver (infection not tumor). The laboratory studies were creatinine, 0.9; hemoglobin, 9.5; PT and PTT, 13.0/31.5 with an INR of 1.2. The comprehensive physical examination showed that the lungs were clear to auscultation and the heart had regular rate and rhythm. The mental status was oriented times three. Temperature, intermittent low-grade fever, up to 101º Fahrenheit, usually occurs at night. The CT-guided biopsy was considered appropriate for this patient. The medical decision making was of high complexity.

A new patient is admitted to the observation unit of the local hospital after a 10 foot fall from a ladder. The patient hit his head on the side of the garage as he fell into a hedge that somewhat broke his fall. He has significant bruising on the left side of his body and complains of a 5 out of 10 pain under his left arm. The physician completed a comprehensive history and physical examination. It was decided to admit the patient to observation based on some evidence that he may have hit the left side of his head during the fall. The medical decision making is moderately complex. Also code for a subsequent observation, one day, Expanded, Problem-Focused History, Expanded, Problem- Focused Exam and Moderate Medical Decision Making; what is noteworthy about the subsequent day observation codes?

2 year-old male requires a central venous catheter. Using xylocaine local anesthesia a percutaneous approach is used in the neck and venous access is achieved. A subcutaneous tunnel is created from the anterior chest wall to the venotomy site and the catheter passed through the tunnel. The CV catheter is then placed at the superior vena cava and sutured in position. Which procedure code is used?

Diagnostic esophagogastroduodenoscopy of the esophagus, stomach, and duodenum was performed after esophageal balloon dilation (less than 30 mm diameter) was done at the same operative session. Code the procedure(s).

A 46 year-old female with history of cervical carcinoma underwent placement of an ileal conduit, with subsequent development of left hydronephrosis. A retrograde ureteral catheter was recently placed. She returns today for catheter exchange. Patient was placed in the supine on the operating table. The ileal conduit was accessed. The existing catheter was removed over a guidewire and replaced with a similar 10 French 50 cm long locking pigtail catheter. Contrast was injected for monitoring, confirming good position of the catheter placement. Interpretation and report is in the record. IMPRESSION: Left retrograde ureteral catheter exchange via the ileal conduit. How is this reported?

70 year-old with significant pelvic prolapse and grade IV cystocele who has failed previous primary repair and is status post hysterectomy. She presents for anterior repair and colpopexy. Procedure: Patient placed in the dorsal lithotomy position and general anesthetic was induced without problems. A midline incision is made from just above the bladder neck to the vaginal cuff. She is noted to have a grade IV cystocele. Vaginal flaps were dissected to the level of the pubocervical fascia. Her vaginal mucosa was in good condition but near the urethra and bladder neck it was a little thinner. There is significant scarring on the left side from previous procedures. Ishcial spine is identified and swept fiber fatty tissue off of the sacrospinous ligament bilaterally. No scarring or adhesions in this area. Anterior needles were passed into place on the elevate mesh and these were fixed in a manner similar to the MiniArc. They were passed along just below the bladder neck toward the obturator foramen and fixed in place. An anterior support was created without tension at the vesicourethral junction. Apical needles were then used to pass the apical arms into place. There were gently fixed into place along the sacrospinous ligament approximately 2cm away from the ischial spine. This was done bilaterally. They passed in a single pass and were fixed in place confirmed by gentle tugging on both arms. Three Vicryl sutures had been placed and the vaginal apex were then passed over into the mesh and tied down. The apical arms were placed through the eyelets of the mesh and passed down toward the sacrospinous ligament bilaterally to create good apical support. Eyelet fasteners placed bilaterally and mesh arms trimmed providing excellent apical and anterior support. Vaginal mucosa was closed and vaginal packed placed. No complications. What CPT® code(s) describe(s) this procedure?

Preoperative Diagnosis: Right hydronephrosis Postoperative Diagnosis: Right hydronephrosis Operation: Cystoscopy and right retrograde pyelogram Procedure: Patient prepped and draped in the dorsolithotomy position. Placed under general anesthesia a 23 French cystoscope was passed into the bladder. No tumors were visualized. Urine from the bladder was sent for urine cytology. Then a 6 French access catheter was passed into the right ureteral orifice. Contrast was injected and there were no filling defects noted. There was no fixed tumor and no stone. There was mild hydroureteral nephrosis against the bladder. There was a narrowing at the UVJ no abnormalities. Renal pelvis barbotaged with saline and renal pelvis urine sent to pathology for urine cytology. After the retrograde pyelogram was performed the access catheter was removed. Interpretation and report are in the medical record. What CPT® codes are reported?

5 year-old male has diminished hearing in the left ear due to chronic otitis media. He has had hearing aid prosthetic devices in the ear which have resulted in additional infections. Parents have decided on an osseointegrated implant to restore hearing. The mastoid cortex is exposed. Spiral drilling is performed to create a pilot hole. The stem of the titanium pedestal is placed in the tunnel adjacent to the cochlea and abutment subsequently secured to the fixture. Which CPT® code should be used?

The physician performs a right thyroid lobectomy. The patient was prepped and draped. After adequate general anesthesia, the neck was incised on the right side and sharp dissection was then used to cut down onto the strap muscles and sternocleidomastoid muscles. The strap muscles were separated and transected on the right side. A small thyroid lobe was visualized and dissected free. There was no evidence of a tumor. The wound was closed with 3-0 interrupted Vicryl for the platysma, 4-0 Vicryl for the deep tissues and 6-0 fast absorbing gut for the skin. Code the encounter.

PROCEDURE: Bilateral lumbar medial branch block under ultrasound guidance for the L3, L4, L5 medial branches injecting the L4-L5, L5-S1 facets for diagnostic and therapeutic purposes. PROCEDURE: The patient was placed in the prone position and automated blood pressure cuff and pulse oximeter applied. The skin entry points for approaching the anatomic target points of the bilateral segmental medial branches or dorsal ramus of L3, L4, L5 were identified with a 22.5 degree from an ultrasound view and marked. Following thorough Chloraprep preparation of the skin and draping and 1% lidocaine infiltration of the skin entry points and subcutaneous tissues, a 22 gauge 6" spinal needle was placed under ultrasound guidance for the L4-L5 and L5-S1 facet joints. At each joint 1 mL consisting of 0.5% bupivacaine and Depo-Medrol was injected. A total of 80 mg of Depo-Medrol was given in both sides. Which CPT® codes should be used?

15 year-old male is seen by the pediatrician in his office for having excessive thirst and frequent urination. A urine dip is performed showing +3 sugar and with some ketones. Glucometer reading is done showing a blood sugar range of 500-600. Physician sends the patient with his father to the hospital for emergency admission and insulin drip. The pediatrician meets the patient at the hospital and performs a detailed history, comprehensive exam and a high complexity medical decision making. How should the pediatrician code the E/M service for this visit?

65 year-old woman is one year post with B-cell non-Hodgkin’s lymphoma. She is having recurrent fever and pain. Tumor recurrence was confirmed by CT studies and chest X-ray. She has failed prior chemotherapy and radiation treatments. A new treatment is being contemplated and she is referred for a radiopharmaceutical distribution imaging as a requirement before starting this new treatment. The provider injects small amounts of gamma-emitting radioactive material paying particular attention for potential reaction. A gamma camera is used to take planar images of the whole body for three days. Three sets of image data are interpreted. Qualitative assessment of distribution and determination of treatment with monoclonal antibody are provided. A report is dictated and placed in the medical record. Which CPT® code is reported?