Which statement is TRUE for an Excludes2 note that is under a code in the Tabular List for ICD-10-CM?
A patient who was experiencing severe abdominal pain underwent abdominal imaging and results showed several peritoneal tumors of various sizes.
The patient elected to have the tumors removed. An incision was made to access the intra-abdominal peritoneal cavity, where four tumors were identified, measured, and excised.
The largest was 2 cm, two were 1 cm each, and the smallest was 0.5 cm. Pathology report indicated the tumors were malignant.
What CPT® and ICD-10-CM coding is reported7
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?
An incision is made in the scalp, a craniectomy is performed to access the area where electrodes are present. The electrodes are removed. The surgical wound is closed.
What procedure code is reported?
View MR 004397
MR 004397
Operative Report
Preoperative Diagnosis: Calculi of the gallbladder
Postoperative Diagnosis: Calculi of the gallbladder, chronic cholecystitis
Procedure: Cholecystectomy
Indications: The patient is a 50-year-old woman who has a history of RUQ pain, which ultrasound revealed to be multiple gallstones. She presents for removal of her gallbladder.
Procedure: The patient was brought to the OR and prepped and draped in a normal sterile fashion. After adequate general endotracheal anesthesia was obtained, a trocar was placed and C02 was insufflated into the abdomen until an adequate pneumoperitoneum was achieved. A laparoscope was placed at the umbilicus and the gallbladder and liver bed were visualized. The gallbladder was enlarged and thickened, and there was evidence of chronic inflammatory changes. Two additional ports were placed and graspers were used to free the gallbladder from the liver bed with a combination of sharp dissection and electrocautery. Cystic artery and duct are clipped. Dye is injected in the gallbladder. Cholangiography revealed no intraluminal defect or obstruction. Gallbladder is dissected from the liver bed. The scope and trocars are removed.
What CPT® coding is reported for this case?
Dr. Burns sees newborn baby James at the birthing center on the same day after the cesarean delivery. Dr. Burns examined baby James, the maternal and newborn history, ordered appropriate blood test tests and hearing screening. He met with the family at the end of the exam.
How would Dr. Bums report his services?
(Regarding the CPT® Surgery Guidelines for a surgical code designated as a“Separate Procedure,”which statement isFALSE?)
(A patient presents with fatigue and unexplained weight gain. To evaluate possible thyroid dysfunction, the provider orders a single laboratory test to measurethyroid-stimulating hormone (TSH). A routine venous blood sample is collected and sent to the laboratory.Which CPT® and ICD-10-CM® codes are reported?)
Mrs. Wilder presents with right and left leg swelling. Venous thrombosis imaging of each leg is done and shows deep venous embolism and thrombosis in each leg.
What CPT® and ICD-10-CM codes are reported?