A patient with a history of a right-hand mass presents for outpatient surgical excision. The surgeon excises the 1.5 cm mass with margins using a scalpel with dissection extending through the dermis into the subcutaneous tissue. Hemostasis is achieved with electrocautery, and the wound is closed. Final pathology confirms the mass is a subcutaneous arteriovenous hemangioma.
Which CPT® and ICD-10-CM codes are reported?
(Full Case:Procedure:Excision of6.0 cm malignant lesionof theright forearmwithadjacent tissue transferusing arotation flap.Pre/Post-op Dx:Basal cell carcinoma, right forearm.Anesthesia:local (1% Xylocaine with epi).Defect size:8 sq cm.Specimen:sent forfrozen section margin control; margins confirmed clear.Closure:rotation flap from adjacent healthy tissue,total area 8 sq cm, secured with layered closure (5-0 Vicryl/6-0 Prolene).Question:What CPT® coding is reported?)
A patient with intermittent asthma with exacerbation undergoes spirometry before and after bronchodilator.
What CPT® and ICD-10-CM codes are reported?
A pediatrician is requested to attend a high-risk delivery and performs initial stabilization of the newborn after cesarean delivery.
What E/M service is reported?
Patient has a 5 cm tumor in the left lower quadrant abdominal wall. A horizontal skin incision is made directly over the tumor in the patient ' s left lower quadrant and dissection was carried
down through the dermis and subcutaneous tissue. The tumor is located and completely excised using electrocautery. The specimen is sent immediately to pathology to rule out cancer. What
CPT® and ICD-10-CM codes are reported?
The CPT® code book provides full descriptions of medical procedures, although some descriptions require the use of a semicolon (;) to distinguish among closely related procedures.
What is the full description of CPT® code 69644?
Which government office is responsible for overseeing and investigating cases of healthcare fraud and abuse?
View MR 099401
MR 099401
Established Patient Office Visit
Chief Complaint: Patient presents with bilateral thyroid nodules.
History of present illness: A 54-year-old patient is here for evaluation of bilateral thyroid nodules. Thyroid ultrasound was done last week which showed multiple thyroid masses likely due to multinodular goiter. Patient stated that she can “feel " the nodules on the left side of her thyroid. Patient denies difficulty swallowing and she denies unexplained weight loss or gain. Patient does have a family history of thyroid cancer in her maternal grandmother. She gives no other problems at this time other than a palpable right-sided thyroid mass.
Review of Systems:
Constitutional: Negative for chills, fever, and unexpected weight change.
HENT: Negative for hearing loss, trouble swallowing and voice change.
Gastrointestinal: Negative for abdominal distention, abdominal pain, anal bleeding, blood in stool, constipation, diarrhea, nausea, rectal pain, and vomiting
Endocrine: Negative for cold Intolerance and heat intolerance.
Physical Exam:
Vitals: BP: 140/72, Pulse: 96, Resp: 16, Temp: 97.6 °F (36.4 °C), Temporal SpO2: 97%
Weight: 89.8 kg (198 lbs ), Height: 165.1 cm (65”)
General Appearance: Alert, cooperative, in no acute distress
Head: Normocephalic, without obvious abnormality, atraumatic
Throat: No oral lesions, no thrush, oral mucosa moist
Neck: No adenopathy, supple, trachea midline, thyromegaly is present, no carotid bruit, no JVD
Lungs: Clear to auscultation, respirations regular, even, and unlabored
Heart: Regular rhythm and normal rate, normal S1 and S2, no murmur, no gallop, no rub, no click
Lymph nodes: No palpable adenopathy
ASSESSMENT/PLAN:
1) Multinodular goiter - the patient will have a percutaneous biopsy performed (minor procedure).
What E/M code is reported for this encounter?
A physician prescribes carbamazepine to treat a patient with epileptic seizures. After six months, the physician performs a therapeutic drug test to monitor the total level of the drug in the patient.
What CPT® and ICD-10-CM coding is used for the six month-evaluation?