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 patient comes in complaining of pain in the lower left back, which is accompanied by a numbing sensation that extends into the leg. Attempts to alleviate the pain with home treatments have been unsuccessful. The provider orders an MRI of the lumbar spine initially without, and then with, contrast material. The images are interpreted by the physician, the final diagnosis is left-sided low back pain with sciatica.
What CPT® and ICD-10-CM codes are 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 code is reported?
(A patient is in her dermatologist’s office for treatment of recurring psoriatic plaques on the upper back and neck resistant to topical therapy. The dermatologist performsExcimer laser therapyon the upper back (300 sq cm) and neck (100 sq cm), total surface area400 sq cm. What CPT® codes are 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 is the radiology coding for this encounter?
(What ICD-10-CM coding is reported forType 1 diabeteswithdiabetic chronic kidney disease?)
(A patient presents with increased intracranial pressure and is scheduled for a lumbar puncture. UnderCT guidance, the physician inserts a needle at the L4 level and advances a catheter into the subarachnoid space toactively drain cerebrospinal fluid. CSF is collected and sent to the lab; the catheter is removed. What CPT® coding is reported?)
A 10-year-old had a cochlear implant in his left ear few weeks ago. Today he sees the audiologist to initialize and program the implant.
What CPT® code is reported?
A patient is having X-ray imaging of his abdomen following a traumatic episode. A decubitus, supine, and erect views are performed on the abdomen.
What CPT® is reported?
TESTED 24 Feb 2026
