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® codes are reported?
A pediatrician removes impacted cerumen using irrigation in the right ear and instrumentation in the left ear.
What CPT® coding is reported?
A patient has a bone infection being treated with vancomycin. A therapeutic drug assay is performed to measure the concentration of vancomycin in the patient ' s blood.
What lab test is reported?
An 8-year-old patient is placed under general anesthesia for treatment of a right orbital fracture due to a traumatic fall to the nose and face from a swing set. An on-call otolaryngologist is
asked to perform a general otolaryngologic examination to evaluate the patient. A mild nasal fracture is the diagnosis given by the otolaryngologist.
What is the CPT® and ICD-10-CM coding for the otolaryngologist ' s services?
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?
A 19-year-old is seen by his, primary care physician for an annual exam. His last exam with the primary care physician was four years ago. He has no complaints.
What CPT code is reported?
Which statement is TRUE for an Excludes2 note that is under a code in the Tabular List for ICD-10-CM?
(A patient is seen for nausea, vomiting, and sharp right lower abdominal pain. CT and labs support a diagnosis ofchronic appendicitis. The physician schedules anopen appendectomyand removes the appendix. What CPT® and diagnosis codes are reported?)