Mr. Woolridge has had a suspicious lesion on his left shoulder for approximately eight weeks that is not healing. On the dermatologist's exam of left shoulder blade, there is excoriation and scabbing and the lesion not healing. Patient agrees and wishes to proceed with a punch biopsy of the lesion. A punch biopsy is taken of the lesion and sent to pathology. A simple repair is performed at the biopsy site.
What CPT® and ICD-10-CM codes are reported?
Answer : C
The surgical preparation of a 25 sq cm wound on the right leg is performed along with a 25 sq cm wound on the left leg.
What CPT® code is reported?
Answer : A
What CPT® code is reported for an excision of a sacral pressure ulcer with a primary closure?
Answer : B
A female patient had an FNA biopsy with ultrasound guidance on two separate nodules in the upper-outer quadrant of left breast.
What CPT® and ICD-10-CM codes are reported?
Answer : A
A 4-year-old has third-degree, circumferential burns to his torso. To avoid respiratory compression an escharotomy is performed. A total of four incisions are made through the eschar down to the subcutaneous fat to release the restrictive effects from the eschar.
What CPT® coding should you report?
Answer : D
A surgeon performed Mohs micrographic surgery on a lesion on the lower leg. This required one stage with six tissue blocks. A direct skin flap was used to cover the defect.
What CPT® codes are reported for the Mohs surgery and the repair?
Answer : C
A surgeon performs midface LeFort I reconstruction on a patient’s facial bones to correct a congenital deformity. The reconstruction is performed in two pieces in moving the upper jawbone forward and repositioning the teeth of the maxilla of the mid face.
What CPT® code is reported?
Answer : C
A patient had surgery a year ago to repair two flexor tendons in his forearm. He is in surgery for a secondary repair for the same two tendons.
Which CPT® coding is reported?
Answer : D
A 45-year-old has a dislocated patella in the left knee after a car accident. She taken to the hospital by EMS for surgical treatment. In the surgery suite, the patient is placed under general anesthesia. After being prepped and draped, the surgeon makes an incision above the knee joint in front of the patella. Dissection is carried through soft tissue and reaching the patella in attempt to reduce the dislocation. When the patella is exposed, it is severely damaged due to cartilage breakdown. The tendon is dissected and using a saw the entire patella is freed and removed. The tendon sheath is closed with sutures.
What procedure code is reported for this surgery?
Answer : D
A 42-year-old with chronic left trochanteric bursitis is scheduled to receive an injection at the Pain Clinic. A 22-gauge spinal needle is introduced into the trochanteric bursa under ultrasonic guidance, and a total volume of 8 cc of normal saline and 40 mg of Kenalog was injected.
What CPT® code should be reported for the surgical procedure?
Answer : C
A 60-year-old male suffering from degenerative disc disease at the L3-L4 and L5-S1 levels was placed under general anesthesia. Using an anterior approach, the L3-L4 disc space was exposed. Using blunt dissection, the disc space was cleaned. The disc space was then sized and trialed. Excellent placement and insertion of the artificial disc at L3-L4 was noted. The area was inspected and there was no compression of any nerve roots. Same procedure was performed on L5-S1 level. Peritoneum was then allowed to return to normal anatomic position and entire area was copiously irrigated. The wound was closed in a layered fashion. The patient tolerated the discectomy and arthroplasty well and was returned to recovery in good condition. What CPT® coding is reported for this procedure?
Answer : B
A 67-year-old male presents with DJD and spondylolisthesis at L4-L5 The patient is placed prone on the operating table and, after induction of general anesthesia, the lower back is sterilely prepped and draped. One incision was made over L1-L5. This was confirmed with a probe under fluoroscopy. Laminectomies are done at vertebral segments L4 and L5 with facetectomies to relieve pressure to the nerve roots. Allograft was packed in the gutters from L1-L5 for a posterior arthrodesis. Pedicle screws were placed at L2, L3, and L4. The construct was copiously irrigated and muscle; fascia and skin were closed in layers.
Select the procedure codes for this scenario.
Answer : C
Which CPT® code is reported for a knee arthrocentesis without ultrasound guidance?
Answer : D
An orthopedic surgeon performs tenolysis releasing the extensor tendon of the finger from adhesions. The surgery extends from the finger to the forearm.
What CPT® code is reported?
Answer : B
The patient presents to the operating room for repair of a right proximal humerus fracture. The surgeon incises the skin over the fractured bone, the fracture is identified, adjusts the bone, and realigns the fracture. Next, the upper end of the humerus bone is replaced with a synthetic humerus bone implant.
What CPT® and ICD-10-CM codes are reported?
Answer : C
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