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A Medicare patient presents for an influenza vaccination and pneumococcal vaccination. This is the only service rendered.
G0008, G0009, V06.6
Dr. Smith performed a bilateral radical mastectomy, including the pectoral muscles and axillary lymph nodes, on a 63-year-old female with breast cancer located on the upper-inner quadrant of the right breast.
A 64-year-old male comes in for his flu (split virus, IM) and pneumonia (23-valent, IM) vaccines. Code only the immunization administration and diagnoses for the vaccines.
90471, 90472, V06.6
Anesthesia provided for an anterior cervical discectomy with decompression of a single interspace of the spinal cord and nerve roots and including osteophytectomy (63075).
If a distinct, separately identifiable procedure is provided in addition to an E/M service, you would add this modifier to the E/M code.
The patient was brought to the operating room to repair an aneurysm of the intracranial artery by balloon catheter.
Which CPT code would the surgeon use to report the shaving of an epidermal lesion of the upper arm when a lesion diameter is greater than 2 cm? The post-procedure diagnosis was a benign growth.
Therapeutic radiology treatment planning is the "prescription" for a patient who will start radiation therapy for a cancerous neoplasm of the adrenal gland. What CPT code would you use for a complex treatment planning?
A patient with spinal stenosis at the C5-C7 level with a painful intervertebral disc displacement had a cervical discectomy, corpectomy, allograft from C5 to C7, and placement of instrumentation (a 34-mm plate from C5 to C7).
An 82-year-old female Medicare patient has a single energy x-ray absorptiometry (SEXA) bone density study of two sites of the left wrist. The patient has osteopenia and is complaining of left wrist pain. SEXA confirms osteopenia in left wrist.
G0130, 733.90, 719.43
This 21-year-old female is seen at the clinic today for a colposcopy. The physician will take multiple biopsies of the cervix uteri. Assign code(s) for the physician service only.
Philip has end-stage renal disease and comes to the clinic lab today for his monthly urinalysis (qualitative, microscopic only).
A 24-year-old female is seen in the office for a chronic candidal paronychia nail abscess that needs to be incised and drained. Assign code for physician services only.
A patient is in the Outpatient Hospital for an MRI (magnetic resonance imaging) of the pelvis with contrast material(s). Assign code for the physician service only.
Kristie, a 15-year-old female, is seen today for removal of bilateral ventilating tubes that Dr. White inserted 1 year ago. Patient required general anesthesia. Assign code for the physician service only.
A patient presents to the clinic for a barium enema that was ordered by his physician. Once the patient drinks the barium, the patient will be taken to radiology for a colon x- ray, including KUB. Assign code for the service only.
Anesthesia time begins when the anesthesiologist begins to prepare the patient for the induction of anesthesia and ends when:
The anesthesiologist is no longer in personal attendance and the patient is under the care of the postoperative supervision
Jim is a 42-year-old male in for a bilateral vasectomy that will include three postoperative semen examinations.
Kristie is a 14-year-old female with a diagnosis of chronic bilateral otitis media. The patient was taken to same-day surgery and placed under general anesthesia. Dr. White inserted ventilating tubes bilaterally. The patient tolerated the procedure well.
The patient presented to the laboratory at the clinic for the following blood tests ordered by her physician: albumin (serum), bilirubin (total), and BUN (quantitative). Assign code(s) for the service only.
82040, 82247, 84520
The patient is seen in the clinic for chronic sinusitis. The physician decides to schedule an endoscopic sinus surgery for the next day. The patient arrives to same-day surgery, and the physician performs a right endoscopic total ethmoidectomy with an endoscopic maxillary antrostomy with removal of maxillary tissue. Postoperative diagnosis includes chronic ethmoidal and maxillary sinusitis. Code the procedure(s) and diagnosis.
31255-RT, 31267-51-RT, 473.2, 473.0
58-year-old patient has a PICC line with a port placed for chemotherapy infusion. Fluoroscopic guidance was used to gain access and check placement. The patient is diagnosed with pancreatic cancer with mets to the lung and lower lobe of the liver. All are being treated.
36571, 77001, 157.9, 197.0, 197.7
A comprehensive physical examination reveals a pleasant, elderly female in no apparent distress. She has a blood pressure of 150/70 with a heart rate of 76. Weight is 131 pounds, and she is 5 foot 4 inches. Head and neck reveal JBP less than 5 cm. Normal carotid volume and upstroke without bruit. Chest examination shows clear to auscultation with no rales, crackles, crepitations, or wheezing. The complete cardiovascular single system examination was documented and revealed a normal PMI without RV lift. Normal S1 and S2 with an S3, without murmur, are noted. The medical decision making complexity is high based on the various diagnosis options. Assign codes for the physician services.
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