The documentation states:
He was then sterilely prepped and draped along the flank and abdomen in the usual sterile fashion. I first made a skin incision off the tip of the twelfth rib, extending medially along the banger’s lines of the skin. This was approximately 3.5 cm in length. Once this incision was carried sharply, electrocautery was used to gain access through the external oblique, internal oblique, and transverse abdominis musculature and fascia.
What surgical approach was used for this procedure?

The heart chambers are called:

Which place of service code is submitted on the claim for a service that is performed in an outpatient surgical floor?

When a patient has ESRD, which system is affected?

The human shoulder is made of which three bones?

Where is a Warthin's tumor found?

The outermost protective layer of skin is called the:

In rhinoplasty:

Patient is diagnosed with dacryocystitis, which is the inflammation of?

The mediastinum is:

According to the Repair (Closure) CPT® guidelines, what type of repair is reported when a single layer closure includes copious irrigation and extensive cleaning to remove particulate matter?

Which entity offers compliance program guidance to form the basis of a voluntary compliance program for a provider practice?

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 bone is located in the lower extremity?

Which one of the following is a commercial or private payer?

A cardiologist attempted to perform a percutaneous transluminal coronary angioplasty of a totally occluded blood vessel. The surgeon stopped the procedure because of an anatomical problem creating risk for the patient and preventing performance of the catheterization.
What modifier is appended to the procedure code?

According to the Application of Cast and Strapping CPT® guidelines, what is reported when an orthopedic provider performs initial fracture care treatment for a closed scaphoid fracture of the wrist, applies a short arm cast, and the patient will be returning for subsequent fracture care?

A patient is diagnosed with diabetic polyneuropathy.
Using ICD-10-CM coding guidelines, what ICD-10-CM coding is reported?

A patient is diagnosed with sepsis and associated acute respiratory failure.
What ICD-10-CM code selection is reported?

Which one of the following is an example of a case in which a diabetes-related problem exists and the code for diabetes is never sequenced first?

A patient suffering from idiopathic dystonia is seen today and receives the following Botulinum injections: three muscle injections in both upper extremities and seven injections in six paraspinal muscles.
How are these injections reported according to the CPT® guidelines?

Which statement regarding lesion excision is TRUE?

What is the ICD-10-CM code for acute bronchitis due to Mycoplasma pneumoniae?

What is the CPT code for an appendectomy?

Which modifier indicates a bilateral procedure?

What is the HCPCS code for a standard power wheelchair?

What is the ICD-10-CM code for type 2 diabetes mellitus without complications?

What is the anatomical term for the windpipe?

Which term describes inflammation of the liver?

What is the CPT code for an adult flu vaccination administration?

What is the CPT code for a screening mammogram of both breasts?

What is the appropriate code for a new patient office visit with a comprehensive history, comprehensive exam, and medical decision making of moderate complexity?

A patient undergoes a laparoscopic cholecystectomy. Which of the following CPT codes should be used?

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.

View MR 007400

MR 007400

Radiology Report

Patient: J. Lowe Date of Service: 06/10/XX

Age: 45

MR#: 4589799

Account #: 3216770

Location: ABC Imaging Center

Study: Mammogram bilateral screening, all views, producing direct digital image

Reason: Screen

Bilateral digital mammography with computer-aided detection (CAD)

No previous mammograms are available for comparison.

Clinical history: The patient has a positive family history (mother and sister) of breast cancer.

Mammogram was read with the assistance of GE iCAD (computerized diagnostic) system.

Findings: No dominant speculated mass or suspicious area of clustered pleomorphic microcalcifications is apparent Skin and nipples are seen to be normal. The axilla are unremarkable.

What CPT coding is reported for this case?

View MR 001394

MR 001394

Operative Report

Procedure: Excision of 11 cm back lesion with rotation flap repair.

Preoperative Diagnosis: Basal cell carcinoma

Postoperative Diagnosis: Same

Anesthesia: 1% Xylocaine solution with epinephrine warmed and buffered and injected slowly through a 30-gauge needle for the patient's comfort.

Location: Back

Size of Excision: 11 cm

Estimated Blood Loss: Minimal

Complications: None

Specimen: Sent to the lab in saline for frozen section margin control.

Procedure: The patient was taken to our surgical suite, placed in a comfortable position, prepped and draped, and locally anesthetized in the usual sterile fashion. A #15 scalpel blade was used to excise the basal cell carcinoma plus a margin of normal skin in a circular fashion in the natural relaxed skin tension lines as much as possible The lesion was removed full thickness including epidermis, dermis, and partial thickness subcutaneous tissues. The wound was then spot electro desiccated for hemorrhage control. The specimen was sent to the lab on saline for frozen section.

Rotation flap repair of defect created by foil thickness frozen section excision of basal cell carcinoma of the back. We were able to devise a 12 sq cm flap and advance it using rotation flap closure technique. This will prevent infection, dehiscence, and help reconstruct the area to approximate the situation as it was prior to surgical excision diminishing the risk of significant pain and distortion of the anatomy in the are

a. This was advanced medially to close the defect with 5 0 Vicryl and 6-0 Prolene stitches.

What CPT coding is reported for this case?

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?

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?

What CPT® code is reported for an excision of a sacral pressure ulcer with a primary closure?

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?

A patient with three thyroid nodules is seen for an FNA biopsy. Using ultrasonic guidance, the provider inserts a 25-gauge needle into each nodule. Nodular tissue is aspirated and sent to pathology.
What CPT® coding reported?

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?

A 25-year-old woman underwent percutaneous breast biopsy on the right breast with placement of a Gelmark clip. The procedure was performed using stereotactic imaging.
What CPT® codes will be reported?

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?

A 35-year-old female has cancer in her left breast. The surgeon performs a mastectomy, removing the breast tissue, skin, pectoral muscles, and surrounding tissue, including the axillary and internal mammary lymph nodes.
Which mastectomy code is reported?

A 30-year-old patient with a scalp defect is having plastic surgery to insert tissue expanders. The provider inserts the implants, closes the skin, and increases the volume of the expanders by injecting saline solution. Tissue is expanded until a satisfactory aesthetic outcome is obtained to repair the scalp defect.
What CPT® code is reported?

A 44-year-old female patient with chest pains had a CT of her chest that identified a mass in her left lower lung. The patient currently has ovarian cancer with metastases to the liver. The radiologist suspects the cancer has spread to her lungs. The physician performed an outpatient bronchoscopic biopsy and the pathology report documents the mass as a tumor of uncertain behavior.
What ICD-10-CM codes are reported for this patient?

A 5-year-old is brought to the QuickCare in the ED to repair two lacerations: a 3 cm laceration on her right arm and 2 cm laceration on her nose. Her arm is repaired with a simple one-layer closure with sutures. Her nose is repaired with a simple repair using tissue adhesive, 2-cyanoacrylate.
How are the repairs reported?

An elderly patient comes into the emergency department (ED) with shortness of breath. An ECG is performed The final diagnosis at discharge is impending myocardial infarction.
According to ICD-10-CM guidelines, how is this reported?

Patient had polyps removed on a previous colonoscopy. The patient returns three months later for a follow-up examination for another colonoscopy. No new polyps are seen.
What diagnosis coding is reported for the second colonoscopy?