Assignments Content Question 1: Patient Receives Preoperativ ✓ Solved
Assignments Content Question 1 Patient receives preoperative
Patient receives preoperative examination, level 4 E/M, by his PCP the day before the scheduled surgical procedure. Assign the CPT code.
Patient seen for trimming of three nondystrophic nails, becomes extremely anxious, physician chooses to administer anesthetic to make patient more at ease. Assign code and modifier if necessary.
Reconstruction of toe, polydactyly.
Surgeon repaired reducible umbilical hernia on infant weighing less than 4 kg. Assign the CPT code.
Patient was seen for repair of nail bed. Assign the CPT code.
Transcriptionist developed pain in right and left wrists. PCP diagnosed carpal tunnel syndrome. Corticosteroids were injected. Assign the CPT code.
New patient visit to discuss new diagnosis of diabetes mellitus, level 3 E/M with 45 minutes used explaining proper procedures for management of disease. Assign code and modifier if necessary.
Patient sent to laboratory for general health panel blood draw. Sample was inadvertently dropped and the patient was asked to return that afternoon to give another sample. Assign code and modifier if necessary.
Biopsy of deep tissue of shoulder area.
Patient with a fractured cervical vertebra undergoes a surgical vertebral decompression with fusion. One surgeon harvests a section of bone from the hip; the second surgeon performs the procedure. Assign the CPT code.
Excision of rectal tumor, transanal endoscopic microsurgical (TEMS) approach. Surgeon supplied regional anesthesia. Assign the CPT code.
On-call radiologist is called to the ED to review the four-x-ray views of a skull taken by radiology technician. Assign the CPT code.
Surgeon performs emergency laparoscopic cholecystectomy on a 550-pound patient. Complicated and extensive measures were necessary to complete the procedure. Assign the CPT code.
Dermatologist performs shaving of dermal lesion, 1.5 cm on arm of patient. Assign the CPT codes.
Closure of rectovaginal fistula using an abdominal approach.
Excision of intracardiac tumor, resection with cardiopulmonary bypass.
Colonoscopy with directed submucosal injection of any substance.
Radiologic examination of the hip, unilateral, with pelvis when performed using 3 views.
Color vision examination, extended, e.g., anomaloscope or equivalent.
While on vacation, a patient is rushed to surgery for laparoscopic treatment of ectopic pregnancy; she will see her regular OB/GYN when she returns home for aftercare. Assign the CPT code.
Paper For Above Instructions
The assignment involves assigning the appropriate CPT (Current Procedural Terminology) codes for various medical scenarios presented. Each scenario details patient encounters or medical procedures, requiring an understanding of medical coding to accurately classify the actions taken by healthcare providers.
1. For the preoperative examination by the PCP, level 4 E/M is indicated as the patient is seen the day before surgery. The relevant CPT code is 99204, as it reflects an established patient office visit with higher complexity.
2. The procedure involving the trimming of three nondystrophic nails, where anesthetic was administered due to patient anxiety, should be assigned the CPT code 11730 for trimming, along with modifier AA indicating that anesthesia services were provided.
3. The reconstruction of a toe due to polydactyly can be coded as 28020, which specifically describes the amputation and reconstruction of a congenital extra digit.
4. For the repair of a reducible umbilical hernia on an infant weighing less than 4 kg, the appropriate CPT code is 49500.
5. A nail bed repair would be coded as 11760, which accurately represents the repair of the nail bed.
6. The diagnosis of carpal tunnel syndrome with corticosteroid injection can be coded as 20526, confirming the injection treatment given.
7. The new patient visit discussing diabetes with a level 3 E/M would be categorized with the code 99203, as it meets the criteria for the level of complexity presented.
8. The situation involving a blood draw where the sample was dropped can be assigned CPT code 36415 for the venipuncture, combined with modifier 52 due to the incomplete service.
9. The biopsy of deep tissue of the shoulder is coded as 20206, which captures the complexity of the biopsy procedure.
10. For the surgical vertebral decompression with fusion for the fractured cervical vertebra, the CPT code is 63030 for the decompression procedure.
11. The excision of a rectal tumor using the transanal endoscopic microsurgical approach would be coded as 45389 for the surgical excision performed with regional anesthesia.
12. The on-call radiologist reviewing the x-ray views has a CPT code of 73560, which covers the examination of the hip and associated area.
13. The emergency laparoscopic cholecystectomy for a complicated case should be measured with the code 47630, reflecting the complexity required for completion of the procedure.
14. The dermatological shaving of the arm’s dermal lesion measures at 1.5 cm can be assigned CPT code 11301.
15. The closure of a rectovaginal fistula, specifically addressed via an abdominal approach, should comply with CPT code 45650.
16. Excision of an intracardiac tumor, where bypass was necessary during the procedure, utilizes CPT code 32999 for the resection with bypass specified.
17. A colonoscopy with directed submucosal injection can be noted as 45385, reflecting the detailed injection procedure.
18. The unilateral hip radiologic examination with pelvis, utilizing three views, can be classified with CPT code 73502.
19. An extended color vision examination is captured by the CPT code 99199, indicating its specialized nature.
20. For the laparoscopic treatment of ectopic pregnancy, the CPT code necessary is 58661, which details the procedure performed in an unexpected geographic location.
References
- AAPC. (2023). Handbook of Medical Coding. AAPC.