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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® and ICD-10-CM code is reported?

A patient in a radiology facility has an X-ray examination of her thoracolumbar junction due to pain while playing golf. The patient also has limited mobility in the hip. A radiologist takes a two view of the thoracolumbar junction.

What CPT® code is reported'

A patient arrived at the emergency department experiencing pain in both legs. The ED physician ordered a comprehensive duplex scan of the arteries in both lower extremities to rule out arteriosclerosis.

What CPT® and ICD-10-CM codes are reported?

A 45-year-old female presents to the ED with chest pain. The provider has an Albumin Cobalt Binding Test to determine if the chest pain is ischemic in nature.

That lab test is reported?

An MRI guided cisternal puncture with diagnostic contrast injection is performed at the C2 level for cervical discography, with imaging supervision and interpretation.

What CPT® coding is reported?

A physician conducts a 15-minute phone call discussing medication management.

How is this reported?

Repeat three-view imaging of both hips and pelvis is performed on the same day due to a new fall, interpreted by the same radiologist.

What CPT® coding is reported?

In medical terminology, suffixes indicate the procedure, condition, disorder, or disease.

Which term contains a suffix?

A planned partial meniscectomy of the temporomandibular joint is cancelled after anesthesia and incision due to respiratory distress.

What CPT® coding is reported for the oral surgeon?

A patient presents to the ER from a nursing home after the patient was found to have foul smelling, large sacral pressure ulcer during daily nursing rounds. The ER provider swabbed the wound

for culture (which measured at 7cm in largest diameter); then cleaned the site before painting with povidone around the entire sacrum to reduce cutaneous bacterial load. The provider made an

elliptical excision with 3mm margins around the outer edge of the ulcer and removed the lesion in its entirety. Further examination revealed deep tissue damage, prompting muscle and

segmental bone removal. The wound was then closed using a layered skin flap closure.

What CPT® coding and ICD-10-CM coding is reported?