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?
For a follow-up examination after the removal of polyps with no new polyps found, the appropriate diagnosis codes are:
Z09: Encounter for follow-up examination after completed treatment for conditions other than malignant neoplasm.
Z86.010: Personal history of colonic polyps.
Using Z09 indicates that the follow-up exam is to check the patient after treatment, and Z86.010 indicates a history of colonic polyps, which is relevant to the patient's medical history.
ICD-10-CM guidelines
AMA's CPT Professional Edition (current year)
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?
Modifier 53 is used to report a discontinued procedure. It indicates that a procedure was started but terminated due to the patient's well-being being at risk. In this scenario, the percutaneous transluminal coronary angioplasty was attempted but stopped because of an anatomical problem that created a risk for the patient, preventing the completion of the procedure. Reference: AMA's CPT Professional Edition, coding guidelines on the use of modifiers.
Patient has esotropia of the right eye and presents to operating suite for strabismus surgery. The physician resects the medial rectus horizontal and lateral rectus muscles of the eye and secures them with adjustable sutures. Extensive scar tissue is noted, due to a previous surgery involving an extraocular muscle. Extraocular muscle is isolated, and the muscle is freed from surrounding scar tissues.
What CPT codes are reported for this surgery?
Esotropia of the right eye: Indicates strabismus surgery is required.
Resection of medial rectus horizontal and lateral rectus muscles: Specific muscles addressed during the surgery.
Adjustable sutures: Used in securing the muscles, indicating specific techniques.
Extensive scar tissue from previous surgery: Requires additional work and isolation.
CPT codes 67314 and 67334 are used to report the resection of two muscles with adjustable sutures (67314) and surgery on an extraocular muscle involving extensive scar tissue (67334).
Which statement regarding lesion excision is TRUE?
Lesion excision codes in the CPT codebook include the removal of the lesion along with the necessary margins and a simple (nonlayered) closure when performed. These codes do not cover intermediate or complex closures, which are reported separately if performed. The measurement for selecting the appropriate lesion excision code includes the lesion and the margins required for complete excision. Reference: AMA's CPT Professional Edition, lesion excision guidelines.
A 4-year-old, critically ill child is admitted to the PICU from the ED with respiratory failure due to an exacerbation of asthma not manageable in the ER. The PICU provider takes over the care of the patient and starts continuous bronchodilator therapy and pharmacologic support with cardiovascular monitoring and possible mechanical ventilation support.
What is the E/M code for this encounter?
The code 99471 is used for initial inpatient neonatal critical care, per day, for the evaluation and management of a critically ill infant or young child. Given the scenario where a 4-year-old critically ill child is admitted to the PICU and requires intensive care management, this code is appropriate as it reflects the critical care provided beyond the emergency department services. Reference: CPT Professional Edition (current year), AMA.
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