An asymmetric nevi, measuring 3.0 cm in length is excised from the patient’s back. The pathology report
identifies the specimen as “interdermal nevi.” What is the correct CPT code assignment for this
procedure? If you do not know what an interdermal nevi is, look it up!
Puncture aspiration of a cyst of the left breast
Simple closure of .9 cm laceration of the back
Repair of nail bed, third digit, left hand
Dressing of a small burn on a patient’s arm
Blepharoplasty of the right upper eyelid
Right shoulder dislocation reduction without anesthesia
Excision, benign lesion on the skin of the patient’s nose, 1.5 cm in length with .5 cm margins on EACH
side. An intermediate repair of the defect was also completed
The physician removes 5 cc of pus from a patient’s wrist. How is this procedure coded?
Closed manipulation of right radial shaft fracture
The physician removes a nasal polyp in the office suite. How is this coded?
A percutaneous needle biopsy of the lung is coded as
Removal of foreign body from nose, in the office
Blalock-Taussig shunt placement
Collection of a blood specimen from a completely implantable venous access device
Modified Fontan procedure
Placement of a non-tunneled central venous catheter in a 36-year-old male, inserted via the femoral vein
Seton placement
The physician performs an Anterior lumbar segmental instrumentation (T12-L4), Anterior lumbar multiple
level arthrodesis for deformity (T12-L4), and uses a bone autograft obtained from the same incision. How
is this coded?
S—Patient is a 68-year-old male who presents today for skin tag removal and treatment of
multiple actinic keratoses. He has several keratoses around the ears and several skin tags
around the neck. He would like to have the lesions examined and removed today.
O—Temp 97.6, pulse 70, resp 20, blood pressure 148/68. Weight of 198 pounds.
SKIN: Shows seven flatter skin tags noted along the neck line, but there are two pedunculated
skin tag lesions and a similar, larger one on the right upper/inner thigh.
He has two actinic keratoses on the chest and back.
He also has two more actinic keratoses located above the right ear and one above the left ear.
Patient also has some lesions that look like compound nevi on the back near the belt line. There
is a confluence of several darker compound nevi. They have regular borders and are
homogenous in color at this time. They do not appear to be any larger than 6 mm in size. No
treatment is done for these today.
A and P—
1. Skin tag removal. These areas were cleansed with alcohol. Curved iris and pickups were
used to snip the skin tags off at the base of the two skin tags around the neck. Triple antibiotic
ointment and a bandage was placed over these. For the skin tag in the right upper/inner thigh,
2% Xylocaine without epinephrine was used for anesthesia. It did have a somewhat large base
but a curved iris and pickups were used to cut the skin tag off at the base and handheld
electrocautery was used to control bleeding. Triple antibiotic ointment and a bandage was put
over this.
2. Multiple actinic keratoses were treated with liquid nitrogen. One keratosis on the chest, one
keratosis on the back, one keratosis above the right ear, one keratosis above the left ear. Each
were treated with liquid nitrogen.
3. Complex nevi. I advised him that he should have these looked at every six months, and he
will return for this.
S—This 17-year-old girl was struck in the nose by a baseball at school this morning. A 1.6 cm
laceration on the right side of her nose is present. There has been only minimal swelling
postinjury. She denies any loss of consciousness. She feels that her nasal airway was stuffy
before the injury and remains slightly congested.
Patient has mild right periorbital ecchymoses. There is deformity of the nasal bones with
angulation to the left. x-rays from Radiology Associates across the hallway show a nasal
fracture.
O—Temp 98.4 degrees. Pulse 92, resp 22, weight 126. Examination of the nasal airway reveals
dried blood in the superior left airway. There is some narrowing with septal deformity of the
superior portion of the right airway. Remainder of the examination of the ears, throat, and neck
were normal. Patient’s x-ray films were reviewed and demonstrate a fracture of the nasal bones.
They are minimally displaced on the x-ray. However, clinical evaluation reveals a moderate
deformity.
A and P—Displaced fracture of nasal bones, 1.6-cm laceration to skin on side of nose.
PROCEDURE: Under topical anesthesia with Pontocaine and Neo-Synephrine, the nasal cavity
was decongested. With closed instrument reduction, the fracture of the nasal bones was
reduced. There was a definite realignment of the nasal bones with good visible and palpable
reduction. The bones are stable postreduction. The 1.6-cm laceration was closed in a single
layer with two stitches after infiltration with 2% Lidocaine. The patient was advised to avoid
further trauma and given a nose guard to wear while sleeping. Avoid suture line with tape.
Return for follow-up in 7 days for suture removal.
Preoperative Diagnosis: Internal derangement left knee
Postoperative Diagnosis: Tear of lateral meniscus
Operative Procedure: Left knee arthroscopy, partial meniscectomy
The arthroscope was inserted through the routine superolateral portal as well as an inferomedial
portal for insertion of scope and instruments. The knee joint was then examined in routine
manner; the medial meniscus was intact. The lateral meniscus was partially detached and this
portion was removed. No other defects were noted. The knee was irrigated well using normal
saline. The instruments were removed from the knee. Wound closed with #4-0 nylon and
dressed. Estimated blood loss 0. Intravenous fluids 1,000 cc. Specimen: meniscus.
Assign CPT code(s) to the following operative report. Do not code any E/M, anesthesia, labs,
radiology,etc. We are coding the surgical codes only. Append modifiers, if applicable.
Preoperative Diagnosis: Chronic laryngitis with polypoid disease
Postoperative Diagnosis: Same
Procedure: Laryngoscopy with removal of polyps
After adequate premedication, the 60-year-old female patient was taken to the operating room
and placed in supine position. The patient was given a general oral endotracheal anesthetic with
a small endotracheal tube. The Jako laryngoscope was then inserted. Large polyps were noted
on both vocal cords, essentially obstructing the glottic airway when the tube was in place. The
polyps appeared larger on the right cord. Using the straight-cup forceps, the polyps were
removed from the left cord first. The polyps were removed from the right cord up to the anterior
commissure. Very minimal bleeding was noted. This opened up the airway extremely well. The
patient was extubated and sent to recovery in good condition
Procedure: Direct microlaryngoscopy under general anesthesia
Diagnosis: Dysphonia
Technique: A 40-year-Dld patient was taken to the OR where; under general a laryngoscope
was inserted with the operating microscope to perform a laryngoscopy. The vocal cords were
found to be totally normal on both sides with no evidence of nodules or granuloma formation.
The entire endolarynx was well visualized. Moreover, there was no evidence of subglottic
stenosis; and as the patient was awakening, vocal cord mobility appeared to be normal. The
procedure was completed, and the patient awakened and was taken to the recovery room in
good condition with stable vital signs.
Preoperative Diagnosis: Symptomatic third-degree heart block
Postoperative Diagnosis: Same
Operation: Placement of permanent pacemaker with transvenous electrode, ventricle
Anesthesia: Local infiltration of lidocaine 1%, total volume 13cc
Complications: None
Indications: This 74-year-old man was admitted with a diagnosis of three-degree heart block
complicated by congestive cardiac failure. Patient is schedule for placement of a permanent
pacemaker today.
Procedures: With the patient supine on the operating table with a shoulder roll placed beneath
the thoracic spine, the chest was prepared and draped in a sterile fashion. In the right
infraclavicular region, a subcutaneous pocket was created for containing the pulse generator.
Using an introducer guide wire, a sheath technique bipolar-targeted lead was introduced into the
right subclavian vein. Under fluoroscopy control, this was directed into the right ventricle. Two
initial locations were not satisfactory for pacing parameters. Finally, the pacemaker was
positioned in satisfactory position with the following parameters: at the threshold 0.4 volts,
current 1.5 milliamps, and R wave 15. The pacing system analyzer was then turned to 10 volts
output and the diaphragm observed for pulsations, which were not proven. The lead was then
secured under the clavicle with a single suture of 2-0 Ethibond. It was then attached to a 5794
Medtronic low-profile VVI pacemaker programmed at 70 beats per minute. The pulse generator
was then anchored in the subcutaneous pocket with a single 0 PDS suture. The subcutaneous
tissue was then approximated with 2-0 PDS and the skin approximated with 4-0 Maxon. Sterile
dressing was applied. A chest x-ray was obtained, which showed no pneumothorax and
satisfactory position of the lead. The patient was then returned to the coronary care unit in good
condition.
Preoperative Diagnosis: Squamous cell carcinoma of the left forearm, 8 mm
Postoperative Diagnosis: Same
Procedure: Excision of the .8 cm lesion with .5 cm margins on each side, layered primary
closure, totaling 4 cm in length
Anestetic: Local
Brief Clinical History: The patient had a biopsy-proven squamous cell carcinoma of the left
forearm. After explanation of the risks, benefits, and alternatives, she agreed to re-excision and
closure. She understood that there would be a scar as a result.
Details of Procedure: The patient was taken to the outpatient operating area. An ellipse was
taken around the primary lesion with .5-cm margins for excision around the .8 cm lesion. The
area was infiltrated with 1/2% Xylocaine with 1:200,000 epinephrines and approximately 5 cc
was used. The area was prepared with Betadine paint and draped in a sterile manner. The
lesion was elliptically excised. After excision, the elliptical defect was closed in layers with 40PDS totally 4 cm in length. The deep subcutaneous layer was closed separately and then a
running subcuticular layer was performed. She tolerated the procedure well. She was given
instructions for local care and will return in 9 days for a checkup and suture removal.
Preoperative Diagnosis: Multiple lacerations to both ears
Postoperative Diagnosis: Multiple lacerations to both ears, one laceration to the left ear and a
series of four lacerations to the right ear.
Anesthetic: Local anesthetic was used. 1% Carbocaine Plain
Indications: The patient sustained the above-named lacerations when she was involved in a
hay wagon accident.
Procedure: The patient was treated in the emergency department. The right ear was treated
first. There were a total of 4 lacerations on the right ear treated. The two smaller, more
superficial lacerations, measuring 1.0 cm each were closed in a single layer after the wounds
had been infiltrated with 1% carbocaine and then cleaned copiously with Betadine, saline, and
peroxide. They were closed with simple interrupted #6-0 Prolene sutures.
The two other lacerations on the right ear, totaling 3 cm in length (one laceration was 1.2 cm in
length and the other laceration was 1.8 cm in length) were closed in multiple layers with #5-0
Vicryl suture after they had been infiltrated with 1% carbocaine prepared and draped in the
appropriate fashion using Betadine, peroxide, and saline. The superficial layers were closed
with interrupted #6-0 Prolene suture. After the right ear was completed the wounds were
covered with polysporin.
The 2.0 cm laceration on the left ear was then closed in a single layer. It was infiltrated with 1%
carbocaine. After the wound was cleaned with Betadine, saline, and peroxide the superficial
layers were closed with interrupted #6-0 Prolene suture. The wounds were then covered with
polysporin.
Preoperative Diagnosis: Dermal Cyst of right breast
Postoperative Diagnosis: Same
Procedure Performed: Excision of Dermal Cyst of right breast
Description of Procedure: Erythematous dermal cystic area of the right breast was marked out
with an elliptical incision, anesthetized with local anesthesia, and prepped and draped sterilely.
Incision was made elliptically, including the whole cyst down through the fatty tissue. On
palpation afterward, no abnormalities were noted. Then the area had hemostasis obtained with
electrocautery. The incision was closed with interrupted 3-0 Vicryl sutures. The skin was closed
with interrupted 5-0 nylon sutures. Steri-Strips and a sterile dressing were applied over it. The
patient tolerated the procedure well and was sent to the recovery room with instructions to be
discharged home with follow-up appointment given.
History of Present Illness: The patient is a 53-year-old man who has dislocated his right
shoulder three previous episodes. Today, he was kayaking and dislocated his shoulder while
paddling.
Past Medical History: Previous right shoulder dislocation
Medications: Vitamins
Allergies: Sulfa
Physical Examination: Alert male in no acute distress
Right Upper Extremity: He has obvious deformity with loss of the right shoulder prominence
with a palpable anterior dislocation of the humeral head. He has good distal pulses with the
remainder of his arm being nontender. X-ray of his right shoulder shows an anterior dislocation.
Diagnosis: Reduction of the shoulder dislocation. The patient was placed on a monitor with
continuous pulse oximetry. He was given Demerol and Phenergan IV for pain control. In-line
traction and reduction was accomplished after three attempts. Reduction films showed good
position of the shoulder. He had good distal neurovascular status after reduction. He tolerated
the procedure well.
Disposition and Plan: Anterior dislocation, right shoulder
Sling and swathe for 2 to 3 days. Vicodin #30. Follow up with Dr. Smith in 1 to 2 days or call for
an orthopedic referral. The patient states he has been avoiding any potential surgery at this
point and would prefer to avoid it. I explained to him that he should follow up with Dr. Smith or
an orthopedist. He should not use the shoulder in the next several days until reevaluation
Chief Complaint: Lacerations; left face
History of Present Illness: Patient is a 26-year-old man who was driving a car with the window
down when another car moving in the opposite direction hit his mirror. Glass from the broken
mirror flew into his face, and he sustained two small lacerations. There were no other injuries.
Past Medical History: Unremarkable
Medications: None
Allergies: None
Physical Examination
General: Alert male in no acute distress
HEENT: Pupils are equal and reactive to light. Extraocular muscles intact. Nose is clear.
Oropharynx negative. Two lacerations are on left cheek region. The uppermost laceration is
about 2 cm below the eye laterally and is about 0.75 cm in length. Full-skin thickness. The
second laceration is about 1.5 cm below the first and is 1.25 cm in length. Full-skin thickness.
No palpable foreign bodies.
1.
2.
Procedure: Local injection with a total of 3 cc's 1% lidocaine with epinephrine. Prepped and
routine exploration performed. The upper laceration is only about 5 mm deep. No foreign bodies
noted. No neurovascular injuries. It was closed with three 6-0 nylon sutures. The lower
laceration was approximately 12 to 15 mm deep. I could not palpate any foreign bodies. There
are no obvious neurovascular injuries. Closed in single layer with five 6-0 nylon sutures.
Polysporin ointment was applied. X-ray to rule out foreign body negative
Diagnosis:
Simple facial laceration, 1.25 cm
Simple facial laceration, 0.75 cm
Disposition and Plan: Wound care instructions given; sutures out in 5 to 7 days.
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