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?

View MR 004397

MR 004397

Operative Report

Preoperative Diagnosis: Calculi of the gallbladder

Postoperative Diagnosis: Calculi of the gallbladder, chronic cholecystitis

Procedure: Cholecystectomy

Indications: The patient is a 50-year-old woman who has a history of RUQ pain, which ultrasound revealed to be multiple gallstones. She presents for removal of her gallbladder.

Procedure: The patient was brought to the OR and prepped and draped in a normal sterile fashion. After adequate general endotracheal anesthesia was obtained, a trocar was placed and C02 was insufflated into the abdomen until an adequate pneumoperitoneum was achieved. A laparoscope was placed at the umbilicus and the gallbladder and liver bed were visualized. The gallbladder was enlarged and thickened, and there was evidence of chronic inflammatory changes. Two additional ports were placed and graspers were used to free the gallbladder from the liver bed with a combination of sharp dissection and electrocautery. Cystic artery and duct are clipped. Dye is injected in the gallbladder. Cholangiography revealed no intraluminal defect or obstruction. Gallbladder is dissected from the liver bed. The scope and trocars are removed.

What CPT® coding is reported for this case?

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?

A 47-year-old female presents to the operating room for a partial corpectomy on one upper thoracic vertebral body, T3. Two surgeons are performing the surgery. One surgeon performs the transthoracic approach and excises the damaged portion of the vertebral body. The second surgeon inserts a bone graft into the vertebral gap, closing the gap, and inserts a metal plate. Both surgeons work together, each as a primary surgeon.

How does each surgeon report their portion of the surgery?

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?

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?

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 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?

Patient has cervical spondylosis with myelopathy. The surgeon performed a bilateral posterior laminectomy with facetectomies at each level and foraminotomies performed between interspaces C5-C6 and C6-C7. Bilateral decompression of the nerve roots is achieved.

What CPT® coding is reported?

A physician prescribes carbamazepine to treat a patient with epileptic seizures. After six months, the physician performs a therapeutic drug test to monitor the total level of the drug in the patient.

What CPT® and ICD-10-CM coding is used for the six month-evaluation?

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?

Where is a Warthin's tumor found?