CPT/ HCPcs coding help 50000 Urinary System, Male Genital System, Female Genital System, and Maternity Care and Delivery 24728 This patient is a

CPT/ HCPcs coding help

50000 Urinary System, Male Genital System, Female Genital System, and

Maternity Care and Delivery

24728 This patient is a 42-year-old female who has been having prolonged and heavy bleeding during menstruation.

SURGICAL FINDINGS: On pelvic exam under anesthesia, the uterus was normal size and firm. The examination revealed no masses. She had a few small endometrial polyps in the lower uterine segment.

DESCRIPTION OF PROCEDURE: After induction of general anesthesia, the patient was placed in the dorsolithotomy position, after which the perineum and vagina were prepped, the bladder straight catheterized, and the patient draped. After bimanual exam was performed, a weighted speculum was placed in the vagina and the anterior lip of the cervix was grasped with a single toothed tenaculum. An endocervical curettage was then done with a Kevorkian curet. The uterus was then sounded to 8.5 cm. The endocervical canal was dilated to 7 mm with Hegar dilators. A 5.5-mm Olympus hysteroscope was introduced using a distention medium. The cavity was systematically inspected, and the preceding findings noted. The hysteroscope was withdrawn and the cervix further dilated to 10 mm. Polyp forceps was introduced, and a few small polyps were removed. These were sent separately. Sharp endometrial curettage was then done. The hysteroscope was then reinserted, and the polyps had essentially been removed. The patient tolerated the procedure well and returned to the recovery room in stable condition. Pathology confirmed benign endometrial polyps.

24729 This patient is 35 years old at 36 weeks' gestation. She presented in spontaneous labor. Because of her prior cesarean section, she is taken to the operating room to have a repeat lower-segment transverse cesarean section performed. The patient also desires sterilization, and so a bilateral tubal ligation will also be performed. A single, liveborn infant was the outcome of the delivery.

60000 Endocrine System, Hemic and Lymphatic Systems, Nervous System, Eye and Ocular Adnexa, Auditory System

24732 OPERATIVE REPORT

PREOPERATIVE DIAGNOSIS: Herniated disc L4-5 on the left.

PROCEDURE PERFORMED: Laminotomy, foraminotomy, removal of herniated disc L4-5 on the left.

PROCEDURE: Under general anesthesia, the patient was placed in the prone position and the back was prepped and draped in the usual manner. An incision was made in the skin extending through subcutaneous tissue. Lumbodorsal fascia was divided. The erector spinae muscles were bluntly dissected from the lamina of L4-5 on the left. The interspace was localized. I then performed a generous laminotomy and foraminotomy here, and retracted on the nerve root. It was obvious there was a herniated disc. I removed it, entered the space, and removed degenerating material, satisfied that I had decompressed the root well. There were free fragments lying around beneath the nerve root. We removed all of these. I was able to pass a hockey stick down the foramen across the midline, satisfied I had taken out the large fragments from the interspace at L4-5, and decompressed it well. I irrigated the wound well, put a Hemovac drain in the wound, and then closed the wound in layers using double-knotted 0 chromic on the lumbodorsal fascia with Vicryl, 2-0 plain in the subcutaneous tissue, and surgical staples on the skin. A dressing was applied. The patient was discharged to the recovery room.

24733 This patient came in with an obstructed ventriculoperitoneal shunt. The procedure performed was to be a revision of shunt. After inspecting the shunt system, the entire cerebrospinal fluid shunt system was removed and a similar replacement shunt system was placed. Patient has normal pressure hydrocephalus (NPH).

Evaluation and Management (E/M)

24735 Dr. Martin admits a 65-year-old female patient to the hospital to rule out acute pericarditis following a severe viral infection. The patient has complained of retrosternal, sharp, intermittent pain of 2 days' duration that is reduced by sitting up and leaning forward, accompanied by tachypnea. ROS: She does not currently have chest pain but is complaining of shortness of breath. She states that her legs and feet have been swollen of late. She reports no change in her vision or her hearing, and she has not had a rash. No dyspnea stated. PFSH: She states that she has had and echocardiogram in the past when she complained of chest tightness and her family physician gave her some medication, but she is not certain what it was. She has three adult children, all healthy. Her husband is deceased. She does not smoke or consume alcohol. Her father died at age 69 from congestive heart failure and her mother died of influenza at 70. Refer to the admission form for a list of current medications. The examination was detailed. The medical decision making was of high complexity.

24736 A gynecologist admits an established patient, a 35-year-old female with dysfunctional uterine bleeding, after seeing her in the clinic that day. During the course of the history, the physician notes that the patient has a history of infrequent periods of heavy flow. She has had irregular heavy periods and intermittent spotting for 4 years. The patient has been on a 3-month course of oral contraceptives for symptoms with no relief. The patient states that she has occasional headaches. A complete ROS was performed, consisting of constitutional factors, ophthalmologic, otolaryngologic, cardiovascular, respiratory, gastrointestinal, genitourinary, musculoskeletal, integumentary, neurologic, psychiatric, endocrine, hematologic, lymphatic, allergic, and immunologic which were all negative, except for the symptoms described above. The family history is positive for endometrial cancer, with mother, two aunts, and two sisters who had endometrial cancer. The patient has a personal history of cervical and endometrial polyp removal 3 years prior to admission. The patients states that she does not smoke and only drinks socially. As a part of the comprehensive examination, the physician notes the patient has a large amount of blood in the vault and an enlarged uterus. The prolonged hemorrhaging has resulted in a very thin and friable endometrial lining. The physician orders the patient to be started on intravenous Premarin and orders a full laboratory workup. The medical decision making is of moderate complexity.

24738 A neurological consultation in the emergency department of the local hospital is requested by the ED physician for a 25-year-old male with suspected closed head trauma. The neurologist saw the patient in the ED. The patient had a loss of consciousness this morning after receiving a blow to the head in a basketball game. He presents to the emergency department with a headache, dizziness, and confusion. During the course of the history, the patient relates that he has been very irritable, confused, and has had a bit of nausea since the incident. All other systems reviewed and are negative: Constitutional, ophthalmologic, otolaryngologic, cardiovascular, respiratory, genitourinary, musculoskeletal, integumentary, psychiatric, endocrine, hematologic, lymphatic, allergic, and immunologic. The patients states that he does have a history of headaches and that both parents have hypertension, also a grandfather with heart disease. He also states that he does drink beer on the weekends and does not smoke. Physical examination reveals the patient to be unsteady and exhibiting difficulty in concentration when stating months in reverse. The pupils dilate unequally. The physician continues with a complete comprehensive examination involving an extensive review of neurological function. The neurologist orders a stat CT and MRI. The physician suspects a subdural hematoma or an epidural hematoma and the medical decision-making complexity is high. The neurologist admits the patient to the hospital. Assign codes for the neurologist's services only.

 24740 Karra Hendricks, a 37-year-old female, is an established patient who presents to the office with right lower quadrant abdominal pain with fever. The patient states she has had the pain for 3 days. She has taken Tylenol for her fever with some relief. The patient does have occasional diarrhea and headaches. She smokes approximately 5-10 cigarettes a day and drinks socially. The physician performs a problem focused examination. The medical decision making is noted to be of a moderate complexity.

70000 Radiology

Direction: Report only the professional component unless specifically directed to do otherwise within the Radiology question.

24742 This 69-year-old female is in for a magnetic resonance examination of the brain because of new seizure activity. After imaging without contrast, contrast was administered and further sequences were performed. Examination results indicated no apparent neoplasm or vascular malformation.

80000 Pathology and Laboratory

Direction:

24743 This 69-year-old female presents to the laboratory after her physician ordered

quantitative and qualitative assays for troponin to assist in the diagnosis of her chief complaint of acute onset of chest pain.

90000 Medicine

24744 INDICATION: Pulmonary hypertension with newly diagnosed acute myocardial infarction.

PROCEDURE PERFORMED: Insertion of Swan-Ganz catheter.

DESCRIPTION OF PROCEDURE: The right internal jugular and subclavian area was prepped with antiseptic solution. Sterile drapes were applied. Under usual sterile precautions, the right internal jugular vein was cannulated. A 9-French introducer was inserted, and a 7-French Swan-Ganz catheter was inserted without difficulty. Right atrial pressures were 2 to 3, right ventricular pressures 24/0, and pulmonary artery 26/9 with a wedge pressure of 5. This is a Trendelenburg position. The patient tolerated the procedure well.

24745 DIAGNOSIS: Atrial flutter.

PROCEDURE PERFORMED: Electrical cardioversion.

DESCRIPTION OF PROCEDURE: The patient was sedated with Versed and morphine. She was given a total of 5 mg of Versed. She was cardioverter with 50

joules into sinus tachycardia.

The patient was given a 20-mg Cardizem IV push. Her heart rate went down to the 110s, and she was definitely in sinus tachycardia.

CONCLUSION: Successful electrical cardioversion of atrial flutter into sinus tachycardia.50000 Urinary System, Male Genital System, Female Genital System, and

Maternity Care and Delivery

24728 This patient is a 42-year-old female who has been having prolonged and heavy bleeding during menstruation.

SURGICAL FINDINGS: On pelvic exam under anesthesia, the uterus was normal size and firm. The examination revealed no masses. She had a few small endometrial polyps in the lower uterine segment.

DESCRIPTION OF PROCEDURE: After induction of general anesthesia, the patient was placed in the dorsolithotomy position, after which the perineum and vagina were prepped, the bladder straight catheterized, and the patient draped. After bimanual exam was performed, a weighted speculum was placed in the vagina and the anterior lip of the cervix was grasped with a single toothed tenaculum. An endocervical curettage was then done with a Kevorkian curet. The uterus was then sounded to 8.5 cm. The endocervical canal was dilated to 7 mm with Hegar dilators. A 5.5-mm Olympus hysteroscope was introduced using a distention medium. The cavity was systematically inspected, and the preceding findings noted. The hysteroscope was withdrawn and the cervix further dilated to 10 mm. Polyp forceps was introduced, and a few small polyps were removed. These were sent separately. Sharp endometrial curettage was then done. The hysteroscope was then reinserted, and the polyps had essentially been removed. The patient tolerated the procedure well and returned to the recovery room in stable condition. Pathology confirmed benign endometrial polyps.

24729 This patient is 35 years old at 36 weeks' gestation. She presented in spontaneous labor. Because of her prior cesarean section, she is taken to the operating room to have a repeat lower-segment transverse cesarean section performed. The patient also desires sterilization, and so a bilateral tubal ligation will also be performed. A single, liveborn infant was the outcome of the delivery.

60000 Endocrine System, Hemic and Lymphatic Systems, Nervous System, Eye and Ocular Adnexa, Auditory System

24732 OPERATIVE REPORT

PREOPERATIVE DIAGNOSIS: Herniated disc L4-5 on the left.

PROCEDURE PERFORMED: Laminotomy, foraminotomy, removal of herniated disc L4-5 on the left.

PROCEDURE: Under general anesthesia, the patient was placed in the prone position and the back was prepped and draped in the usual manner. An incision was made in the skin extending through subcutaneous tissue. Lumbodorsal fascia was divided. The erector spinae muscles were bluntly dissected from the lamina of L4-5 on the left. The interspace was localized. I then performed a generous laminotomy and foraminotomy here, and retracted on the nerve root. It was obvious there was a herniated disc. I removed it, entered the space, and removed degenerating material, satisfied that I had decompressed the root well. There were free fragments lying around beneath the nerve root. We removed all of these. I was able to pass a hockey stick down the foramen across the midline, satisfied I had taken out the large fragments from the interspace at L4-5, and decompressed it well. I irrigated the wound well, put a Hemovac drain in the wound, and then closed the wound in layers using double-knotted 0 chromic on the lumbodorsal fascia with Vicryl, 2-0 plain in the subcutaneous tissue, and surgical staples on the skin. A dressing was applied. The patient was discharged to the recovery room.

24733 This patient came in with an obstructed ventriculoperitoneal shunt. The procedure performed was to be a revision of shunt. After inspecting the shunt system, the entire cerebrospinal fluid shunt system was removed and a similar replacement shunt system was placed. Patient has normal pressure hydrocephalus (NPH).

Evaluation and Management (E/M)

24735 Dr. Martin admits a 65-year-old female patient to the hospital to rule out acute pericarditis following a severe viral infection. The patient has complained of retrosternal, sharp, intermittent pain of 2 days' duration that is reduced by sitting up and leaning forward, accompanied by tachypnea. ROS: She does not currently have chest pain but is complaining of shortness of breath. She states that her legs and feet have been swollen of late. She reports no change in her vision or her hearing, and she has not had a rash. No dyspnea stated. PFSH: She states that she has had and echocardiogram in the past when she complained of chest tightness and her family physician gave her some medication, but she is not certain what it was. She has three adult children, all healthy. Her husband is deceased. She does not smoke or consume alcohol. Her father died at age 69 from congestive heart failure and her mother died of influenza at 70. Refer to the admission form for a list of current medications. The examination was detailed. The medical decision making was of high complexity.

24736 A gynecologist admits an established patient, a 35-year-old female with dysfunctional uterine bleeding, after seeing her in the clinic that day. During the course of the history, the physician notes that the patient has a history of infrequent periods of heavy flow. She has had irregular heavy periods and intermittent spotting for 4 years. The patient has been on a 3-month course of oral contraceptives for symptoms with no relief. The patient states that she has occasional headaches. A complete ROS was performed, consisting of constitutional factors, ophthalmologic, otolaryngologic, cardiovascular, respiratory, gastrointestinal, genitourinary, musculoskeletal, integumentary, neurologic, psychiatric, endocrine, hematologic, lymphatic, allergic, and immunologic which were all negative, except for the symptoms described above. The family history is positive for endometrial cancer, with mother, two aunts, and two sisters who had endometrial cancer. The patient has a personal history of cervical and endometrial polyp removal 3 years prior to admission. The patients states that she does not smoke and only drinks socially. As a part of the comprehensive examination, the physician notes the patient has a large amount of blood in the vault and an enlarged uterus. The prolonged hemorrhaging has resulted in a very thin and friable endometrial lining. The physician orders the patient to be started on intravenous Premarin and orders a full laboratory workup. The medical decision making is of moderate complexity.

24738 A neurological consultation in the emergency department of the local hospital is requested by the ED physician for a 25-year-old male with suspected closed head trauma. The neurologist saw the patient in the ED. The patient had a loss of consciousness this morning after receiving a blow to the head in a basketball game. He presents to the emergency department with a headache, dizziness, and confusion. During the course of the history, the patient relates that he has been very irritable, confused, and has had a bit of nausea since the incident. All other systems reviewed and are negative: Constitutional, ophthalmologic, otolaryngologic, cardiovascular, respiratory, genitourinary, musculoskeletal, integumentary, psychiatric, endocrine, hematologic, lymphatic, allergic, and immunologic. The patients states that he does have a history of headaches and that both parents have hypertension, also a grandfather with heart disease. He also states that he does drink beer on the weekends and does not smoke. Physical examination reveals the patient to be unsteady and exhibiting difficulty in concentration when stating months in reverse. The pupils dilate unequally. The physician continues with a complete comprehensive examination involving an extensive review of neurological function. The neurologist orders a stat CT and MRI. The physician suspects a subdural hematoma or an epidural hematoma and the medical decision-making complexity is high. The neurologist admits the patient to the hospital. Assign codes for the neurologist's services only.

 24740 Karra Hendricks, a 37-year-old female, is an established patient who presents to the office with right lower quadrant abdominal pain with fever. The patient states she has had the pain for 3 days. She has taken Tylenol for her fever with some relief. The patient does have occasional diarrhea and headaches. She smokes approximately 5-10 cigarettes a day and drinks socially. The physician performs a problem focused examination. The medical decision making is noted to be of a moderate complexity.

70000 Radiology

Direction: Report only the professional component unless specifically directed to do otherwise within the Radiology question.

24742 This 69-year-old female is in for a magnetic resonance examination of the brain because of new seizure activity. After imaging without contrast, contrast was administered and further sequences were performed. Examination results indicated no apparent neoplasm or vascular malformation.

80000 Pathology and Laboratory

Direction:

24743 This 69-year-old female presents to the laboratory after her physician ordered

quantitative and qualitative assays for troponin to assist in the diagnosis of her chief complaint of acute onset of chest pain.

90000 Medicine

24744 INDICATION: Pulmonary hypertension with newly diagnosed acute myocardial infarction.

PROCEDURE PERFORMED: Insertion of Swan-Ganz catheter.

DESCRIPTION OF PROCEDURE: The right internal jugular and subclavian area was prepped with antiseptic solution. Sterile drapes were applied. Under usual sterile precautions, the right internal jugular vein was cannulated. A 9-French introducer was inserted, and a 7-French Swan-Ganz catheter was inserted without difficulty. Right atrial pressures were 2 to 3, right ventricular pressures 24/0, and pulmonary artery 26/9 with a wedge pressure of 5. This is a Trendelenburg position. The patient tolerated the procedure well.

24745 DIAGNOSIS: Atrial flutter.

PROCEDURE PERFORMED: Electrical cardioversion.

DESCRIPTION OF PROCEDURE: The patient was sedated with Versed and morphine. She was given a total of 5 mg of Versed. She was cardioverter with 50

joules into sinus tachycardia.

The patient was given a 20-mg Cardizem IV push. Her heart rate went down to the 110s, and she was definitely in sinus tachycardia.

CONCLUSION: Successful electrical cardioversion of atrial flutter into sinus tachycardia.