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The questions for CPC were last updated on Nov 19, 2024.
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A patient with empyema requires a Schede thoracoplasty.
What CPT code is reported for this procedure?
The Schede thoracoplasty for empyema is accurately described by CPT code 32905, which covers the radical procedure involving the resection of multiple ribs and often the obliteration of the pleural cavity to treat chronic empyema.
AMA's CPT Professional Edition (current year)
A patient presents with recurrent spontaneous episodes of dizziness of unclear etiology. Caloric vestibular testing is performed irrigating both ears with warm and cold water while evaluating the patient's eye movements. There is a total of three irrigations.
What CPT coding is reported?
Procedure: Caloric vestibular testing performed on both ears with three irrigations.
CPT Code:
92537: Caloric vestibular test with recording, bilateral; bithermal (i.e., one warm and one cool irrigation in each ear).
Modifier -50: Bilateral procedure.
Code Selection Justification: The procedure performed was bilateral caloric vestibular testing with bithermal irrigation, appropriately coded with 92537 and modifier -50 for bilateral procedures.
AMA 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.
A 55-year-old patient was recently diagnosed with an enlarged goiter. It has been two years since her last visit to the endocrinologist. A new doctor in the exact same specialty group will be examining her. The physician performs a medically appropriate history and exam. The provider reviewed the TSH results and ultrasound. The provider orders a fine needle aspiration biopsy which is a minor procedure.
What E/M code is reported?
The patient is seeing a new doctor in the same specialty group for an enlarged goiter and is undergoing a medically appropriate history and exam, along with a fine needle aspiration biopsy.
Procedure Description:
Medically appropriate history and exam.
Review of TSH results and ultrasound.
Ordering of fine needle aspiration biopsy.
CPT Coding:
99202: Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and straightforward medical decision making.
Since it has been two years since the last visit and the patient is being seen by a new doctor in the same specialty group, the encounter is considered a new patient visit.
AMA's CPT Professional Edition (current year).
CPT Assistant for detailed coding guidelines on evaluation and management services.
View MR 002395
MR 002395
Operative Report
Pre-operative Diagnosis: Acute rotator cuff tear
Post-operative Diagnosis: Acute rotator cuff tear, synovitis
Procedures:
1) Rotator cuff repair
2) Biceps Tenodesis
3) Claviculectomy
4) Coracoacromial ligament release
Indication: Rotator cuff injury of a 32-year-old male, sustained while playing soccer.
Findings: Complete tear of the right rotator cuff, synovitis, impingement.
Procedure: The patient was prepared for surgery and placed in left lateral decubitus position. Standard posterior arthroscopy portals were made followed by an anterior-superior portal. Diagnostic arthroscopy was performed. Significant synovitis was carefully debrided. There was a full-thickness upper 3rd subscapularis tear, which was repaired. The lesser tuberosity was debrided back to bleeding healthy bone and a Mitek 4.5 mm helix anchor was placed in the lesser tuberosity. Sutures were passed through the subcapulans in a combination of horizontal mattress and simple interrupted fashion and then tied. There was a partial-thickness tearing of the long head of the biceps. The biceps were released and then anchored in the intertubercular groove with a screw. There was a large anterior acromial spur with subacromial impingement. A CA ligament was released and acromioplasty was performed. Attention was then directed to the
supraspinatus tendon tear. The tear was V-shaped and measured approximately 2.5 cm from anterior to posterior. Two Smith & Nephew PEEK anchors were used for the medial row utilizing Healicoil anchors. Side-to-side stitches were placed. One set of suture tape from each of the medial anchors was then placed through a laterally placed Mitek helix PEEK knotless anchor which was fully inserted after tensioning the tapes. A solid repair was obtained. Next there were severe degenerative changes at the AC joint of approximately 8 to 10 mm. The distal clavicle was resected taking care to preserve the superior AC joint capsule. The shoulder was thoroughly lavaged. The instruments were removed and the incisions were closed in routine fashion. Sterile dressing was applied. The patient was transferred to recovery in stable condition.
What CPT coding is reported for this case?
29827: Arthroscopic rotator cuff repair is correctly coded as 29827.
29828: Arthroscopic biceps tenodesis is an additional procedure and should be coded as 29828 with modifier -51 (Multiple Procedures).
29824: Arthroscopic claviculectomy (partial resection of the distal clavicle) is coded as 29824 with modifier -51.
29826: Arthroscopic subacromial decompression, including coracoacromial ligament release, is coded as 29826.
All these procedures were performed arthroscopically and documented in the operative report, justifying the use of these codes and the use of modifier -51 for multiple procedures.
CPT Professional Edition, AMA
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