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Eric is buying his first life insurance policy from XYZ Life Insurance Company. The company requires Eric have a physical exam prior to issuance of the policy. Eric sees his primary care provider who completes the required documentation and forms provided by the insurance company.
How does the primary care provider report his services?
CPT code 99450 is used for the examination of a patient for the purpose of establishing medical baseline information or for insurance purposes. Since Eric's primary care provider completed the required physical exam documentation for his life insurance policy, this is appropriately reported with code 99450. Reference: CPT Professional Edition (current year), AMA.
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?
Cervical spondylosis with myelopathy: Condition requiring decompressive surgery.
Bilateral posterior laminectomy, facetectomies, foraminotomies: Procedures performed to decompress nerve roots.
Interspaces C5-C6 and C6-C7: Specific levels where the procedures were performed.
CPT code 63045 is used for the initial cervical laminectomy, and 63048 is for each additional segment. The combination covers the decompression across two interspaces.
A 25-year-old woman underwent percutaneous breast biopsy on the right breast with placement of a Gelmark clip. The procedure was performed using stereotactic imaging.
What CPT codes will be reported?
CPT code 19081 is used for percutaneous biopsy of breast(s) using stereotactic guidance, which includes the placement of a localization device and imaging of the biopsy specimen when performed. This accurately describes the procedure performed on the right breast with the placement of a Gelmark clip using stereotactic imaging. The other codes either describe open biopsies or separate procedures that are not applicable here. Reference: AMA's CPT Professional Edition (current year)
View MR 006399
MR 006399
Operative Report
Preoperative Diagnosis: Chronic otitis media in the right ear
Postoperative Diagnosis: Chronic otitis media in the right ear
Procedure: Eustachian tube inflation
Anesthesia: General
Blood Loss: Minimal
Findings: Serous mucoid fluid
Complications: None
Indications: The patient is a 2-year-old who presented to the office with chronic otitis media refractory to medical management. The treatment will be eustachian tube inflation to remove the fluid. Risks, benefits, and alternatives were reviewed with the family, which include general anesthetic, bleeding, infection, tympanic membrane perforation, routine tubes, and need for additional surgery. The family understood these risks and signed the appropriate consent form.
Procedure in Detail: After the patient was properly identified, he was brought into the operating room and placed supine. The patient was prepped and draped in the usual fashion. General anesthesia was administered via inhalation mask, and after adequate sedation was achieved, a medium-sized speculum was placed in the right ear and cerumen was removed atraumatically using instrument with operative microscope. The tube is dilated, an incision is made to the tympanum and thick mucoid fluid was suctioned. The patient was awakened after having tolerated the procedure well and taken to the recovery room in stable condition.
What CPT coding is reported for this case?
The procedure involves eustachian tube inflation to remove serous mucoid fluid in the right ear of a 2-year-old patient with chronic otitis media.
Procedure Description:
Eustachian tube inflation to remove fluid.
General anesthesia.
Incision to the tympanum and suctioning of thick mucoid fluid.
CPT Coding:
69421-RT: Eustachian tube inflation, transnasal or transoral; with catheterization, including general anesthesia. The modifier -RT indicates the right ear.
AMA's CPT Professional Edition (current year).
CPT Assistant for detailed coding guidelines on eustachian tube procedures.
The outermost protective layer of skin is called the:
The outermost protective layer of the skin is called the epidermis. It serves as a barrier to protect the body against environmental elements, pathogens, and helps to retain moisture. The epidermis itself is composed of several sub-layers, with the stratum corneum being the outermost layer. Reference: ICD-10-CM (current year), Chapter 12: Diseases of the Skin and Subcutaneous Tissue (L00-L99).
