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Which place of service code is submitted on the claim for a service that is performed in an outpatient surgical floor?
The place of service code 22 is used for services performed in an outpatient hospital setting, including outpatient surgical floors. This code indicates that the procedure was done in a hospital but not requiring an inpatient admission.
AMA's CPT Professional Edition (current year), Place of Service Codes.
A 7-year-old boy was brought 10 the ED by his mother after he had been playing with small beads and one got lodged in his right external ear canal. After examination, the physician decided to remove the foreign body from the external auditory canal using alligator forceps without anesthesia.
What CPT code is reported?
69200 -- Removal of foreign body from external auditory canal; without anesthesia
Correct for simple removal using forceps
Patient tolerated procedure without anesthesia
Why Other Options Are Incorrect:
69110 / 69105 -- Middle ear procedures
69205 -- Removal with general anesthesia
A patient who was experiencing severe abdominal pain underwent abdominal imaging and results showed several peritoneal tumors of various sizes.
The patient elected to have the tumors removed. An incision was made to access the intra-abdominal peritoneal cavity, where four tumors were identified, measured, and excised.
The largest was 2 cm, two were 1 cm each, and the smallest was 0.5 cm. Pathology report indicated the tumors were malignant.
What CPT and ICD-10-CM coding is reported7
Procedure Coding:
49186 -- Excision or destruction of intra-abdominal tumors, 1--4 tumors
Four tumors excised correct code selection
Size does not alter code selection once tumor count is determined
Diagnosis Coding:
C48.2 -- Malignant neoplasm of peritoneum, unspecified
Pathology confirms malignancy
C76.2 is used for ill-defined sites, not appropriate when peritoneum is specified
Why Other Options Are Incorrect:
B -- 49187 is for 5 or more tumors
D -- K66.8 = non-malignant peritoneal disorder
A patient in a radiology facility has an X-ray examination of her lumbosacral spine due to pain while playing golf. The radiologist takes a complete 7-view of the lumbosacral spine, including
bending views.
What CPT code is reported?
1. Procedure and CPT Code Selection:
The patient underwent a 7-view X-ray of the lumbosacral spine, which included bending views. A complete set of views is captured.
CPT Code 72114 is appropriate for a complete lumbosacral spine X-ray with a minimum of six views. This code includes comprehensive imaging, such as bending and other specialized views, which were taken in this scenario.
2. Rationale for Excluding Other Options:
Code 72020 is for a single-view X-ray of the spine, which is not adequate to describe a 7-view series.
Code 72080 is for a two- or three-view X-ray of the thoracolumbar spine, which does not cover the full set of seven views described in this scenario.
Code 72084 represents a complete thoracic spine study with multiple views but does not specifically cover the lumbosacral spine, which is the focus of this X-ray examination.
3. AAPC and CPT Coding Guidelines:
According to AAPC and CPT guidelines, 72114 is the correct choice for a complete lumbosacral spine study involving multiple views, including specialized views like bending.
Therefore, the correct answer is C. 72114.
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?
The documentation describes making a skin incision off the tip of the twelfth rib and extending medially along the banger's lines of the skin. The use of electrocautery to gain access through multiple layers of musculature and fascia indicates an open surgical approach. Open surgery involves making a large incision to expose and directly view the surgical site. This is distinct from percutaneous (which involves needles or catheters), laparoscopic (which uses small incisions and a camera), and other minimally invasive techniques.
AMA's CPT Professional Edition, ICD-10-CM, and HCPCS Level II (current year)
