A 60-year-old male suffering from degenerative disc disease at the L3-L4 and L5-S1 levels was placed under general anesthesi
a. Using an anterior approach, the L3-L4 disc space was exposed. Using blunt dissection, the disc space was cleaned. The disc space was then sized and trialed. Excellent placement and insertion of the artificial disc at L3-L4 was noted. The area was inspected and there was no compression of any nerve roots. Same procedure was performed on L5-S1 level. Peritoneum was then allowed to return to normal anatomic position and entire area was copiously irrigated. The wound was closed in a layered fashion. The patient tolerated the discectomy and arthroplasty well and was returned to recovery in good condition. What CPT coding is reported for this procedure?
This scenario describes an anterior discectomy and arthroplasty at two levels (L3-L4 and L5-S1) using artificial discs. CPT code 22857 describes total disc arthroplasty (artificial disc), anterior approach, including discectomy to prepare interspace (other than for decompression), single interspace, lumbar. Since the procedure was performed at two levels, the code should be reported twice.
AMA's CPT Professional Edition (current year), Code 22857
The human shoulder is made of which three bones?
The human shoulder is composed of three main bones: the clavicle (collarbone), scapula (shoulder blade), and humerus (upper arm bone). These bones form the shoulder joint, which is one of the most flexible and mobile joints in the human body, allowing for a wide range of motion. Reference: AMA's CPT Professional Edition (current year), Musculoskeletal System section.
A patient has chronic cholesteatoma in the right middle ear. The otolaryngologist performed a tympanoplasty with a radical mastoidectomy, removing the middle ear cholesteatom
a. Grafting technique was used to repair the eardrum without ossicular chain reconstruction.
What CPT code is reported for this surgery?
The procedure involves a tympanoplasty with a radical mastoidectomy and removal of a cholesteatoma from the middle ear, including grafting of the eardrum without ossicular chain reconstruction.
Procedure Description:
Tympanoplasty.
Radical mastoidectomy.
Removal of cholesteatoma from the middle ear.
Grafting technique used to repair the eardrum without ossicular chain reconstruction.
CPT Coding:
69645: Tympanoplasty with mastoidectomy (including canalplasty, atticotomy and/or middle ear surgery), radical or complete, with removal of cholesteatoma; with mastoid obliteration.
AMA's CPT Professional Edition (current year).
CPT Assistant for detailed coding guidelines on otolaryngology procedures.
A patient presents to the labor and delivery department for a planned cesarean section for triplets. She is at 37 weeks gestation. She is given a continuous epidural for the delivery.
What anesthesia coding is reported?
The patient presents for a planned cesarean section for triplets and receives continuous epidural anesthesia. CPT code 01967 is used for neuraxial labor analgesia/anesthesia for planned vaginal delivery, and code 01968 is an add-on code for cesarean delivery following neuraxial labor analgesia/anesthesia. Since this is a planned cesarean section with triplets, both codes 01967 and 01968 are applicable. Reference: CPT Professional Edition (current year), AMA.
Which statement regarding lesion excision is TRUE?
Lesion excision codes in the CPT codebook include the removal of the lesion along with the necessary margins and a simple (nonlayered) closure when performed. These codes do not cover intermediate or complex closures, which are reported separately if performed. The measurement for selecting the appropriate lesion excision code includes the lesion and the margins required for complete excision. Reference: AMA's CPT Professional Edition, lesion excision guidelines.
