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An established patient suffering from migraines without aura, no mention of intractable migraine, and no mention of status migrainosus, is seen by his ophthalmologist who conducts a visual field examination of both eyes. The examination was accomplished plotting four isopters utilizing the Goldmann perimeter testing method. The patient and requesting physician receive the interpretation and report on the same date of service.
What procedure and diagnosis codes are reported for this encounter?
Procedure: Visual field examination of both eyes using Goldmann perimeter testing with four isopters.
CPT Code:
92082: This code is for visual field examination with intermediate examination.
ICD-10-CM Code:
G43.009: Migraine without aura, not intractable, without status migrainosus.
Code Selection Justification: The visual field exam method and complexity align with 92082. The patient's diagnosis of non-intractable migraine without aura is coded as G43.009.
AMA CPT Professional Edition (current year)
ICD-10-CM (current year)
Mr. Woolridge has had a suspicious lesion on his left shoulder for approximately eight weeks that is not healing. On the dermatologist's exam of left shoulder blade, there is excoriation and scabbing and the lesion not healing. Patient agrees and wishes to proceed with a punch biopsy of the lesion. A punch biopsy is taken of the lesion and sent to pathology. A simple repair is performed at the biopsy site.
What CPT and ICD-10-CM codes are reported?
CPT code 11102 is for punch biopsy of skin, including simple closure. CPT code 12001-51 is for simple repair of superficial wounds, with modifier 51 indicating multiple procedures. ICD-10-CM code D49.2 is used for a neoplasm of unspecified behavior of the bone, soft tissue, and skin. This coding accurately reflects the punch biopsy and simple repair performed on the lesion. Reference: AMA's CPT Professional Edition (current year), ICD-10-CM (current year)
Patient had polyps removed on a previous colonoscopy. The patient returns three months later for a follow-up examination for another colonoscopy. No new polyps are seen.
What diagnosis coding is reported for the second colonoscopy?
For a follow-up examination after the removal of polyps with no new polyps found, the appropriate diagnosis codes are:
Z09: Encounter for follow-up examination after completed treatment for conditions other than malignant neoplasm.
Z86.010: Personal history of colonic polyps.
Using Z09 indicates that the follow-up exam is to check the patient after treatment, and Z86.010 indicates a history of colonic polyps, which is relevant to the patient's medical history.
ICD-10-CM guidelines
AMA's CPT Professional Edition (current year)
A 47-year-old female presents to the operating room for a partial corpectomy on one upper thoracic vertebral body, T3. Two surgeons are performing the surgery. One surgeon performs the transthoracic approach and excises the damaged portion of the vertebral body. The second surgeon inserts a bone graft into the vertebral gap, closing the gap, and inserts a metal plate. Both surgeons work together, each as a primary surgeon.
How does each surgeon report their portion of the surgery?
For this scenario, two surgeons are working together, each as a primary surgeon. Therefore, the correct coding requires the use of the modifier -62, which indicates co-surgeons.
The transthoracic approach to excise the damaged portion of the vertebral body is coded with 63087.
The insertion of the bone graft and metal plate is coded with 63088.
Both codes are appended with modifier -62 to indicate that two surgeons worked together as primary surgeons on this case.
AMA's CPT Professional Edition (current year)
ICD-10-CM (current year)
HCPCS Level II (current year)
A 5-year-old who has an allergy history experienced a possible reaction to peanuts. A quantitative, high-sensitive fluorescent enzyme immunoassay was used to measure specific IgE for recombinant peanut components. Results showed there was no reaction indicating the child has a peanut allergy.
What lab test is reported?
For the quantitative, high-sensitive fluorescent enzyme immunoassay used to measure specific IgE for recombinant peanut components, the correct lab test code is 86003. This code is specific to quantitative allergen-specific IgE testing.
AMA's CPT Professional Edition (current year)
