View MR 004397
MR 004397
Operative Report
Preoperative Diagnosis: Calculi of the gallbladder
Postoperative Diagnosis: Calculi of the gallbladder, chronic cholecystitis
Procedure: Cholecystectomy
Indications: The patient is a 50-year-old woman who has a history of RUQ pain, which ultrasound revealed to be multiple gallstones. She presents for removal of her gallbladder.
Procedure: The patient was brought to the OR and prepped and draped in a normal sterile fashion. After adequate general endotracheal anesthesia was obtained, a trocar was placed and C02 was insufflated into the abdomen until an adequate pneumoperitoneum was achieved. A laparoscope was placed at the umbilicus and the gallbladder and liver bed were visualized. The gallbladder was enlarged and thickened, and there was evidence of chronic inflammatory changes. Two additional ports were placed and graspers were used to free the gallbladder from the liver bed with a combination of sharp dissection and electrocautery. Cystic artery and duct are clipped. Dye is injected in the gallbladder. Cholangiography revealed no intraluminal defect or obstruction. Gallbladder is dissected from the liver bed. The scope and trocars are removed.
What CPT coding is reported for this case?
47563: Laparoscopic cholecystectomy with cholangiography is coded as 47563. The report details the laparoscopic removal of the gallbladder with intraoperative cholangiography.
74300-26: The radiological supervision and interpretation for the cholangiography is coded as 74300 with modifier -26 (Professional Component) since the interpretation was done by the physician.
CPT Professional Edition, AMA
A 35-year-old female has cancer in her left breast. The surgeon performs a mastectomy, removing the breast tissue, skin, pectoral muscles, and surrounding tissue, including the axillary and internal mammary lymph nodes.
Which mastectomy code is reported?
For a mastectomy that involves removing the breast tissue, skin, pectoral muscles, and surrounding tissue, including the axillary and internal mammary lymph nodes, the appropriate CPT code is:
19306: Mastectomy, radical, including pectoral muscles, axillary lymph nodes.
This code captures the extent of the surgery, including the removal of the breast tissue, skin, pectoral muscles, and lymph nodes.
CPT Professional Edition (current year)
Surgery guidelines for mastectomy procedures
Which entity offers compliance program guidance to form the basis of a voluntary compliance program for a provider practice?
The Office of Inspector General (OIG) provides compliance program guidance to form the basis of a voluntary compliance program for provider practices. This guidance is intended to help healthcare providers develop effective internal controls to monitor adherence to applicable statutes, regulations, and program requirements of Federal healthcare programs. The OIG issues various compliance guidelines and resources to assist organizations in establishing comprehensive compliance programs to prevent fraud, waste, and abuse. Reference: OIG Compliance Program Guidance, AMA's CPT Professional Edition, and healthcare compliance resources.
The gastroenterologist performs a simple excision of three external hemorrhoids and one internal hemorrhoid, each lying along the left lateral column. The operative report indicates that the internal hemorrhoid is not prolapsed and is outside of the anal canal.
What CPT and ICD-10CM codes are reported?
CPT code 46255 describes the excision of both internal and external hemorrhoids, which matches the procedure described. The ICD-10-CM codes K64.0 (First degree hemorrhoids) and K64.4 (Residual hemorrhoids) describe the conditions treated.
AMA's CPT Professional Edition (current year), Code 46255
ICD-10-CM (current year), Codes K64.0, K64.4
A Medicare patient that is on dialysis for ESRD is seen by the nurse for a Hep B vaccination. This patient is given a dialysis patient dosage as part of a three-dose schedule. The nurse administers the Hep B vaccine in the right deltoid. The physician reviews the chart and signs off on the nurse's note.
What procedure and diagnosis codes are reported for the scheduled vaccine injection for this Medicare patient?
Procedure: Hepatitis B vaccine administration for a Medicare patient on dialysis.
CPT and HCPCS Codes:
G0010: Administration of Hepatitis B vaccine.
90740: Hepatitis B vaccine, dialysis or immunosuppressed patient dosage, 3-dose schedule.
ICD-10-CM Codes:
Z23: Encounter for immunization.
N18.6: End-stage renal disease.
Z99.2: Dependence on renal dialysis.
Code Selection Justification: G0010 is used for the administration of the vaccine for Medicare patients, and 90740 captures the specific vaccine for dialysis patients. The ICD-10 codes represent the encounter for vaccination and the patient's dialysis status.
AMA CPT Professional Edition (current year)
ICD-10-CM (current year)
HCPCS Level II (current year)
