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A 45-year-old has a dislocated patella in the left knee after a car accident. She taken to the hospital by EMS for surgical treatment. In the surgery suite, the patient is placed under general anesthesi
a. After being prepped and draped, the surgeon makes an incision above the knee joint in front of the patella. Dissection is carried through soft tissue and reaching the patella in attempt to reduce the dislocation. When the patella is exposed, it is severely damaged due to cartilage breakdown. The tendon is dissected and using a saw the entire patella is freed and removed. The tendon sheath is closed with sutures.
What procedure code is reported for this surgery?
CPT code 27566 involves excision of the patella. Given the surgical description provided, this code is appropriate as the patella was severely damaged and removed entirely.
Patient's Condition: Dislocated patella with cartilage breakdown and severe damage.
Surgical Procedure: The surgeon made an incision, dissected through soft tissue, exposed, and completely removed the patella.
Coding Decision: CPT 27566 is chosen because it specifies excision of the patella. The modifier LT indicates the procedure was performed on the left side.
AMA's CPT Professional Edition (current year).
ICD-10-CM for corresponding diagnosis codes if needed.
A 42-year-old with chronic left trochanteric bursitis is scheduled to receive an injection at the Pain Clinic. A 22-gauge spinal needle is introduced into the trochanteric bursa under ultrasonic guidance, and a total volume of 8 cc of normal saline and 40 mg of Kenalog was injected.
What CPT code should be reported for the surgical procedure?
The injection into the trochanteric bursa under ultrasonic guidance is coded with CPT 20611, which describes an injection of a major joint or bursa with ultrasound guidance. The modifier -LT indicates the procedure was performed on the left side.
AMA's CPT Professional Edition (current year), Code 20611
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
Where is a Warthin's tumor found?
Warthin's tumor, also known as papillary cystadenoma lymphomatosum, is a benign tumor of the salivary glands, most commonly affecting the parotid gland. It typically presents as a painless, slow-growing mass near the angle of the jaw. Reference: ICD-10-CM, medical dictionaries, and oncology textbooks
A patient is diagnosed with diabetic polyneuropathy.
Using ICD-10-CM coding guidelines, what ICD-10-CM coding is reported?
Diabetic polyneuropathy is coded as E11.42, which indicates type 2 diabetes mellitus with diabetic polyneuropathy. The ICD-10-CM guidelines direct that when a patient has both diabetes and polyneuropathy, a single combination code is used to capture both conditions. Reference: ICD-10-CM (current year), Chapter 4: Endocrine, Nutritional, and Metabolic Diseases (E00-E89), ICD-10-CM Official Guidelines for Coding and Reporting, Section I.C.4.a.6.
