Part 1

Review the following scenario. Assign the CPT code(s). Add one or more modifiers, if necessary.

A 71-year-old male patient comes to the hospital after having been previously diagnosed with benign prostatic hypertrophy with urinary obstruction.

Due to this condition, the patient is experiencing increased urination, straining during urination, and a continual feeling of fullness after the bladder has been emptied. The physician performs a cystourethroscopy to examine the condition of the bladder and urethra, and then subsequently performs a UroLift transprostatic implant procedure using three adjustable implants.

Intermediate Medical Coding 3

Part 2a

Review each of the following procedures. Assign the CPT code(s). Add one or more modifiers, if necessary.

1. An established patient comes to the office complaining of migraine headaches. The physician performs an expanded problem-focused history and exam. The physician's medical decision making is of low complexity. During the office visit, the physician also removes a benign 0.5 cm lesion from the back of the patient's left hand.

2. Dr. Kline, a plastic surgeon, is ready to perform a simple repair of a 2.0cm wound on the cheek of a 10 year old boy, but he is concerned about how the child might react. The boy has a neurological disorder that is triggered by anxiety and changes in his normal environment, and he has become combative at past office appointments. Although anesthesia is not typically used for a simple repair of a superficial wound, Dr. Kline has opted to administer the general anesthesia for this procedure. Dr. Kline proceeds with a simple repair of the child's superficial wound on his face.

3. A surgeon performs a total abdominal hysterectomy with partial removal of the vagina, lymph node sampling, andremoval of the ovary. The coder assigns code 58200-51. Is this code correct or incorrect? Why or why not?

Correct; Reasons - Total abdominal hysterectomy, including partial vaginectomy, with para-aortic and pelvic lymph node sampling, with or without removal of tube(s), with or without removal of ovary(s
4 Intermediate Medical Coding

Part 2b

Review each of the following procedures. Assign the HCPCS code(s).

4. A patient weighing 252 pounds sustains a hip fracture. The physician prescribes a Group 2 standard single power wheelchair with a solid seat, solid back, and a sling. HCPCS code(s): Code 27267, Code 27268, and Code 27269

5. A patient comes to the emergency room complaining of a chronic migraine. The nurse administers a 1 unit injection of onabotulinumtoxinA. HCPCS code(s): J0585

6. A patient with chronic venous insufficiency comes to the doctor's office complaining of leg pain. The physician prescribes two thigh-length gradient compression stockings, 45 mmHg each.

Part 3

Review the following coding scenario. Assign the CPT code(s) for only the wound repair.

A patient comes to the emergency room after sustaining a 12.2-cm wound to the left side of her face. She was cut with a piece of glass during a physical altercation with her husband. The physician performs a detailed history and examination.

Medical decision making was of moderate complexity. The physician repairs the facial wound without difficulty; however, the wound requires extensive cleaning to remove the glass particles beforehand.

The physician also repaired a superficial 2.5-cm wound to the left ear. Bothwounds were closed using 4-0 Vicryl.