A couple presents to the freestanding fertility clinic to start in vitro fertilization. Under radiologic guidance, an aspiration needle is inserted (by aid of a superimposed guiding-line) puncturing the ovary and preovulatory follicle and withdrawing fluid from the follicle containing the egg.
What is the correct CPT code for this procedure?
The procedure involves the aspiration of fluid from an ovarian follicle to retrieve the egg under radiologic guidance.
Procedure Description:
Aspiration needle insertion.
Puncture of the ovary and preovulatory follicle.
Withdrawal of fluid containing the egg.
Radiologic guidance was used.
CPT Coding:
58976: Aspiration of ovarian follicle(s) with ultrasound guidance.
AMA's CPT Professional Edition (current year).
CPT Assistant for detailed coding guidelines on reproductive procedures.
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
Which place of service code is submitted on the claim for a service that is performed in an outpatient surgical floor?
The place of service code 22 is used for services performed in an outpatient hospital setting, including outpatient surgical floors. This code indicates that the procedure was done in a hospital but not requiring an inpatient admission. Reference: AMA's CPT Professional Edition (current year), Place of Service Codes.
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 patient had surgery a year ago to repair two flexor tendons in his forearm. He is in surgery for a secondary repair for the same two tendons.
Which CPT coding is reported?
The scenario involves a secondary repair of two flexor tendons in the forearm. CPT code 25272 describes the repair of a secondary flexor tendon injury, including a graft, in the forearm and/or wrist, which fits the description provided. This code should be reported once, as the procedure encompasses the repair of multiple tendons.
AMA's CPT Professional Edition (current year), Code 25272
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