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Operative ReportPre-Operative and Post-Operative Diagnosis:     Squamous cell carcinoma, left legOpen wound, right legPersonal history of squamous cell carcinoma, right legINDICATIONS FOR SURGERY: The patient is an 81-year-old white man with biopsy proven squamous cell carcinoma of his left leg. I marked the areas for excision with gross normal margins of 5 mm, and I drew my planned skin graft donor site from his left lateral thigh. He also had an open wound of his right leg from a squamous cell carcinoma excised four months ago; the skin graft had not taken. We plan on re-skin grafting the area. The patient is aware of all of these markings, and understands the surgery and location.DESCRIPTION OF PROCEDURE: The patient was taken to the operating room. IV Ancef was given. I used plain lidocaine for his local anesthetic throughout the procedure until the skin grafts were inset. The anterior of his leg and the thigh were infiltrated with local anesthetic. Both lower extremities were prepped and draped circumferentially, which included the left thigh on the left side. I excised the lesion on his left leg as drawn into the subcutaneous fat. Hemostasis achieved with the Bovie cautery. I then excised the wound on his right leg to lower the bacterial counts. I took a 1-2 mm margin around the wound and excised the granulation tissue as well. Hemostasis was achieved using the Bovie cautery. I then changed gloves. A split-thickness skin graft was harvested from the left thigh using the Zimmer dermatome. This was meshed 1:5:1. By this time, the pathology returned showing the margins were clear.Skin grafts were inset on each leg wound using the skin stapler. Xeroform and gauze bolster was placed over the skin graft using 4-0 nylon. The skin graft donor site was dressed with OpSite. The legs were further dressed with heavy cast padding and the double Ace wrap. The patient tolerated the procedure well.PROCEDURES: Excision squamous cell carcinoma, left leg with excised diameter of 2.5 cm, repaired with a split-thickness skin graft measuring 5.1 cm2. Excisional preparation of right leg wound repaired with a split-thickness skin graft measuring 3.2 cm2.What CPT® codes are reported?

A 37-year-old female is seen in the clinic for follow-up of lower extremity swelling. She has had this issue for the past six months. HPI: Patient is here today for follow-up of bilateral lower extremity swelling. The swelling responded to hydrochlorothiazide.DATA REVIEW: I reviewed her CBC lab. EXAM: Patient is in no acute distress. ASSESSMENT: 1. Bilateral lower extremity swelling. This has resolved with diuretics.PLAN: Will order an echocardiogram and kidney function lab test. Refill prescription. Return in 2 months.

The Global Surgical Package applies to services performed in what setting?

A 26-year-old female with a one-year history of a left tympanic membrane perforation has consented to have it repaired. A postauricular incision was made under general anesthesia. Dissection was carried down to the temporalis fascia and a 3 x 3 cm segment of fascia was harvested and satisfactorily desiccated. The tympanic membrane was excised. Using a high speed drill a canaloplasty was performed until the entire annulus could be seen. The ossicular chain was examined, it was found to be freely mobile. The previously harvested skin was trimmed and placed in the anterior canal angle with a slight overlapping over the temporalis fascia. Packing is placed in the ear canal, external incisions are closed, and dressings are applied. What CPT® code is reported?

Patient has TAH-BSO. What CPT® code is reported?

The Medicare program is made up of several parts. Which part is affected by the Centers for Medicare & Medicaid Services – Hierarchical Condition Categories (CMS-HCC)?

The patient is a 63-year-old gentleman diagnosed with rectal cancer, who had a resection of the cancer performed. He now presents to have a Port-A-Cath (a central venous access device) inserted for postoperative adjuvant therapy. An 18-gauge introducer needle was inserted into the left subclavian vein through which a soft tipped guide wire was inserted into the superior vena cava under fluoroscopy. A subcutaneous pouch in the anterior part of the chest was created for the port. The catheter was then tunneled and measured to length. The dilator and introducer sheath were passed over the wire into the superior vena cava under fluoroscopic guidance. The catheter was passed through the sheath and the port was applied with good venous return. What CPT® codes are reported?

What ICD-10-CM code is used to report Herpes Zoster iridocyclitis?

Transurethral resection of bladder neck and nodular prostatic regrowth. What CPT® code is reported for this service?

During an inpatient hospitalization, a patient who suffered myocardial infarction had a combined right and left heart catheterization. Access was achieved through the right femoral artery and the right femoral vein. Selective catheterization of the coronary arteries and selective catheterization of the left ventricle were followed by injections of contrast and angiography. During right heart catheterization, angiography of the right atrium was performed. Imaging supervision, interpretation and report for all angiography was performed during the cardiac catheterization. Select the CPT® coding for this procedure by the cardiologist.