Review each of the following medical coding scenarios Assign

Review each of the following medical coding scenarios. Assign the CPT code for the services and procedures indicated in each scenario.

1. A 48-year-old male patient comes to the emergency room with complaints of GERD. The physician performs a laparoscopic fundoplasty with a Collis gastroplasty. What CPT code(s) should be assigned? CPT:

2. A 40-year-old female patient is diagnosed with cervical cancer. She also complains about difficulty breathing. She is admitted to the hospital, where the physician begins to perform a bronchoscopy after anesthesia administration. However, the procedure is discontinued due to unforeseen complications. Later the same day, a bilateral cervical lymphadenectomy is performed to address the patient’s cervical cancer. What CPT code(s) are assigned?? CPT:

3. A 50-year-old patient is admitted for a repair of a laceration to the diaphragm resulting from an accident involving a bus that ran into a ditch. She also received eight trigger point injections due to muscle pain resulting from the accident. What CPT code(s) are assigned? CPT:

4. A 23-year-old patient comes to the emergency room after being physically assaulted by her boyfriend. She complains of nasal pain and bleeding from the left nostril. The physician obtains an x-ray of the nasal cavity, and the x-ray confirms a nasal septum fracture. The physician performs an open treatment of the nasal fracture with a concomitant open treatment of the fractured septum. What CPT code(s) should be assigned? CPT:

5. A 33-year-old patient is seen in the emergency room due to complaints of headaches and congestion. The final diagnosis is maxillary sinus infection. The physician performs a nasal endoscopy with a maxillary antrostomy. She also removes some tissue from the maxillary sinus. What CPT code(s) should be assigned? CPT:

Solution

1. CPT code is 43235 for endoscopy procedures for GERD.

2. CPT code is 38724 for bilateral cervical lymphadenectomy is performed to address the patient’s cervical cancer.

3. 39501 for repair of laceration of diaphragm by means of abdominal approach.

4. 21335 for Open treatment of nasal fracture; with concomitant open treatment of fractured septum.

5 31256 Nasal/sinus endoscopy, surgical, with maxillary antrostomy for the maxillary antrostomy. 31267 Nasal/sinus endoscopy; with removal of tissue from maxillary sinus.