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  1. J

    Question Bone grafting of the femur and tibial tunnels CPT code

    I need help with coding the following procedure as soon as possible: Preoperative Diagnosis: INSTABILITY RIGHT KNEE Postoperative Diagnosis: INSTABILITY RIGHT KNEE Procedure Performed: Bone grafting of the femur and tibial tunnels as a stage procedure for future ACL reconstruction...
  2. J

    Question Sigmoid Granulomatous Mass

    Help is needed on how to code this. PATIENT IS BROUGHT TO THE OR ON 9/19/19 AND PLACED ON TABLE SUPINE POSITION. AFTER ADEQUATE GENERAL ANESTHESIA, SHE HAD A FOLEY CATHETER PLACED AND WAS PREPPED DRAPED STERILE FASHION. AN INFRAUMBILICAL INCISION WAS MADE AND A 5 MM BLADELESS TROCAR WAS...
  3. J

    Question Revision of Fundoplication code

    Our surgeon took his patient back to surgery to do a revision of a fundoplication. He removed some stitches to allow the fundoplication to open and did a dilation of the esophagus. I have CPT code 43450 for the dilation but I have no idea how to code the stitch removal. The OP note is below. If...
  4. J

    Question Percutaneous pinning of Hammertoe

    I am not sure how to code this procedure and hopefully someone can help! Preoperative Diagnosis Hammertoe deformities bilateral feet in the 2nd, 3rd, 4th, and 5th toes Procedure Performed Closed reduction and pinning of the bilateral 2nd, 3rd, 4th toes Indications Patient with rigid...
  5. J

    Question Lower extremity procedure codes

    I always get confused with these procedures done in arteries as to what is being done and what CPT codes to use. If someone could look at the OP note below and help me with the codes for what was done I would appreciate it! Also if anyone knows of a source I can turn to so I can understand these...
  6. J

    Revision of Fundoplication code

    Our surgeon took his patient back to surgery to do a revision of a fundoplication. He removed some stitches to allow the fundoplication to open and did a dilation of the esophagus. I have CPT code 43450 for the dilation but I have no idea how to code the stitch removal. The OP note is below. If...
  7. J

    Question Repair of External Iliac Artery

    My surgeon was called into a surgery to repair the External Iliac Artery accidentally cut by the surgeon performing the intended surgery. I am trying to find a code for this procedure and am not sure what code to use. If anyone can help with a code it would be appreciated!! REANASTOMOSIS OF...
  8. J

    Bone allograft to tibial and femur tunnels staged for future ACL reconstruction

    Any ideas on the correct coding for this procedure would be greatly appreciated! I have searched for an answer in other threads but do not see a definitive answer! Someone out there must have had one of these surgeries!! If I have to use an unlisted code, then with what code would this be...
  9. J

    Arthroscopic shoulder procedure questions

    Hi All! I am trying to figure out how to code some arthroscopic procedures and the more I try to figure it out the more I am confusing myself! :confused: If some one could help explain this to me it would be appreciated!! First - if the doctor does a subacromial decompression along with other...
  10. J

    Help with correct CPT codes!

    I'm looking for some help with this surgery...vascular procedures confuse me! I have looked at codes 34203, 35302 & 35666 for the vascular surgery. I am not sure if I am looking at the right codes or if the documentation is clear as to the areas or if any of these are bundled. If I could get...
  11. J

    Help with correct codes for this vascular surgery

    I'm looking for some help with this surgery...vascular procedures confuse me! I have looked at codes 34203, 35302 & 35666 for the vascular surgery. I am not sure if I am looking at the right codes or if the documentation is clear as to the areas. If I could get some answers, as well as some...
  12. J

    Laparoscopic resection of colon polyp

    Any ideas on how to code this procedure? Preoperative Diagnosis Adenomatous polyp of right colon _ Postoperative Diagnosis Same _ Procedure Performed Laparoscopic resection of colon polyp Indications Recurrent adenomatous polyp that could not be resected endoscopically The patient...
  13. J

    How do you code a umbilicoplasty with hernia repair?

    I need some help coding this surgery. The doctor did an umbilical hernia repair with an umbilicoplasty. There is no code for the umbilicoplasty. How would I code that part of the procedure? Would it be included in the hernia repair code? I've seen some suggestions to use 15830 and 15847, however...
  14. J

    Subchondral bone graft surgery code??

    Any idea what the CPT code would be for this procedure? I was thinking 27415 but it does not appear to be a open procedure. And 29867 is Arthroscopy, which I don't see in the note! All help is appreciated! Preoperative Diagnosis Subchondral fracture lateral femoral condyle/medial tibial...
  15. J

    Any ideas on CPt codes for this procedure?

    PREOPERATIVE DIAGNOSIS: Recurrent gastric volvulus and hiatal hernia. POSTOPERATIVE DIAGNOSES: 1. Recurrent gastric volvulus and hiatal hernia. 2. Serosal tear. PROCEDURE: Exploratory laparotomy reduction of gastric volvulus and hernia and gastropexy and gastric ligation. FINDINGS...
  16. J

    What codes for this procedure?

    I posted this in General Surgery but have not gotten any help, so I am re-posting here hoping someone may have suggestions! Thanks, I am not sure what codes to use for this laparoscopic procedure! If someone could please review this OP note and help it would be appreciated!! So far I have...
  17. J

    Not sure how to code this! Need help fast!

    I am not sure what codes to use for this laparoscopic procedure! If someone could please review this OP note and help it would be appreciated!! So far I have tentatively used unlisted codes 47379, 44238 and 47562-52 for the cholecystectomy attempt. I am not sure if I am looking at this correctly...
  18. J

    How would you code a failed knee replacement - patellar component

    I am having trouble coming up with what CPT codes I should use for this surgery 27488, 29874, 29876, etc. - I am just not sure which of these if any! The patient was brought to the operating room theater, placed supine upon the operating room table after satisfactory general endotracheal...
  19. J

    Failed knee replacement

    I am having trouble coming up with what CPT codes I should use for this surgery 27488, 29874, 29876, etc. - I am just not sure which of these if any! The patient was brought to the operating room theater, placed supine upon the operating room table after satisfactory general endotracheal...
  20. J

    2 Hospital visits on same date of service

    I am repeating my question here as I have not received a response on another thread! Any ideas? I have a neurologist who saw a patient for a consult earlier in the day for what was diagnosed as a TIA. The patient was in Observation status - this being her second day. The patient was discharged...
  21. J

    Two hospital visits same date

    I have a neurologist who saw a patient for a consult earlier in the day for what was diagnosed as a TIA. The patient was in Observation status - this being her second day. The patient was discharged that morning. Later that day the patient returned with further symptoms and the neurologist was...
  22. J

    Hematocrit CPT code

    Our lab is trying to bill for a Hematocrit on body fluid from a patient's Jackson Pratt drain. They want to use CPT code 85014. Can this code be used for that reason or is it only for whole blood? If this code is not correct, any suggestions on how to code this? All responses will be welcomed...
  23. J

    Which code can be used?

    Our lab is trying to bill for a Hematocrit on body fluid from a patient's Jackson Pratt drain. They want to use CPT code 85014. Can this code be used for that reason or is it only for whole blood? If this code is not correct, any suggestions on how to code this? All responses will be welcomed...
  24. J

    Discontinued procedure with return to OR

    Hi everyone! I was wondering if anyone could answer this question! A patient was taken to the OR for a procedure, anesthesia was administered and the patient was intubated, however the provider discontinued the procedure at this point because the patient's platelet count was low. The patient...
  25. J

    Discontinued procedure with return to OR

    Hi everyone! I was wondering if anyone could answer this question! A patient was taken to the OR for a procedure, anesthesia was administered and the patient was intubated, however the provider discontinued the procedure at this point because the patient's platelet count was low. The patient...
  26. J

    Lap appedndectomy, partial cecectomy and closure of enterotomy?

    Any suggestions on how this should be coded? I am not sure if I should be coding the appy with an unlisted code for the other procedures, just the appy or something else! Help! :confused: PREOPERATIVE DIAGNOSIS: Acute appendicitis. POSTOPERATIVE DIAGNOSIS: Acute and chronic appendicitis...
  27. J

    Excision and Drainage of fallopian tube code?

    I am hoping someone can help as I need to get this claim processed: My surgeon did a laparoscopic Cholecystectomy and while in there he states he did lysis of intestinal adhesions and a drainage of fallopian collection. I have the code for the chole - 47563 and I know the lysis is bundled...
  28. J

    Code for a fallopian tube collection?

    Hello all! My surgeon did a laparoscopic Cholecystectomy and while in there he states he did lysis of intestinal adhesions and a drainage of fallopian collection. I have the code for the chole - 47563 and I know the lysis is bundled. However, I am not sure of the code for the fallopian tube...
  29. J

    How would this procedure be coded?

    My surgeon did a laparoscopic Cholecystectomy and while in there he states he did lysis of intestinal adhesions and a drainage of fallopian collection. I have the code for the chole - 47563 and I know the lysis is bundled. However, I am not sure of the code for the fallopian tube drainage. The...
  30. J

    Open procedure and Laproscopic - which codes?

    I am having issues figuring out the correct codes for this surgery - any help would be appreciated! The surgeon wants to code 49320 and 48100. I agree with the 48100 however I do not believe 49320 is the correct code. It appears he did an exploratory lap, then made an incision to perform the...
  31. J

    99053 and on call Orthopedist

    Can anyone tell me if a Hospital employed Orthopedist who is on-call can bill code 99053 for after hours in the ED? Our Orthopedist is insisting that he bill this code (which we have never billed) so that he can get the RVU credits for being pulled out of bed at night for a patient in the ED...
  32. J

    Manipulation of previous fracture and re-casting in the office

    My Ortho billed the global codes for fracture care without manipulation for a patient who had a tib-fib fracture. The patient presented to the office for a follow-up visit with a complaint that the cast was too tight and bothering her. He removed the cast and x-rays show that the fracture site...
  33. J

    Which CPT codes would be used?

    My surgeon did a surgery which appears to be a co-surgery with the GYN. The patient had a large mass that was attached to the colon, as well as the ovary. They both have documented their portions. The following is my surgeon's portion. If someone could look at this and help me with some codes it...
  34. J

    Help needed for codes for this surgery!!

    My surgeon did a surgery which appears to be a co-surgery with the GYN. The patient had a large mass that was attached to the colon, as well as the ovary. They both have documented their portions. The following is my surgeon's portion. If someone could look at this and help me with some codes...
  35. J

    Lipoma removal or more?-Reposting here as I have

    Reposting here as I have not gotten any responses and need some feedback! I am not sure if I have this coded correctly. I have used 27047 for the lipoma removal, however I am not sure if there is more to this procedure than that. PREOPERATIVE DIAGNOSIS: Left inguinal mass. POSTOPERATIVE...
  36. J

    Lipoma removal or more?

    I am not sure if I have this coded correctly. I have used 27047 for the lipoma removal, however I am not sure if there is more to this procedure than that. PREOPERATIVE DIAGNOSIS: Left inguinal mass. POSTOPERATIVE DIAGNOSIS: Left inguinal mass. OPERATION: Left inguinal exploration...
  37. J

    Re-repair of Inguinal Hernia

    My surgeon brought her patient, who had an inguinal hernia repair in March, back to the OR for re-exploration and mesh removal due to pain. (ultrasound showed no recurrent hernia). The surgeon removed the mesh and then re-repaired the hernia with new mesh. The diagnosis was Right inguinal nerve...
  38. J

    What CPT code for this?

    My surgeon did a subtotal gastrectomy with Roux-en-y and then had to take the patient back to surgery 3 days later for a duodenal stump leak. I am not sure what CPT code to use. I was looking at 43840-78 but am not sure that this is what was done. I was thinking of going the unlisted route...
  39. J

    7th place A or P

    My doctor saw the patient in the office for fractured Humerus and determined that the patient needed surgery. The patient had other medical conditions, so the surgery was not done for another 3 weeks until she was cleared. At this time the patient now has a malunion of the fracture. The doctor...
  40. J

    Need help coding this surgery - the CPT codes

    Can someone please help with the CPT codes on this one! I have read this over and over and I am really not sure what I am looking at! I am not sure what I can or cannot code - can I code the bone grafts and if so, what codes? So far have 27236 and 27507, but I am not sure if those are correct...
  41. J

    Confusing OP note

    Can someone please help with the CPT codes on this one! I have read this over and over and I am really not sure what I am looking at! I am not sure what I can or cannot code - can I code the bone grafts and if so, what codes? So far have 27236 and 27507, but I am not sure if those are correct...
  42. J

    Wiki Excludes 1 & 2 note question

    am finding some things in ICD-10 that are very confusing! I have a patient who was diagnosed with a periprosthetic supracondylar fracture of left knee. During surgery the doctor found that the prosthetic was broken and needed to be replaced. So, I looked up the code for the periprosthetic...
  43. J

    Wiki Contradicting Excludes 1 & 2 Notes

    I am finding some things in ICD-10 that are very confusing! I have a patient who was diagnosed with a periprosthetic supracondylar fracture of left knee. During surgery the doctor found that the prosthetic was broken and needed to be replaced. So, I looked up the code for the periprosthetic...
  44. J

    How to code a non-union

    I need some help in coding this surgery correctly. All help would be appreciated! PREOPERATIVE DIAGNOSIS: Left humerus fracture delayed union with soft tissue interposition. POSTOPERATIVE DIAGNOSIS: Left humerus fracture delayed union with soft tissue interposition. OPERATION: Left humeral...
  45. J

    How to code this surgery?

    I am not sure which code to use and was hoping for some help with the following procedure: PREOPERATIVE DIAGNOSIS: Left proximal femur, periprosthetic femoral fracture. POSTOPERATIVE DIAGNOSIS: Left proximal femur, periprosthetic femoral fracture. OPERATION: Open reduction, internal fixation...
  46. J

    Fractured femur procedure code

    I am not sure which code to use and was hoping for some help with the following procedure: PREOPERATIVE DIAGNOSIS: Left proximal femur, periprosthetic femoral fracture. POSTOPERATIVE DIAGNOSIS: Left proximal femur, periprosthetic femoral fracture. OPERATION: Open reduction, internal...
  47. J

    Help coding this surgery.

    I am trying to get more opinions on this surgery, so I am re-posting here for help!!! My surgeon brought this patient to the OR for what he thought was a sebaceous cyst, but turned out to be a traumatic pseudoaneurysm of the left eyebrow. I am unsure on how to code this!! I've come up with...
  48. J

    What is this surgery?

    My surgeon brought this patient to the OR for what he thought was a sebaceous cyst, but turned out to be a traumatic pseudoaneurysm of the left eyebrow. I am unsure on how to code this!! I've come up with either 37609 -(which I am not sure of since he does not say temporal artery) or unlisted...
  49. J

    Which type of catheter?

    My cardiologists do PCI's in the cath lab and use a system to document their procedures which is very lacking in completeness and I feel does not document fully or correctly the procedures they say the have performed. I could use some help in distinguishing if a procedure was done? One...
  50. J

    Which codes - 28615, 28485 or another?

    I am new to ortho coding and am not sure exactly what was done here - if anyone can help that would be great!! Also if someone could explain the difference between fracture and dislocation as it seems this doctor uses these terms interchangably!! PREOPERATIVE DIAGNOSIS: Left foot Lisfranc...
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