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Medical Coding

Medical Coding

1) Assign the CPT Code(s) and appropriate modifiers to each statement.

The physician treated a soft tissue abscess that was due to osteomyelitis by making an incision and examining, debriding, and draining the subfascia; the physician also irrigated the affected area, examined underlying tissue and bone for signs of infection, and closed the site.

2) Patient underwent exploration of a penetrating wound of the chest, which involve surgical exploration and enlargement of the wound, debridement, removal of a foreign body, and ligation of subcutaneous tissue.

3) Open bone biopsy, superficial, left femur.

4) Patient underwent aspiration of ganglion cyst, right wrist.

5) Patient received a cortisone injection to a single trigger point, which consisted of the trapezius deltoid, and latissimus dorsi muscles.

6) A patient diagnosed with joint contracture of the right ankle underwent application of a multiplane external fixation device.

7) A patient severed his right index finger while using a chain saw. He underwent successful replantation of the index finger, which included metacarpophalangeal (MCP) joint insertion of flexor sublimis tendon.

8) Fascia lata graft was harvested using a stripper.

9) Patient underwent structural allograft as part of an arthrodesis, posterior technique, craniocervical (occiput-C2).

10) Electrical stimulation procedure was performed to aid bone healing, invasive type.

1) Arthrotomy of temporomandibular joint, right and left sides.

2) Excision of two facial bones (due to bone abscesses).

3) Impression and custom preparation of speech aid prosthesis.

4) Sliding osteotomy genioplasty, single piece.

5) Reconstruction midface, Lefort II with anterior intrusion.

6) Osteotomy of mandible, segmental.

7) Malar augmentation with prosthetic material.

8) Closed treatment of orbit fracture, with manipulation.

9) Closed treatment of maxillary alveolar ridge fracture.

10) Open treatment of mandibular condylar fracture.

1) Deep incision with opening of bone cortex, thorax.

2) Hyoid myotomy and suspension.

3) Closed treatment of sternum fracture.

4) Partial excision of rib.

5) Sternal debridement.

6) Needle biopsy, soft tissue, thorax.

7) Excision of tumor, subcutaneous soft tissue of back, 2.5 cm.

8) The physician removed a 4-cm malignant soft tissue tumor, including adjacent tissue, from the patient’s flank. Radial resection was performed to remove the tumor and adjacent tissue. The 5-cm surgical wound was repaired with complex closure.

9) Patient underwent biopsy of superficial soft tissues of the back.

10) Biopsy, soft tissue flank, deep.

1) Patient underwent arthrodesis at L4-L5 interspace. Posterior interbody technique laminectomy was performed. Discectomy was also performed to prepare the verbal interspace for fusion.

2) Physician performed “spinal manipulation under anesthesia, “cervical, thoracic, and lumbar spine.

3) Patient underwent osteotomy and discectomy of a single cervical spine vertebral segmet. Anterior approach was used.

4) Physician performed arthrodesis using posterior technique of atlas-axis (C1-C2) with internal spinal fixation by wiring the spinous processes.

5) Patient underwent poster arthrodesis of L2-L3 for spinal deformity, with casting. Morselized autogenous iliac bone graft was harvested through a separate skin incision.

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