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The Coding Challenge Question: A 16-year-old male is seen in the ED with complaints of pain and difficulty breathing through his nose. He states he was playing basketball at his high school earlier when another player accidentally elbowed him in the mid-face area. After clinical examination, the physician diagnoses a nasal bone fracture. The nose…
The Coding Challenge Question: A female patient with chronic complaints of left pelvic pain is taken to the operating room for a laparoscopy. Upon inspection of the pelvis, multiple adhesions were found attached to the right fallopian tube and ovary. A probe was used to bluntly lyse the adhesions. No other abnormalities were found. What…
The Coding Challenge Question: An established 44-year-old male is seen at his physician’s office today for a new 3-cm lump on the left arm. The physician spends 5 minutes reviewing the patient’s chart while other qualified clinical staff takes the patient’s vitals. The physician then spends 15 minutes updating the patient’s history and performing a…
This article has been updated to reflect the FY 2023 ICD-10-CM coding guidelines. Coding Challenge A new patient presents for an initial office visit with complaints of moderate pain and swelling of the right ankle. The physician performs a history and examination and documents it in the medical record. The patient is diagnosed with a…
Radiology Service Components and Unconfirmed Diagnoses Often when a radiology service is performed, there are two components involved: a technical component and a professional component. When only the technical or professional component is provided, the appropriate modifier needs to be appended to the CPT code to indicate to the payer how that portion of the…
The Coding Challenge Question: A patient undergoes an Ivor Lewis esophagectomy with a thoracotomy. Dr. Blue, a thoracic surgeon, performs the thoracic approach and thoracic procedures, and Dr. Green, a general surgeon, performs the abdominal procedures. How would Dr. Blue report for his part of the procedure? A. 43122-59B. 43287-80C. 43117-62D. 43118-81 Answer: