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Selecting the most specific code for a craniotomy to evacuate a hematoma in CPT comes down to the documentation, where the hematoma is located, and the approach taken to treat it. Question: A patient suffers an extradural hematoma in the supratentorial region of the brain, and the neurosurgeon performs a craniotomy to evacuate it. What CPT code…
In this coding scenario, you will learn one patient’s experience with gender dysphoria and how to assign the correct CPT code for psychotherapy for gender dysphoria based on who was involved in the counseling and how much face-to-face time was spent. Question: Patient with gender dysphoria is seen for psychotherapy today due to feelings of anxiety…
ICD-10 coding for HIV and AIDS begins with knowing what to look for in the documentation and the coding guidelines and sequencing rules. Try your skill on this Name That Code! practice exercise and then compare your answer to the one provided. Name That Code! Question: Patient is diagnosed with symptomatic HIV. What ICD-10-CM code…
This post has been updated to reflect the FY 2022 coding guidelines. Name That Code! Question: A 67-year-old male patient with primary prostate cancer with metastasis to the left lung presents for a wedge resection of the lung. Assign the ICD-10-CM code(s). Answer: Once you have assigned the code(s), read the information below. The answer is…
When all else fails and the weight doesn’t come off, a patient may choose to have a procedure done to limit the amount of food the stomach can hold. This coding exercise involves the coding of laparoscopic gastric banding procedures. See if you can assign the correct CPT code and then check it against the…
Brain herniation is a serious and often fatal problem that requires immediate medical care. Therefore, when a patient presents with possible brain herniation, a surgeon may elect to perform a ventricular puncture to drain cerebrospinal fluid (CSF). Question: Patient is brought to the operating room with possible brain herniation. The surgeon performs a ventricular puncture…