When it is documented that the patient is both using tobacco and has a dependence on tobacco, how is this reported in ICD-10-CM?

The skin over the left groin was prepped and draped in a sterile fashion and anesthetized with 1% Xylocaine. Through a right femoral artery access, a 5 French pigtail catheter was placed in the abdominal aorta and a run-off was performed following injection of 80cc of contrast. Oblique DSA images of the iliac circulation were performed following two injections, each 15cc.Findings: Abdominal aorta: no signs of renal artery stenosis. There is mild atheromatous change involving the lower abdominal aorta. There are two eccentric plaques arising from the distal aorta just above the iliac bifurcation. There are high-grade stenoses involving both proximal iliacs, the right far more pronounced than the left.The right superficial femoral, profunda femoral, popliteal arteries are normal. The trifurcation vessels are unremarkable.On the left, there is an eccentric plaque in the common femoral artery just below the catheter entrance site. This creates approximately 40-50% stenosis at this site. The remainder of the proximal femoral artery is normal. The trifurcation vessels and popliteal artery are normal. What CPT® codes are reported?

A 27-year-old girl has been on the lung transplant list for months and today she will be receiving a LT and RT lung from an individual involved in an MVA. This person was DOA at the hospital and is an organ donor. The donor pneumonectomy was performed by physician A, the backbench work by physician B and the transplant of both lungs into the prepped and waiting patient by physician C. What is the correct coding for the removal (physician A), preparation (physician B) and insertion (physician C) of the lungs?

Operative ReportDiagnosis: Basal Cell CarcinomaProcedure: Mohs micrographic excision of skin cancer.Site: Face left lateral upper canthus eyelidPre-operative size: 0.8 cmIndications for surgery: Area of high recurrence, area of functional and/or cosmetic importance. Discussed procedure including alternative therapy, expectations, complications, and the possibility of a larger or deeper defect than expected requiring significant reconstruction. Patient’s questions were answered. Local anesthesia 1:1 Marcaine and 1% Lidocaine with Epinephrine. Sterile prep and drape.Stage 1: The clinically apparent lesion was marked out with a small rim of normal appearing tissue and excised down to subcutaneous fat level with a defect size of 1.2 cm. Hemostasis was obtained and a pressure bandage placed. The tissue was sent for slide preparation. Review of the slides show clear margins for the site.Repair: Complex repair. Repair of Mohs micrographic surgical defect. Wound margins were extensively undermined in order to mobilize tissue for closure. Hemostasis was achieved. Repair length 3.4 cm. A layered closure was performed. Multiple buried absorbable sutures were placed to re-oppose deep fat. The epidermis and dermis were re-opposed using monofilament sutures. There were no complications; the patient tolerated the procedure well. Post-procedure expectations (including discomfort management), wound care and activity restrictions were reviewed. Written Instructions with urgent contact numbers given, follow-up visit and suture removal in 3-5 daysWhat CPT® and ICD-10-CM codes are reported?

A 60-year-old woman is seeking help to quit smoking. She makes an appointment to see Dr. Lung for an initial visit. The patient has a constant cough due to smoking and some shortness of breath. No night sweats, weight loss, night fever, CP, headache or dizziness. She has tried patches and nicotine gum which has not helped. Patient has been smoking for 40 years and smokes 2 packs per day. She has a family history of emphysema. A limited three system exam was performed. Dr Lung discussed in detail the pros and cons of medications used to quit smoking. Total time spent with the patient was 32 minutes. Prescriptions for Chantix and Tetracycline were given. The patient to follow up in 1 month. A chest X-ray and cardiac work up was ordered. Select the appropriate CPT code(s) for this visit.

A 74-year-old male presented with ankle avascular necrosis of the talus with collapse of the body. After general anesthesia and sterile prep, the patient was placed prone. A lateral incision was made. The fibula was dissected and approximately 6 cm of the fibula was removed for the autograft. There were a lot of free fragments of bone around the subtalar joint and the talus itself. The bone fragments were removed and a large defect consistent with avascular necrosis of the body of the talus was noted. An egg-shaped burr was introduced and the articulating cartilage of the ankle joint was excised and debrided. The subtalar joint was approached and resection of the articulating surface of the subtalar joint was completed. Bone graft from the fibula was prepared on the back table. We made two large blocks to fill the defect in the talus and then additional small fragments of cortical cancellous bone to fill in smaller defects around the talus and ankle. Fixation was performed in the calcaneocuboid. The talar screw was inserted, followed by fixation of the talonavicular, tibiotalar and additional compression. The ankle screws were inserted proximally and the wound was irrigated and closed in layers. What CPT® codes are reported?

A 30-year-old male cut his right hand on a nail repairing the gutter on his house. Six days later it became infected. He went to the intermediate care center in his neighborhood, his first visit there. The wound was very red and warm with purulent material present. The wound was irrigated extensively with sterile water and covered with a clean sterile dressing. An injection of Bicillin CR, 1,200,000 units was given. The patient was instructed to return in three to four days. The provider diagnosed open wound of the hand with cellulitis. A medically appropriate history and examination with a straightforward MDM were performed. What are the codes?

A 32-year-old patient is coming into an outpatient facility to have a catheterization performed of the uterus with saline infusion sonohysterography due to dysfunctional uterine bleeding. A previous scan showed suspected endometrial polyps. What CPT® and ICD-10-CM codes are reported?

What ICD-10-CM code is reported for male stress incontinence?

A patient with hydronephrosis has a left nephrostomy and he has agreed to a pyelography (IVP) to rule out a right renal obstruction. The patient was placed prone on the X-ray table one hour after IV infusion of contrast. Contrast flowed from the left and right renal pelvis, down the ureters into the bladder where a Foley catheter was positioned. The IVP showed no obstruction or abnormalities in the urinary tract aside from the left hydronephrosis of the pelvis. The right kidney and ureter showed no obstruction. Bladder appeared within normal limits. What CPT® code is reported for the radiological services?