Sample Coding Report for 36903 CPT code (AV fistulogram with stent)

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Pre-op Diagnosis:     Stenosis of the proximal arteriovenous fisutla  Post-op Diagnosis: Same as Pre-op Procedure(s): Left – Arteriovenous Fistulogram with angioplasty and stent graft placement Proc. Description(s) & CPT Code(s): Arteriovenous Fistulogram:  Anesthesia: Procedural Sedation  Estimated Blood Loss: Minimal Drain: none Total IV Fluids: minimal  Specimens: No specimens Complications: none Disposition: aroused from sedation, and taken to the recovery room in a stable condition Condition: doing well Anesthesia: Monitored … Read more

Cpt code 36471 & 36478 Coding tips

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Cpt code 36471 & 36478 Coding tips

When to use CPT 36478 and 36479 The physician uses percutaneous, laser, endovenous ablation therapy to treat venous incompetence in an extremity vein. Laser energy is used to heat the vein and seal the vein closed. The most common site of treatment is the greater saphenous vein. The procedure includes any imaging guidance and monitoring. … Read more

Avoiding Common Mistakes in Dual Surgeon Coding with 62 Modifier

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62 modifier

Basics of 62 Modifier When two surgeons work together as primary surgeons performing distinct part(s) of a single reportable procedure, each surgeon should report his/her distinct operative work by submitting CPT modifier 62. Each surgeon should report the co-surgery once using the same procedure code. Do not submit this modifier for assistant at surgery services … Read more

Coding tips for CPT code 22310

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Fracture/Dislocation Treatment Definitions ( CPT code 22310) In the Musculoskeletal System subsection of the Surgery section in the CPT 2024 code set, “closed treatment” is defined as follows: The treatment site is not surgically opened (ie, not exposed to the external environment nor directly visualized). Closed treatment of a fracture/dislocation may be performed without manipulation … Read more

Vascular Surgery Sample Coded Charts

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Medical coding Sample Coded Report 1 Pre-op Diagnosis: Nodular sclerosis Hodgkin lymphoma of lymph nodes of multiple regions (CMS/HCC) [C81.18] Post-op Diagnosis: Same as Pre-op Procedure(s): Right – VASCULAR ACCESS – IMPLANTABLE PORT PLACEMENT – Wound Class: Clean Proc. Description(s) & CPT Code(s): VASCULAR ACCESS – IMPLANTABLE PORT PLACEMENT: Anesthesia: General Estimated Blood Loss: Minimal … Read more

Simple Abscess (CPT 26010) Coded sample report

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Pre-op Diagnosis: Abscess of right ring finger [L02.511] Post-op Diagnosis: Same as Pre-op Procedure(s): Right – INCISION AND DRAINAGE RIGHT RING FINGER – Wound Class: Clean Contaminated – Incision Closure: Deep and Superficial Layers Proc. Description(s) & CPT Code(s): INCISION AND DRAINAGE RIGHT RING FINGER: Anesthesia: Monitor Anesthesia Care Estimated Blood Loss: less than 50 … Read more

Wound Debridement Sample Coded report (CPT 11043, 11046)

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Sample Coded report (CPT 11043, 11046) Pre-op Diagnosis: Open wound of right knee, subsequent encounter [S81.001D] Post-op Diagnosis: Same as Pre-op Procedure(s): Right medial knee irrigation and debridement Right medial knee wound VAC application Anesthesia: Monitor Anesthesia Care Estimated Blood Loss: less than 50 mL Drain: woundvac Specimens: ID Type Source Tests Collected by Time … Read more

CPT code 96160 and 96161 coding tips

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Basics of CPT code 96160 and 96160 A provision in the Patient Protection and Affordable Care Act of 2010 (ACA) established a Medicare Wellness Visit, which included a Health Risk Assessment (HRA) and customized wellness or prevention plan. HRAs are typically completed by a patient or caregiver prior to the encounter with a physician or … Read more

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