Question

Case 5.3 Procedure codes

Find the correct procedure codes for the following:

5. Patient Tonisha Williams had a total abdominal hysterectomy and removal of tubes and ovaries for submucous leiomyoma of the uterus and severe polycystic disease of the ovaries.

6. Established patient: Randy Kane. Visit to Ashworth Dermatology Clinic for recurrence of forearm rash. He is a previous patient who presented with this condition twenty days ago. I saw him for a ten-minute follow-up examination because of the flare-up. Has 4x6 cm rash over mid-forearm with scaly, erythematous, raised papules.

7. Dr. LaFarge is called to the home of the BeGeorgs family. She is the family physician and has taken care of the patient, Ralph, since birth. He is now thirteen years old and is recovering well from a recent broken leg. She decided to visit this established patient at home to check on possible swelling or soreness due to the cast.

8. Juanita Escobar, age two, has an intramuscular injection for immunization with diphtheria and tetanus toxoids (DT). (Hint: Check the possible codes for patients’ ages.)

Answer 1

1) Total abdominal hysterectomy is a procedure to remove uterus and removal of fallopian tubes and ovaries is termed as salpingo-ophrectomy. Leiomyoma is a benign tumors of connective tissue of uterus. The CPT procedure code is 58150 describes total total abd hysterectomy with bilateral salpingo-oophrectomy.

2) Evaluation and management codes are used to describe the physician and patient encounter. Established patient are the patients who consulted the same physician or health care professionals within 3 years. E and M codes have three components, history ,exam ,medical decision making and time based. In the above scenario patient came for a follow up visit for his flare up of erythematous papules .

99212 can be coded as three components are met like problem focused history, problem focused examination and a straight medical decision making.

8) Immunization is a process of making strong immune system by injecting vaccines. Diphtheria and tetanus vaccines are given to protect from these diseases. Diphtheria spreads from one person to other by infectious droplet. Tetanus bacteria spreads mainly through cut wounds and scratches.Here Ms Juanita age of two receives Intramuscular injection of Diphtheria and teatatus toxoids

90702 describes the CPT code for DT vaccine for children under 7 years old.