Question

1. A physician performs an exploration of a penetrating wound of the neck. During the same surgical session, he also performs and exploration of a penetrating wound on the leg. How would these services be reported? 2. What is the correct code used to report a reconstruction of the zygomatic arch and glenoid fossa with bone and cartilage using an autograft? 3. A physician partially excises the posterior vertebral component of two thoracic vertebral segments. This procedure is performed for intrinsic bony lesions. How would these services be reported? 4. A surgeon performed an osteotomy (including diskectomy) of the L2 spine by anterior approach. During the same surgical session, the surgeon also performed arthrodesis of the L3-L4 lumbar interspace using the anterior interbody technique. How would these services be reported? 5. A patient has been diagnosed with scoliosis. The surgeon performs anterior arthrodesis, with an application of a Risser jacket body cast (not including the head), on five thoracic vertebral segments. How would these services be reported? 6. A physician biopsied a soft tissue mass of the upper arm involving muscle fascia. The physician documented that the mass was superficial. How would these services be reported? 7. A patient has fractured his ulnar shaft. The physician performs a closed treatment of the ulnar shaft with manipulation. After manipulating the fracture site, the physician then applied a long arm cast. How would these services be reported?

Answer 1

Exploration of penetrating wound in neck can be coded as 20101 and exploration of penetrating wound of the leg can be reported with CPT code 20103. This procedure is done by the physician at the same session the final code for this procedure this 20101,20103 - 59 . Modifier 59 states Distinct procedural services indicates wound exploration procedure done in different site at same session.

Reconstruction of zygomatic arch and glenoid fossa with bone and cartilage (includes obtaining autografts ) CPT code can be 21255.

Partial excision of posterior vertebral component for intrinsic bony lesion thoracic, single vertebral segment., thoracic can be coded as 22101., each additional thoracic segment can be coded 22103.

CPT codes 22101 , 22103-59 indicates procedure osteotomy with diseconomy of L2 spine by anterior approach with arthrodesis of L3-L4 interspace using anterior inter body technique . 59 modifier indicate distinct procedures done by same physician in same session.

CPT code 24065 explains the procedure Biopsy , soft tissue of upper arm or elbow superficial.

CPT code 25535 coded to explain the closed treatment of the ulnar shaft with manipulation. Long arm casts should not be coded separately as it is an integral component of fracture treatment.