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MEDICAL CODING

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Assign CPT code(s) and appropriate modifiers to each statement.

1)      After performing an emergency cesarean section, the physician noticed that the appendix was distended, resulting in medical necessity for an appendectomy performed during the same operative session.

2)      The physician freed intestinal adhesions.

3)      The physician resected two segments of small intestine and performed an anastomosis between the remaining intestinal ends. An open approach was used for this surgery.

4)      The physician repaired a defect in the mesentery with sutures.

5)      The physician performed a laparoscopic partial colectomy with end colostomy and closure of the distal segment.

6)      The physician drained a pelvic abscess through the rectum.

7)      The physician removed a portion of the rectum through combined abdominal and transsacral approaches.

8)      The physician performed rigid proctosigmoidoscopy and obtained brushings.

9)      The physician performed a flexible sigmoidoscopy and removed a polyp. The physician inserted the sigmoidoscope through the anus and advanced the scope into the sigmoid colon. The lumen of the sigmoid colon and rectum were well visualized, and the polyp was identified and removed with hot biopsy forceps. The sigmoidoscope was withdrawn upon completion of the procedure.

10)  The physician inserted a colonscope through the anus and advanced the scope past the splenic flexure. Two polps were identified and removed by hot biopsy forceps.

1)      Hepatotomy for open drainage of abscess or cyst, 1 stage.

2)      Surgeon removed segments II, III, and IV (the whole left lobe) of the liver from a living donor.

3)      The physician performed radiofrequency ablation of a liver tumor via open laparotomy.

4)      The physician removed the gallbladder and performed a common bile duct exploration through the laparoscope.

5)      The physician performed a cholecystostomy with removal of calculus.

6)      Subsequent to previous peritoneocentesis (performed at a different operative session), the physician withdrew fluid and performed infusion and drainage of fluid from the abdominal cavity (peritoneal lavage).

7)      The physician reopened a recent laparotomy incision, before the incision had fully healed, to drain a postoperative infection.

8)      The physician performed laparoscopic repair of an initial inguinal hernia.

9)      The physician performed a reducible ventral hernia (initial) repair and inserted mesh implantation.

10)  The physician repaired an initial reducible, inguinal hernia with hydrocelectomy in a 5 month old infant.  

1)      Physician made an open incision and inserted multiple drain tubes to drain an infection (abscess) from the kidney.

2)      The physician pulverized a kidney stone (renal calculus) by directing shock waves through a water cushion that was placed against the left side of the patient’s body at the location of the kidney stone.

3)      The physician removed a kidney stone (calculus) by making an incision in the right kidney.

4)      The interventional radiologist inserted a percutaneous nephrostomy catheter into the right renal pelvis for drainage. Fluoroscopic guidance was provided.

5)      The physician performed a laparoscopic ablation of a solid mass from the posterior hilum of the left kidney.

6)      The physician made an incision in the left ureter through the abdominal wall for examination of the ureter and insertion of a catheter for drainage.

7)      The physician examined the patient’s right and left renal and ureteral structures with an endoscope, which passed through an established opening between the skin and the ureter (ureterostomy). He also inserted a catheter into the ureter.

8)      The physician revised a surgical opening between the skin and the right ureter.

9)      The physician injected contrast agent through an opening between the skin and the left ureter (ureterostomy) for ureterography (study of renal collecting system).

10)  The physician made an incision in the left ureter (ureterotomy) to insert a catheter (stent) into the ureter.

11)   The physician performed a transurethral resection of a postoperative bladder neck contracture using a resectoscope.

12)  The physician inserted a special instrument through the cystourethroscope to fragment a calculus in the ureter using electrohydraulics.

13)   The physician inserted a cystourethroscope through the urethra to drain an abscess on the prostate.

14)  The physician made an incision through the abdominal wall into the urinary bladder and inserted a suprapubic catheter to withdraw urine.

15)  The physician performed a cystourethroscopy with fulguration of the bladder neck and then removed a calculus from the ureter.

16)  The physician performed a sling procedure using synthetic material to treat a male patient’s urinary incontinence.

17)  The physician made an initial attempt to treat a male patient’s urethral stricture using a dilator.

18)  The physician, in the first two stages to reconstruct the urethra identified the area of stricture by urethrography and marked it with ink.

19)  The physician performed a transurethral destruction of the prostate using microwave therapy.

 The physician excised a specimen of tis

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