Certified Professional Coder CPC Release Date

A pediatrician removes impacted cerumen using irrigation in the right ear and instrumentation in the left ear.

What CPT® coding is reported?

A patient undergoes an MRI of the lumbar spine without and with contrast for left-sided low back pain with sciatica.

What CPT® and ICD-10-CM codes are reported?

View MR 099401

MR 099401

Established Patient Office Visit

Chief Complaint: Patient presents with bilateral thyroid nodules.

History of present illness: A 54-year-old patient is here for evaluation of bilateral thyroid nodules. Thyroid ultrasound was done last week which showed multiple thyroid masses likely due to multinodular goiter. Patient stated that she can “feel" the nodules on the left side of her thyroid. Patient denies difficulty swallowing and she denies unexplained weight loss or gain. Patient does have a family history of thyroid cancer in her maternal grandmother. She gives no other problems at this time other than a palpable right-sided thyroid mass.

Review of Systems:

Constitutional: Negative for chills, fever, and unexpected weight change.

HENT: Negative for hearing loss, trouble swallowing and voice change.

Gastrointestinal: Negative for abdominal distention, abdominal pain, anal bleeding, blood in stool, constipation, diarrhea, nausea, rectal pain, and vomiting

Endocrine: Negative for cold Intolerance and heat intolerance.

Physical Exam:

Vitals: BP: 140/72, Pulse: 96, Resp: 16, Temp: 97.6 °F (36.4 °C), Temporal SpO2: 97%

Weight: 89.8 kg (198 lbs ), Height: 165.1 cm (65”)

General Appearance: Alert, cooperative, in no acute distress

Head: Normocephalic, without obvious abnormality, atraumatic

Throat: No oral lesions, no thrush, oral mucosa moist

Neck: No adenopathy, supple, trachea midline, thyromegaly is present, no carotid bruit, no JVD

Lungs: Clear to auscultation, respirations regular, even, and unlabored

Heart: Regular rhythm and normal rate, normal S1 and S2, no murmur, no gallop, no rub, no click

Lymph nodes: No palpable adenopathy

ASSESSMENT/PLAN:

1) Multinodular goiter - the patient will have a percutaneous biopsy performed (minor procedure).

What E/M code is reported for this encounter?

A patient is sent to the hospital by his family care provider for admission due to a high fever and neck pain The patient is admitted to the hospital to rule out bacterial meningitis. The hospitalist admits the patient and orders a CBC. CMR Blood culture, CT of the head and chest, and a lumbar puncture (spinal tap). After review of the results, he determines the patient has bacterial meningitis and starts the patient on IV antibiotics.

What CPT® and ICD-10-CM codes are reported for the admission?