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93454 = Coronary angiography

R07.9 = Chest pain, unspecified

CAD code is not reported when ruled out

The procedure involves a tympanoplasty with a radical mastoidectomy and removal of a cholesteatoma from the middle ear, including grafting of the eardrum without ossicular chain reconstruction.

Procedure Description:

Tympanoplasty.

Radical mastoidectomy.

Removal of cholesteatoma from the middle ear.

Grafting technique used to repair the eardrum without ossicular chain reconstruction.

CPT® Coding:

69645: Tympanoplasty with mastoidectomy (including canalplasty, atticotomy and/or middle ear surgery), radical or complete, with removal of cholesteatoma; with mastoid obliteration.

AMA ' s CPT® Professional Edition (current year).

CPT® Assistant for detailed coding guidelines on otolaryngology procedures.

Basal cell carcinoma is amalignantskin neoplasm, so the excision is coded from11600–11646(malignant lesion excision), not11400–11446(benign lesion excision). The scalp is in the anatomic group that includesscalp/neck/hands/feet/genitalia, and the excised diameterincluding marginsdetermines the malignant excision code range. A size of3.7 cmfalls into the3.1–4.0 cmcategory, which corresponds to11624for malignant excision in that location group. Closure is separately reportable when it is anintermediate (layered) repair, so you add12032(intermediate repair, scalp/axillae/trunk/extremities;2.6–7.5 cm) when documentation supports layered closure beyond simple repair. Diagnosis coding should reflectbasal cell carcinoma of scalp/neck, which isC44.41. Options that use benign excision or benign diagnosis codes are incorrect for basal cell carcinoma.

94060 = Spirometry pre- and post-bronchodilator

94010 = Baseline spirometry

J45.21 = Mild intermittent asthma with exacerbation