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Click here for more sample CPC practice exam questions and answers with full rationale

Foreign Body Removal

Hi All.

I’m not sure there even is a procedure for this, none seem to grasp what is going on with this patient.

He came in with a wire piercing his hand. The following is the pertinent part of the note:

The R hand has a wire piercing through the palm, just ulnar to the 3rd metacarpal. No bleeding, no other wounds
*
Imaging: R hand XR shows no fx, wire passing in 3-4 metacarpal interspace
*
Assessment:
1. R hand retained foreign body
*
After the wire was prepped, it was pulled out without difficulty using a hemostat. Pt tolerated well. Wounds washed. Pt subsequently showed FROM all digits with FDS and FDP intact to all fingers.

I’m thinking this is just part of the NP Office Visit … But another set of eyes would be appreciated. I know this should be simple …

Thank you.

Medical Billing and Coding Forum

Endoscopic nasal foreign body removal

Hi all,

I’m unsure as to what to code for this report:

"After informed consent was obtained, the patient was brought to the operating room and placed supine on the operating table. General anesthesia was administered by the anesthesiologist. After a time out was performed and the patient was properly identified, the bed was rotated.

The nasal endoscope was placed in the right nares with no purulence or edema present. The nasal endoscope was placed in the left nares with copious purulence which was cultured. The purulence was suctioned and a foriegn body was identified. The foreign body was grasped with a blakesly forcep and removed. It appeared to be rolled up gauze or tissue. The nasal cavity was exmined with granulation tissue along the septum, nasal floor and inferior turbinate. The cavity was irrigated with nasal saline until clean. Hemostasis was checked with minimal bleeding from the granulation tissue. The adenoids were examine and found to be nonobstructive without exudates so no adenoidectomy was performed. Two afrin pledgets were placed until extubation.

The patient was turned over to anesthesia for extubation. The nasal pledgets were removed once the patient was extubated. He was brought to the recovery room in stable condition."

Please note that the scope was in the nose while the foreign body was removed. I’m confused if 30999 with comparative code 30310 should be billed or both 31231 & 30310.

Your assistance will be greatly appreciated!

Medical Billing and Coding Forum

CT scan for the whole body

Has any one every code for a whole body CT scan before? I am looking for a code and the only code that I keep getting reference to is 76497 which is unlisted computed tomography procedure(eg, diagnostic, interventional). Does anyone know if this is correct, or do I need to code each area of the body separate for this test.

Thank you,
Felicia
CPC,CPB, AAPC Professional

Medical Billing and Coding Forum

Foreign Body Removal Floor of Mouth

Physician took a patient to surgery for removal of a titanium screw from the floor of mouth. Looking for CPT code for procedure.

"The radiographic films revealed that the patient had a lesion approximately 1/2 inch, approximately 1.5 cm below the floor of mouth, just slightly to the mid-line. An incision was made in the lingual frenulum area and it was approximately 1.5 cm to 2 cm in length. Then the floor of the mouth musculature was divided and the dissection carried down through the scar tissue, since the patient had had previous genioglossus surgery, down to the foreign body which was an extruded titanium screw, which had become extruded from the medial aspect of the symphysis. The patient actually had a small divot and radiolucency in the jaw where this titanium screw had been extruded. Very carefully, the screw was removed with its associated Prolene, which was still approx. 3 cm in length and removed from the floor of mouth"

Should I use the unlisted code 41599 (unlisted procedure, tongue, floor of mouth) – My initial thought was 40805, but that seems to be more for the vestibule of mouth (nothing in that description says floor of mouth).

Thanks for any and all help

Lori

Medical Billing and Coding Forum

HELP!! Esophagus foreign body removal using laryngoscope. What to code?

Hi,

I am coming across several reports wherein there is a foreign body in the esophagus. However, instead of using a rigid esophagoscope, the physician is using a laryngoscope and a telescope.
What code should be coded?

43194 – Esophagoscopy, rigid, transoral; with removal of foreign body(s)

or

31531 – Laryngoscopy, direct, operative, with foreign bodyremoval; with operating microscope or telescope

Please help!

Medical Billing and Coding Forum