instruction stringlengths 47 331 | input stringlengths 0 445 | output stringlengths 74 825 |
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Determine the appropriate ICD-10-CM and CPT codes for a screening colonoscopy where a polyp was discovered and removed via snare technique. | 55-year-old male with no personal history of colon polyps or cancer presents for a routine screening colonoscopy. Family history is negative. During the procedure, a 6mm polyp was identified in the transverse colon and successfully removed using a snare technique. Pathology confirmed a benign tubular adenoma. | ICD-10-CM Codes:
1. Z12.11 - Encounter for screening for malignant neoplasm of colon (Primary diagnosis)
2. D12.3 - Benign neoplasm of transverse colon (Secondary diagnosis)
CPT Code:
- 45385 - Colonoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique
Modifier:
- Append modifier... |
Code a complex chronic care management visit for a patient with Type 2 Diabetes Mellitus and stage 3b chronic kidney disease. | 68-year-old female established patient presents for follow-up of Type 2 diabetes mellitus and chronic kidney disease. Lab work indicates eGFR is 38 mL/min/1.73m2 (Stage 3b). Physician reviews lab results, adjusts insulin dosage, and orders quarterly renal function monitoring. Medical Decision Making (MDM) is of moderat... | ICD-10-CM Codes:
1. E11.22 - Type 2 diabetes mellitus with diabetic chronic kidney disease
2. N18.32 - Chronic kidney disease, stage 3b
CPT Code:
- 99214 - Office or other outpatient visit for the evaluation and management of an established patient, moderate level of medical decision making
Coding Rationale:
Accordin... |
Code an emergency department visit where an established laceration repair was performed alongside an unrelated evaluation and management service. | 24-year-old male presents to the ED with a 2.5 cm superficial laceration on his left forearm from broken glass, and also complains of severe acute onset right lower quadrant abdominal pain with nausea. The physician performs a detailed history and exam for the abdominal pain, orders an abdominal CT scan, and diagnoses ... | ICD-10-CM Codes:
1. K35.80 - Unspecified acute appendicitis (for abdominal pain/E&M)
2. S51.812A - Laceration without foreign body, left forearm, initial encounter
CPT Codes:
1. 99284-25 - Emergency department visit, high level MDM (Modifier -25 appended to indicate a significant, separately identifiable evaluation an... |
Assign ICD-10-CM and CPT codes for an orthopedic procedure involving closed reduction of a distal radius fracture. | 32-year-old female presents following a fall on an outstretched hand. X-rays confirm a closed, displaced transverse fracture of the right distal radius (Colles' fracture). The orthopedist performs closed reduction with manual manipulation under hematoma block, followed by post-reduction X-ray confirmation and applicati... | ICD-10-CM Codes:
1. S52.531A - Colles' fracture of right radius, initial encounter for closed fracture
2. W19.XXXA - Unspecified fall, initial encounter
CPT Code:
1. 25605 - Closed treatment of distal radial fracture (eg, Colles or Smith type) or epiphyseal separation, includes closed treatment of fracture of ulnar st... |
Code an outpatient office visit that qualifies for Level 4 based strictly on time documentation. | 50-year-old male established patient presents for follow-up of hypertension and hyperlipidemia. The physician spent a total of 32 minutes of dedicated time on the date of the encounter, which included reviewing prior records (5 mins), face-to-face counseling on diet and medication adherence (20 mins), and updating the ... | ICD-10-CM Codes:
1. I10 - Essential (primary) hypertension
2. E78.5 - Hyperlipidemia, unspecified
CPT Code:
- 99214 - Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 30 minutes of total time spent on the date of the encounter.
Coding Rationale:
Per... |
Determine CPT and ICD-10-CM coding for a bilateral screening mammography that was immediately followed by a diagnostic mammography due to a suspicious lesion. | 62-year-old female presents for routine screening mammography. The radiologist observes a suspicious focal asymmetry in the right upper outer quadrant. The patient is immediately recalled standard diagnostic mammographic views (3D digital breast tomosynthesis) of the right breast during the same visit. Diagnostic findi... | ICD-10-CM Codes:
1. Z12.31 - Encounter for screening mammogram for malignant neoplasm of breast
2. R92.8 - Other abnormal and inconclusive findings on diagnostic imaging of breast
CPT Codes:
1. 77067 - Screening mammography, bilateral (2-view study of each breast), including computer-aided detection (CAD) when perform... |
Code the surgical excision of a malignant skin lesion on the trunk with 0.5 cm margins. | 48-year-old male presents for excision of a biopsy-proven malignant melanoma on his back. The lesion measured 1.2 cm at its greatest diameter. The surgeon excised the lesion with 0.5 cm circumferential margins (total excised diameter = 2.2 cm). Primary closure was performed in a simple single-layer fashion. | ICD-10-CM Code:
1. C44.511 - Malignant melanoma of skin of trunk
CPT Code:
1. 11603 - Excision, malignant lesion including margins, trunk, arms, or legs; excised diameter 2.1 to 3.0 cm
Coding Rationale:
Total excised diameter calculation: 1.2 cm (lesion) + 0.5 cm (margin) + 0.5 cm (margin) = 2.2 cm. Simple primary cl... |
Determine coding for an initial inpatient hospital encounter for severe sepsis secondary to acute pyelonephritis. | 72-year-old male admitted through the emergency department directly to the ICU with severe sepsis, fever, altered mental status, and hypotension. Blood and urine cultures confirm Escherichia coli pyelonephritis leading to severe sepsis with acute kidney injury. The attending physician completes an initial hospital E/M ... | ICD-10-CM Codes:
1. A41.51 - Sepsis due to Escherichia coli (Underlying systemic infection)
2. R65.20 - Severe sepsis without septic shock
3. N10 - Acute pyelonephritis
4. N17.9 - Acute kidney failure, unspecified
CPT Code:
1. 99223 - Initial hospital care, per day, for the evaluation and management of a patient, high... |
Code a trigger point injection procedure targeting multiple muscle groups. | 45-year-old male with chronic myofascial pain syndrome presents for trigger point injections. The physician injects 1% lidocaine into two distinct muscle groups: the right trapezius (2 sites) and the right levator scapulae (1 site). | ICD-10-CM Code:
1. M79.18 - Myalgia, myofascial pain syndrome
CPT Code:
1. 20552 - Injection(s); single or multiple trigger point(s), 1 or 2 muscle(s)
Coding Rationale:
CPT 20552 covers 1 or 2 muscle groups regardless of how many individual injection punctures are made into those muscles. Since two muscle groups were... |
Assign codes for an annual preventive medicine evaluation and a separately identifiable problem-focused E/M visit on an established adult patient. | 52-year-old female presents for her routine comprehensive annual preventive exam. During the visit, she reports severe acute onset lower back pain radiating down her left leg for 3 days. The physician completes the preventive exam and performs a separate detailed neurological and musculoskeletal examination, diagnosing... | ICD-10-CM Codes:
1. Z00.00 - Encounter for general adult medical examination without abnormal findings
2. M54.16 - Radiculopathy, lumbar region
CPT Codes:
1. 99396 - Periodic comprehensive preventive medicine reevaluation and management of an individual; established patient, age 40-64 years
2. 99214-25 - Office or oth... |
Code a standard cataract extraction with intraocular lens implantation procedure. | 71-year-old male with age-related nuclear cataract in the right eye undergoes elective phacoemulsification with intraocular lens (IOL) implantation under local anesthesia without complications. | ICD-10-CM Code:
1. H25.11 - Age-related nuclear cataract, right eye
CPT Code:
1. 66984 - Extracapsular cataract removal with insertion of intraocular lens prosthesis (1-stage procedure), manual or mechanical technique (eg, phacoemulsification, intracapsular cataract extraction)
Modifier:
- Append modifier -RT to indi... |
Determine CPT and ICD-10-CM codes for knee arthroscopy involving a partial medial meniscectomy. | 38-year-old female presents with right knee pain and locking after a sports injury. MRI shows a complex tear of the medial meniscus. The surgeon performs diagnostic knee arthroscopy and subsequent arthroscopic partial medial meniscectomy. The lateral compartment and patellofemoral joint were inspected and normal. | ICD-10-CM Code:
1. M23.22 - Derangement of meniscus due to old tear or injury, medial meniscus, right knee
CPT Code:
1. 29881 - Arthroscopy, knee, surgical; with meniscectomy (medial OR lateral, including any meniscal shaving)
Coding Rationale:
Diagnostic arthroscopy (29810) is bundled into surgical arthroscopy (2988... |
Assign correct ICD-10-CM codes for hypertensive heart disease with acute congestive systolic heart failure. | 74-year-old male with longstanding essential hypertension is admitted to the hospital with acute exacerbation of systolic heart failure (HFrEF). Workup shows decompensated heart failure directly attributed to uncontrolled hypertension. | ICD-10-CM Codes:
1. I11.0 - Hypertensive heart disease with heart failure
2. I50.21 - Acute systolic (congestive) heart failure
Coding Rationale:
According to ICD-10-CM guideline I.C.9.a.1, a causal relationship is assumed between hypertension and heart conditions classified to I50.-. Code I11.0 is listed first, follo... |
Code a laparoscopic cholecystectomy procedure including intraoperative cholangiogram. | 44-year-old female presents with acute severe upper right quadrant pain, nausea, and vomiting. Ultrasound reveals acute cholecystitis with gallstones. The surgeon performs a laparoscopic cholecystectomy and conducts an intraoperative cholangiogram via the cystic duct to rule out choledocholithiasis. | ICD-10-CM Code:
1. K80.00 - Calculus of gallbladder with acute cholecystitis without obstruction
CPT Code:
1. 47563 - Laparoscopy, surgical; cholecystectomy with cholangiography |
Assign codes for an intermediate repair of a laceration on the scalp measuring 4.5 cm. | 19-year-old male suffered a 4.5 cm laceration to his scalp from an assault. The wound required layered closure of subcutaneous tissues and galea aponeurotica prior to skin closure using staples. | ICD-10-CM Codes:
1. S01.01XA - Laceration without foreign body of scalp, initial encounter
2. Y04.0XXA - Assault by unarmed brawl or fight, initial encounter
CPT Code:
1. 12032 - Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities (excluding hands and feet); 2.6 cm to 7.5 cm |
Code critical care services provided in the ED for 65 minutes. | 60-year-old male presents to the ED in septic shock. The ED physician provides direct, continuous critical care face-to-face for 65 minutes, excluding separate billable procedures. Care involves invasive hemodynamic monitoring, aggressive fluid resuscitation, and titration of vasopressors. | ICD-10-CM Codes:
1. R57.2 - Septic shock
2. A41.9 - Sepsis, unspecified organism
CPT Code:
1. 99291 - Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes
Coding Rationale:
CPT 99291 is used to report the first 30 to 74 minutes of critical care time. Since ... |
Code a Medicare Annual Wellness Visit (AWV), First Visit. | 66-year-old female Medicare beneficiary presents for her initial Annual Wellness Visit. The provider collects personalized prevention plan information, performs a health risk assessment, reviews family and medical history, checks vitals, assesses cognitive function, and provides a screening schedule for preventive serv... | ICD-10-CM Code:
1. Z00.00 - Encounter for general adult medical examination without abnormal findings
HCPCS Code:
1. G0438 - Annual wellness visit; includes a personalized prevention plan of service (PPS), initial visit
Coding Rationale:
Medicare does not reimburse routine CPT preventive codes (99381-99397). Initial ... |
Assign CPT and ICD-10-CM codes for primary total hip replacement surgery due to severe left hip osteoarthritis. | 67-year-old male with end-stage primary osteoarthritis of the left hip undergoes elective total hip arthroplasty using a cemented acetabular and femoral component. | ICD-10-CM Code:
1. M16.12 - Unilateral primary osteoarthritis, left hip
CPT Code:
1. 27130 - Arthroplasty, acetabular and proximal femoral prosthetic replacement (total hip arthroplasty), with or without autograft or allograft
Modifier:
- Append modifier -LT to indicate left side. |
Code an upper GI endoscopy (EGD) with biopsy of the esophagus. | 53-year-old male with chronic gastroesophageal reflux disease (GERD) presents for upper endoscopy. Inspection reveals columnar-lined mucosa in the distal esophagus suspicious for Barrett's esophagus. Biopsies are taken of the esophageal mucosa using cold forcep technique. Pathology reveals intestinal metaplasia (Barret... | ICD-10-CM Code:
1. K22.70 - Barrett's esophagus without dysplasia
CPT Code:
1. 43239 - Esophagogastroduodenoscopy, flexible, transoral; with biopsy, single or multiple
Coding Rationale:
Diagnostic EGD (43235) is included in surgical/biopsy EGD (43239) and should not be separately reported. |
Assign coding for diagnostic bronchoscopy with transbronchial lung biopsy of a single lobe. | 58-year-old female with persistent solitary pulmonary nodule in the right upper lobe undergoes flexible fiberoptic bronchoscopy. Transbronchial biopsy samples are successfully obtained from the right upper lobe lesion. | ICD-10-CM Code:
1. R91.1 - Solitary pulmonary nodule
CPT Code:
1. 31628 - Bronchoscopy, rigid or flexible, including fluoroscopic guidance when performed; with transbronchial lung biopsy(ies), single lobe |
Code an incision and drainage (I&D) of a complicated pilonidal cyst. | 28-year-old male presents with a large, recurrent, infected pilonidal cyst. The surgeon performs incision and drainage, breaking down multiple loculations, placing a Penrose drain, and packing the cavity with iodoform gauze. | ICD-10-CM Code:
1. L05.01 - Pilonidal cyst with abscess
CPT Code:
1. 10081 - Incision and drainage of pilonidal cyst; complicated
Coding Rationale:
Code 10081 is selected over simple I&D (10080) because the procedure involved breaking loculations, insertion of packing/drains, and addressed a complex/recurrent cyst. |
Determine CPT coding for an in-office 12-lead EKG with interpretation and report. | 61-year-old male presents with intermittent chest tightness. An in-office 12-lead electrocardiogram (EKG) is performed using the clinic's equipment, and the attending physician generates a written interpretation and report showing sinus tachycardia with non-specific ST changes. | ICD-10-CM Code:
1. R07.9 - Chest pain, unspecified
CPT Code:
1. 93000 - Electrocardiogram, routine EC3 with at least 12 leads; with interpretation and report
Coding Rationale:
CPT 93000 represents the complete global procedure (tracing + technical component + professional interpretation/report). Modifiers -26 or -TC ... |
Code surgical debridement of subcutaneous tissue covering 15 sq cm. | 70-year-old male with a non-healing Stage 3 pressure ulcer of the right heel undergoes sharp debridement of infected subcutaneous tissue down to, but not including, fascia. The total wound surface area debrided is 15 sq cm. | ICD-10-CM Code:
1. L89.613 - Pressure ulcer of right heel, stage 3
CPT Code:
1. 11042 - Debridement, subcutaneous tissue (includes epidermis and dermis, if performed); first 20 sq cm or less |
Assign ICD-10-CM codes for COPD exacerbation with an acute lower respiratory infection. | 69-year-old male with underlying severe COPD presents with increased dyspnea, purulent sputum, and fever. Workup confirms acute exacerbation of chronic obstructive pulmonary disease secondary to acute bronchitis. | ICD-10-CM Code:
1. J44.0 - Chronic obstructive pulmonary disease with an acute lower respiratory infection
2. J20.9 - Acute bronchitis, unspecified
Coding Rationale:
Per ICD-10-CM guidelines for category J44, J44.0 is reported when COPD is presenting with an acute lower respiratory infection. An additional code for th... |
Code a complex cystourethroscopy with fulguration of a 1.5 cm bladder tumor. | 63-year-old male presents with painless hematuria. Cystourethroscopy reveals a single papillary lesion measuring 1.5 cm along the posterior wall of the bladder. The lesion is fulgurated and electrocauterized. | ICD-10-CM Code:
1. C67.2 - Malignant neoplasm of posterior wall of urinary bladder
CPT Code:
1. 52234 - Cystourethroscopy, with fulguration (including cryosurgery or laser surgery) or resection of; small bladder tumor(s) (0.5 up to 2.0 cm) |
Code a major depressive disorder encounter, recurrent, severe without psychotic features. | 34-year-old female established patient presents for psychiatric evaluation. She exhibits severe depressed mood, anhedonia, significant weight loss, insomnia, and psychomotor agitation lasting 4 weeks. She has a history of prior treated depressive episodes but exhibits no delusional or psychotic symptoms. | ICD-10-CM Code:
1. F33.2 - Major depressive disorder, recurrent, severe without psychotic features
CPT Code:
1. 99215 - Office or other outpatient visit, established patient, high level of MDM |
Assign CPT and ICD-10-CM codes for a initial 1-hour IV chemotherapy administration for primary non-small cell lung cancer. | 64-year-old male with non-small cell lung cancer of the right lower lobe attends the outpatient infusion clinic. He receives IV infusion chemotherapy (Carboplatin) lasting 60 minutes. | ICD-10-CM Code:
1. C34.31 - Malignant neoplasm of lower lobe, right bronchus or lung
2. Z51.11 - Encounter for antineoplastic chemotherapy
CPT Code:
1. 96413 - Chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug |
Code removal of impacted cerumen using instrumentation in one ear. | 78-year-old male presents with persistent hearing loss in his left ear. Examination reveals hard, dark impacted cerumen completely occluding the left external auditory canal. The physician removes the impacted cerumen using an ear curette and suction under direct visualization with an otoscope. | ICD-10-CM Code:
1. H61.22 - Impacted cerumen, left ear
CPT Code:
1. 69210 - Removal impacted cerumen requiring instrumentation, unilateral
Coding Rationale:
Instrumentation (curette/suction under visualization) is required for 69210. Simple irrigation/lavage is not separately billable under 69210. |
Assign HCPCS and ICD-10-CM codes for a Medicare screening Pap smear and pelvic exam. | 67-year-old female Medicare beneficiary with no history of cervical cancer presents for a routine preventive pelvic examination and collection of a screening Pap smear specimen. | ICD-10-CM Code:
1. Z12.4 - Encounter for screening for malignant neoplasm of cervix
HCPCS Codes:
1. G0101 - Cervical or vaginal cancer screening; pelvic and clinical breast examination
2. Q0091 - Screening Papanicolaou smear; obtaining, preparing and conveyance of cervical or vaginal smear to laboratory |
Code surgical excision of a subcutaneous lipoma measuring 3.0 cm on the back. | 41-year-old male presents for excision of a painful, growing subcutaneous lipoma on his upper back. The surgeon makes an incision over the mass, dissects through the subcutaneous layer, and completely excises the 3.0 cm fatty tumor. Primary layered closure was performed. | ICD-10-CM Code:
1. D17.1 - Benign lipomatous neoplasm of skin and subcutaneous tissue of trunk
CPT Code:
1. 21931 - Excision, tumor, soft tissue of back or flank, subcutaneous; 3 cm or greater |
Determine coding for a single hemodialysis treatment session with a single physician evaluation. | 56-year-old end-stage renal disease (ESRD) inpatient receives a single hemodialysis session. The nephrologist performs a single face-to-face evaluation during dialysis, reviewing fluid balance, adjusting dialysate bath, and examining the vascular access site. | ICD-10-CM Code:
1. N18.6 - End stage renal disease
CPT Code:
1. 90935 - Hemodialysis procedure with single evaluation by a physician or other qualified health care professional |
Code bilateral myringotomy with ventilating tube insertion under general anesthesia. | 4-year-old child with chronic serous otitis media bilaterally undergoes bilateral myringotomy with placement of fluoroplastic ventilating tubes in the tympanic membranes under general endotracheal anesthesia. | ICD-10-CM Code:
1. H65.33 - Chronic mucoid otitis media, bilateral
CPT Code:
1. 69436 - Tympanostomy (requiring insertion of ventilating tube), general anesthesia
Modifier:
- Append modifier -50 to 69436 to indicate a bilateral procedure. |
Assign codes for open carpal tunnel release surgery on the right wrist. | 49-year-old female with severe, conservative-treatment-refractory carpal tunnel syndrome of the right hand undergoes open transverse carpal ligament release under local intravenous regional anesthesia (Bier block). | ICD-10-CM Code:
1. G56.01 - Carpal tunnel syndrome, right upper limb
CPT Code:
1. 64721 - Neuroplasty and/or transposition; median nerve at carpal tunnel
Modifier:
- Append modifier -RT. |
Code a initial physical therapy evaluation of low complexity. | 30-year-old male presents for physical therapy evaluation following a mild cervical strain from a motor vehicle accident. The physical therapist performs a low-complexity evaluation including history, examination of 1-2 elements, and clinical decision making with no comorbidities. Total time spent face-to-face is 20 mi... | ICD-10-CM Codes:
1. S13.4XXA - Sprain of ligaments of cervical spine, initial encounter
2. V89.2XXA - Person injured in unspecified motor-vehicle accident, traffic, initial encounter
CPT Code:
1. 97161 - Physical therapy evaluation: low complexity, requiring 20 minutes |
Determine CPT and ICD-10-CM codes for a CABG procedure using 3 saphenous vein grafts. | 65-year-old male with severe three-vessel coronary artery disease undergoes coronary artery bypass graft (CABG) surgery using three saphenous vein autografts. No arterial grafts were utilized. | ICD-10-CM Code:
1. I25.10 - Atherosclerotic heart disease of native coronary artery without angina pectoris
CPT Code:
1. 33512 - Coronary artery bypass, vein only; 3 coronary venous grafts |
Assign ICD-10-CM coding for Non-ST elevation myocardial infarction (NSTEMI). | 59-year-old male admitted with chest pain, elevated troponin I (3.4 ng/mL), and ST segment depressions on EKG. The final diagnosis established by the cardiologist is Non-ST elevation myocardial infarction (NSTEMI). | ICD-10-CM Code:
1. I21.4 - Non-ST elevation (NSTEMI) myocardial infarction |
Code a diagnostic lumbar puncture performed in an outpatient clinic. | 37-year-old female presenting with severe headache, fever, and neck stiffness undergoes diagnostic lumbar puncture in the outpatient procedure suite under sterile field and local anesthesia. Cerebrospinal fluid (CSF) samples are obtained and sent to pathology. | ICD-10-CM Code:
1. R51.9 - Headache, unspecified
CPT Code:
1. 62270 - Spinal puncture, lumbar, diagnostic |
Code the excision of skin tags from multiple anatomical sites (8 total lesions). | 54-year-old female presents for removal of multiple skin tags on her neck (5 lesions) and right axilla (3 lesions). The physician removes all 8 skin tags using scissoring technique followed by electrocautery for hemostasis. | ICD-10-CM Code:
1. L91.8 - Other hypertrophic disorders of the skin (Skin tags)
CPT Code:
1. 11200 - Removal of skin tags, multiple fibrocutaneous tags, any area; up to and including 15 lesions
Coding Rationale:
Code 11200 covers any location for up to 15 skin tags total. Add-on code 11201 is only used for each addit... |
Determine coding for intra-articular joint injection of the knee with fluoroscopic guidance. | 61-year-old male with primary osteoarthritis of the left knee undergoes intra-articular injection of 20 mg triamcinolone acetonide into the left knee joint. Fluoroscopic guidance was utilized to ensure precise needle placement within the joint space. | ICD-10-CM Code:
1. M17.12 - Unilateral primary osteoarthritis, left knee
CPT Codes:
1. 20611 - Arthrocentesis, aspiration and/or injection, major joint or bursa (eg, shoulder, hip, knee, subacromial bursa); with ultrasound guidance
2. 20610 - Arthrocentesis, aspiration and/or injection, major joint or bursa; without u... |
Code left heart catheterization with selective coronary angiography. | 62-year-old male presenting with stable angina undergoes diagnostic cardiac catheterization. Access is established via the radial artery. Left heart catheterization, retrograded arterial entry, coronary arteriography, and left ventriculography are performed with imaging supervision and interpretation. | ICD-10-CM Code:
1. I25.110 - Atherosclerotic heart disease of native coronary artery with angina pectoris with documented spasm
CPT Code:
1. 93458 - Catheter placement in coronary artery(ies) for coronary angiography, including intra-aortic balloon pump insertion, when performed, with catheter placement(s) in bypass g... |
Assign codes for an adult sleep study (polysomnography) with 6 or more parameters. | 46-year-old male with severe daytime somnolence and habitual snoring undergoes an attended, full-night polysomnography in an accredited sleep center with 8 parameters recorded (EEG, EOG, EMG, ECG, airflow, respiratory effort, pulse oximetry, leg movements). | ICD-10-CM Code:
1. G47.33 - Obstructive sleep apnea (adult) (pediatric)
CPT Code:
1. 95810 - Polysomnography; age 6 years or older, sleep staging with 4 or more additional parameters of sleep, attended by a technologist |
Code the excision of a basal cell carcinoma on the nose with an excised diameter of 0.8 cm. | 68-year-old male presents for excision of a biopsy-confirmed basal cell carcinoma on the tip of his nose. The lesion is 0.5 cm in size and excised with 0.15 cm margins on all sides (total excised diameter = 0.8 cm). The wound was closed with simple sutures. | ICD-10-CM Code:
1. C44.311 - Basal cell carcinoma of skin of nose
CPT Code:
1. 11641 - Excision, malignant lesion including margins, face, ears, eyelids, nose, lips; excised diameter 0.6 to 1.0 cm |
Code screening dual-energy X-ray absorptiometry (DEXA) scan for osteoporosis in a postmenopausal female. | 65-year-old postmenopausal female presents for routine screening bone density measurement. Axial DEXA scan of the central skeleton (lumbar spine and bilateral hips) is performed. | ICD-10-CM Code:
1. Z13.820 - Encounter for screening for osteoporosis
CPT Code:
1. 77080 - Dual-energy X-ray absorptiometry (DXA), bone density study, 1 or more sites; axial skeleton (eg, hips, pelvis, spine) |
Assign ICD-10-CM codes for acute appendicitis with localized peritonitis. | 22-year-old female presents to the hospital with severe RLQ pain, fever, and rebound tenderness. Emergency laparoscopic surgery confirms acute appendicitis with localized peritonitis and early rupture. | ICD-10-CM Code:
1. K35.32 - Acute appendicitis with perforation and localized peritonitis, without abscess
Coding Rationale:
Code K35.32 captures acute appendicitis complicated by rupture/perforation and localized peritonitis. |
Code a complex repair of a 3.0 cm facial wound. | 27-year-old male sustained a complex facial laceration involving skin, subcutaneous tissue, and underlying facial musculature across his cheek following a glass injury. The plastic surgeon performed extensive debridement, undermining, and multi-layer reconstruction of the muscular and cutaneous structures measuring 3.0... | ICD-10-CM Code:
1. S01.411A - Laceration without foreign body of right cheek, initial encounter
CPT Code:
1. 13132 - Repair, complex, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; 1.1 cm to 2.5 cm... (Wait: wound is 3.0 cm -> 13132 is 1.1-2.5 cm; 13132 + 13133 or 13132 is 2.6 to 7.5 cm? L... |
Determine codes for initial outpatient consultation requested by a primary care physician. | 51-year-old male is referred to a cardiologist by his PCP for evaluation of refractory hypertension. The cardiologist conducts a detailed history and physical exam, reviews external labs, formulates a new antihypertensive regimen, and sends a written report with recommendations back to the referring PCP. MDM is moderat... | ICD-10-CM Code:
1. I10 - Essential (primary) hypertension
CPT Code:
1. 99244 - Office or other outpatient consultation for a new or established patient, moderate MDM
Coding Rationale:
Where accepted by commercial payers, 99244 is appropriate because the 3 R's of consultation were met: Request from PCP, Render of serv... |
Assign codes for transurethral resection of the prostate (TURP). | 72-year-old male with severe urinary retention and lower urinary tract symptoms secondary to benign prostatic hyperplasia (BPH) undergoes complete transurethral resection of the prostate (TURP) under spinal anesthesia. | ICD-10-CM Code:
1. N40.1 - Benign prostatic hyperplasia with lower urinary tract symptoms
2. R33.9 - Retention of urine, unspecified
CPT Code:
1. 52601 - Transurethral electrosurgical resection of prostate, including control of postoperative bleeding, complete (1 or 2 stages) |
Code the initial care of a normal newborn infant born in the hospital. | Healthy newborn male delivered via uncomplicated spontaneous vaginal delivery at 39 weeks gestation in the hospital. The attending pediatrician performs the initial comprehensive newborn physical exam and inpatient hospital admission evaluation. | ICD-10-CM Code:
1. Z38.00 - Single liveborn infant, delivered vaginally
CPT Code:
1. 99460 - Initial hospital or birthing center care, per day, for evaluation and management of normal newborn infant |
Determine ICD-10-CM and CPT codes for bilateral digital breast tomosynthesis (3D mammography) added to screening mammogram. | 50-year-old female undergoes routine screening 2D digital mammography along with 3D digital breast tomosynthesis of both breasts. | ICD-10-CM Code:
1. Z12.31 - Encounter for screening mammogram for malignant neoplasm of breast
CPT Codes:
1. 77067 - Screening mammography, bilateral (2-view study of each breast), including computer-aided detection (CAD) when performed
2. 77063 - Screening digital breast tomosynthesis, bilateral (List separately in a... |
Code posterior lumbar interbody fusion (PLIF) at L4-L5. | 42-year-old male with severe spondylolisthesis at L4-L5 undergoes posterior lumbar interbody fusion (PLIF) with insertion of interbody biomechanical device and local bone autograft. | ICD-10-CM Code:
1. M43.16 - Spondylolisthesis, lumbar region
CPT Codes:
1. 22612 - Arthrodesis, posterior or posterolateral technique, single level; lumbar (with lateral transverse technique when performed)
2. 22853 - Insertion of interbody biomechanical device(s) (eg, synthetic cage) with integral arthrodesis design,... |
Determine the appropriate ICD-10-CM and CPT codes for an established patient presenting with uncontrolled Type 2 Diabetes Mellitus with diabetic polyneuropathy, who also has primary essential hypertension. An established office visit with moderate medical decision making (MDM) was performed. | Physician note: 58-year-old male established patient presents for routine follow-up. BP 138/84. FBS 182. Patient reports burning paresthesias in bilateral feet consistent with diabetic peripheral neuropathy. Adjusting glipizide dose and prescribing duloxetine. Total time spent 32 minutes. | ICD-10-CM Codes:
- E11.42 (Type 2 diabetes mellitus with diabetic polyneuropathy)
- I10 (Essential (primary) hypertension)
CPT Code:
- 99214 (Office or other outpatient visit for the evaluation and management of an established patient, moderate complexity MDM, 30-39 minutes)
Reasoning: Per ICD-10-CM coding guidelines... |
Assign CPT codes and modifiers for a patient who underwent a screening colonoscopy, during which a 6mm polyp in the sigmoid colon was removed via snare technique and a 4mm polyp in the ascending colon was removed via cold biopsy forceps. | CPT Codes:
- 45385 (Colonoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique)
- 45380-59 or 45380-XS (Colonoscopy, flexible; with biopsy, single or multiple; modified for distinct procedural service)
ICD-10-CM Codes:
- K63.5 (Polyp of colon)
- Z12.11 (Encounter for screening for... | |
Code a surgical encounter for a 24-year-old female diagnosed with acute appendicitis with localized peritonitis who underwent an uncomplicated laparoscopic appendectomy. | Operative report summary: Patient presented to the ED with RLQ pain and fever. CT scan confirmed acute appendicitis with localized peritonitis. Laparoscopic appendectomy performed without complication. Path report confirms acute appendicitis with localized peritonitis. | CPT Code:
- 44970 (Laparoscopy, surgical, appendectomy)
ICD-10-CM Code:
- K35.30 (Acute appendicitis with localized peritonitis, without perforation or gangrene)
Reasoning: CPT 44970 covers the laparoscopic approach to an appendectomy. ICD-10-CM code K35.30 specifically captures acute appendicitis with localized peri... |
Code an emergency department scenario where a patient presents with a closed, displaced fracture of the right distal radius. The ED physician performs a closed reduction under hematoma block and applies a short arm fiberglass splint. | ED Provider Note: Displaced right distal radius fracture confirmed on X-ray. Performed hematoma block (10mL 1% lidocaine). Manipulated distal radius back into anatomical alignment with manual traction. Post-reduction X-ray shows acceptable alignment. Applied short-arm fiberglass splint. | CPT Codes:
- 25605-RT (Closed treatment of distal radial fracture; with manipulation, right side)
- 99284-25 (Emergency department visit, level 4, significant, separately identifiable service)
ICD-10-CM Code:
- S52.501A (Unspecified fracture of lower end of right radius, initial encounter for closed fracture)
Reasoni... |
A 52-year-old established female patient visits her primary care physician for her annual preventive medicine exam. During the exam, she reports a 3-week history of worsening right knee pain. The physician evaluates the knee, diagnoses osteoarthritis, orders an X-ray, and prescribes meloxicam. How should this encounter... | CPT Codes:
- 99396 (Periodic comprehensive preventive medicine evaluation and management... established patient, age 40-64)
- 99213-25 (Office or other outpatient visit... established patient, low-to-moderate MDM; modified with modifier 25)
ICD-10-CM Codes:
- Z00.00 (Encounter for general adult medical examination wit... | |
Code an outpatient encounter for a patient with Chronic Obstructive Pulmonary Disease (COPD) presenting with an acute exacerbation and acute bronchitis. | Clinical note: 67-year-old male with severe COPD presenting with increased dyspnea, wheezing, and purulent sputum production for 3 days. Diagnosed with acute COPD exacerbation and acute bronchitis. Nebulizer treatment administered in office. | ICD-10-CM Code:
- J44.1 (Chronic obstructive pulmonary disease with (acute) exacerbation)
CPT Code:
- 94640 (Pressurized or nonpressurized inhalation treatment for acute airway obstruction)
Reasoning: According to ICD-10-CM Coding Guideline I.C.10.a.1, when a patient has COPD with an acute bronchitis exacerbation, co... |
Assign CPT and ICD-10 codes for an uncomplicated extracapsular cataract removal with insertion of intraocular lens (IOL) power calculation and placement in the right eye for a nuclear sclerotic senile cataract. | CPT Code:
- 66984-RT (Extracapsular cataract removal with insertion of intraocular lens prosthesis, manual or mechanical technique, right eye)
ICD-10-CM Code:
- H25.11 (Age-related nuclear cataract, right eye)
Reasoning: CPT 66984 represents standard (non-complex) cataract extraction with IOL implantation. Anatomical... | |
A patient presents for a routine screening mammogram. The radiologist notes a suspicious mass in the left upper outer quadrant and immediately converts to a diagnostic mammogram on the same day. How is this coded under Medicare guidelines? | CPT Codes:
- 77067 (Screening bilateral mammography)
- 77065-GG-LT or 77066-GG (Diagnostic mammography; GG modifier indicates performance of diagnostic mammogram converted from screening)
ICD-10-CM Codes:
- Z12.31 (Encounter for screening mammogram for malignant neoplasm of breast)
- N63.12 (Unspecified lump in the le... | |
Code an inpatient admission note where the patient was admitted with Severe Sepsis due to Escherichia coli Urinary Tract Infection (UTI) leading to acute kidney injury (AKI). | Discharge summary: 72-year-old female admitted for high fevers, altered mental status, and hypotension. Urine culture positive for E. coli. Diagnosed with E. coli UTI progressing to severe sepsis with acute kidney injury (resolved with IV fluids). | ICD-10-CM Codes (in correct sequence):
- A41.51 (Sepsis due to Escherichia coli [E. coli])
- R65.20 (Severe sepsis without septic shock)
- N39.0 (Urinary tract infection, site not specified)
- N17.9 (Acute kidney failure, unspecified)
Reasoning: Per ICD-10-CM Official Guidelines for Coding and Reporting (Section I.C.1... |
Code a psychiatric evaluation where the patient is diagnosed with Major Depressive Disorder, recurrent episode, severe, without psychotic features. | Psychiatric Evaluation: 34-year-old male with long history of depressive episodes. Presents with severe depressed mood, anhedonia, 15lb weight loss, insomnia, and psychomotor agitation lasting 6 weeks. No delusions or hallucinations present. | ICD-10-CM Code:
- F33.2 (Major depressive disorder, recurrent, severe without psychotic features)
Reasoning: ICD-10 category F33 represents recurrent major depressive disorder. Specifier .2 designates that the current episode is severe and lacks psychotic symptoms. Proper documentation requires defining episodic frequ... |
Code a superficial dermal and subcutaneous tissue laceration repair measuring 4.5 cm on the forearm, requiring layered closure. | Surgical Note: Cleaned and prepped 4.5 cm deep laceration of right forearm. Performed layered closure using 4-0 Vicryl for subcutaneous tissue and 5-0 Ethilon for dermal layer. | CPT Code:
- 12032 (Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities (excluding hands and feet); 2.6 cm to 7.5 cm)
ICD-10-CM Code:
- S51.811A (Laceration without foreign body, right forearm, initial encounter)
Reasoning: CPT guidelines define intermediate repair (12030-12057) as repair of wound... |
A patient undergoes elective right total knee replacement due to end-stage primary osteoarthritis. Code the procedure and primary diagnosis. | CPT Code:
- 27447-RT (Arthroplasty, knee, condyle and plateau; medial AND lateral compartments with or without patellar resurfacing [Total Knee Arthroplasty], right side)
ICD-10-CM Code:
- M17.11 (Unilateral primary osteoarthritis, right knee)
Reasoning: CPT 27447 represents total knee arthroplasty (TKA). Anatomical ... | |
Select correct ICD-10-CM codes for a patient with Type 2 Diabetes Mellitus who has Chronic Kidney Disease (CKD) Stage 4 caused by diabetic nephropathy. | ICD-10-CM Codes:
- E11.22 (Type 2 diabetes mellitus with diabetic nephropathy)
- N18.4 (Chronic kidney disease, stage 4 (severe))
Reasoning: Per ICD-10-CM guidelines for Type 2 Diabetes with kidney complications, code E11.22 must be assigned first, followed by an additional code from category N18 to specify the exact ... | |
Code an outpatient procedure for a lumbar epidural steroid injection performed at L4-L5 under fluoroscopic guidance for lumbar radiculopathy. | Procedure note: Patient in prone position. L4-L5 interspace identified under fluoroscopy. Epidural space reached via interlaminar approach. 80mg Depo-Medrol injected. Fluoroscopic images archived. | CPT Code:
- 62323 (Injection(s), of diagnostic or therapeutic substance(s)... epidural or subarachnoid; lumbar or sacral, with imaging guidance [fluoroscopy or CT])
ICD-10-CM Code:
- M54.16 (Radiculopathy, lumbar region)
Reasoning: CPT code 62323 describes single lumbar/sacral epidural injection WITH fluoroscopic or ... |
Determine the CPT code for an emergency room visit for a patient presenting with high fever and acute confusion, requiring a high level of Medical Decision Making (MDM). | CPT Code:
- 99285 (Emergency department visit for the evaluation and management of a patient, which requires a high level of medical decision making)
ICD-10-CM Code:
- R41.0 (Disorientation, unspecified) / R50.9 (Fever, unspecified)
Reasoning: Under 2023 revised E/M guidelines, Emergency Department visits (99281-9928... | |
Code trigger point injections performed on 3 distinct muscle groups (left trapezius, left levator scapulae, and left rhomboid). | Procedure Note: Administered 1% lidocaine TPIs into trigger points within 3 muscles: left trapezius, left levator scapulae, and left rhomboid major. | CPT Code:
- 20553 (Injection(s); single or multiple trigger point(s), 3 or more muscle(s))
ICD-10-CM Code:
- M79.18 (Myalgia, auxiliary ligaments and fascia)
Reasoning: CPT trigger point injection codes are chosen by the number of muscles injected, not the number of needle insertions. Code 20552 covers 1 or 2 muscles... |
A surgeon excises a malignant lesion from the upper back. Excision diameter is 1.5 cm with 0.5 cm margin on each side. Simple closure was performed. Code the surgical procedure. | CPT Code:
- 11603 (Excision, malignant lesion including margins, trunk, arms, or legs; excised diameter 2.1 to 3.0 cm)
ICD-10-CM Code:
- C44.511 (Basal cell carcinoma of skin of trunk)
Reasoning: CPT excision code calculation equals lesion diameter (1.5 cm) plus twice the narrowest margin (0.5 cm x 2 = 1.0 cm), yield... | |
Code a diagnostic Esophagogastroduodenoscopy (EGD) where a biopsy of the stomach mucosa was performed to evaluate persistent epigastric pain. | Endoscopy Report: EGD advanced to second portion of duodenum. Biopsy taken from gastric antrum due to diffuse erythema. Path report: Helicobacter pylori gastritis. | CPT Code:
- 43239 (Esophagogastroduodenoscopy, flexible, transoral; with biopsy, single or multiple)
ICD-10-CM Code:
- K29.50 (Unspecified chronic gastritis, without bleeding) or B96.81 (Helicobacter pylori as cause of diseases classified elsewhere)
Reasoning: CPT 43239 includes transoral flexible EGD with single or ... |
Assign ICD-10 codes for a patient documented as having Paroxysmal Atrial Fibrillation on long-term Eliquis (apixaban) therapy. | ICD-10-CM Codes:
- I48.0 (Paroxysmal atrial fibrillation)
- Z79.01 (Long term (current) use of anticoagulants)
Reasoning: Specific subcategory I48.0 identifies paroxysmal atrial fibrillation. Status code Z79.01 must be reported as a secondary code to capture long-term use of oral anticoagulants like Eliquis for risk a... | |
Code a diagnostic full-night sleep study (polysomnography) for a 45-year-old patient with suspected obstructive sleep apnea (OSA) with 4 additional parameters recorded, attended by a technologist. | CPT Code:
- 95810 (Polysomnography; age 6 years or older, sleep staging with 4 or more additional parameters of sleep, attended by a technologist)
ICD-10-CM Code:
- G47.33 (Obstructive sleep apnea (adult) (pediatric))
Reasoning: CPT 95810 describes an attended diagnostic polysomnography with 4+ sleep parameters (e.g.... | |
Code 65 minutes of critical care time spent by a physician managing an unstable ICU patient in septic shock. | Physician Note: Spent 65 minutes of continuous direct critical care time evaluating and stabilizing a patient in septic shock, reviewing lab results, adjusting pressors, and managing ventilator settings. | CPT Code:
- 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes)
ICD-10-CM Code:
- R65.21 (Severe sepsis with septic shock)
Reasoning: Critical care codes are time-based. CPT 99291 requires a minimum of 30 minutes up to 74 minutes. Times under 30 mi... |
Code an open carpal tunnel release performed on the right wrist of a patient with carpal tunnel syndrome. | CPT Code:
- 64721-RT (Neuroplasty and/or transposition; median nerve at carpal tunnel, right side)
ICD-10-CM Code:
- G56.01 (Carpal tunnel syndrome, right upper limb)
Reasoning: CPT 64721 represents open carpal tunnel release (median nerve decompression). Modifier RT indicates right side, matching ICD-10 code G56.01. | |
Assign CPT codes for an image-guided percutaneous core needle biopsy of a single right breast mass using ultrasound guidance, including placement of a metallic tissue marker. | CPT Code:
- 19083 (Biopsy, breast, open or percutaneous, including ultrasound guidance, with placement of breast localization device(s) [eg, clip, metallic pellet], when performed; first lesion)
ICD-10-CM Code:
- N63.10 (Unspecified lump in the right breast, unspecified quadrant)
Reasoning: CPT code 19083 is a compre... | |
Code a clinical diagnosis of Urge Incontinence in a female patient with documented Overactive Bladder (OAB). | ICD-10-CM Codes:
- N39.41 (Urge incontinence)
- N32.81 (Overactive bladder)
Reasoning: Per ICD-10-CM guidelines, both N39.41 (urge incontinence) and N32.81 (overactive bladder) should be reported together when both conditions are documented, as OAB describes the underlying neuromuscular etiology while urge incontinenc... | |
Code excisional debridement of a diabetic foot ulcer extending into subcutaneous tissue, surface area measuring 12 sq cm. | Operative note: Diabetic ulcer on left plantar foot debrided down through subcutaneous tissue using scalpel until viable bleeding tissue reached. Total area 12 cm². | CPT Code:
- 11042 (Debridement, subcutaneous tissue (includes tissue removal, if performed); first 20 sq cm or less)
ICD-10-CM Code:
- E11.621 (Type 2 diabetes mellitus with foot ulcer)
- L97.522 (Non-pressure chronic ulcer of other part of left foot with fat layer exposed)
Reasoning: CPT 11042 covers subcutaneous ti... |
Code an inpatient encounter where a patient is admitted for an acute ST-segment elevation myocardial infarction (STEMI) involving the anterior wall. | ICD-10-CM Code:
- I21.09 (ST elevation (STEMI) myocardial infarction involving other coronary artery of anterior wall)
Reasoning: ICD-10 category I21.0- covers acute STEMI of anterior wall. Code I21.09 is selected when specific coronary artery (e.g., LAD) is not further isolated in initial diagnosis. | |
Code a 5-year-old child presenting for a routine well-child exam during which DTaP-IPV and MMR vaccines are administered with physician counseling. | CPT Codes:
- 99393 (Periodic comprehensive preventive medicine evaluation... established patient, age 5 through 11 years)
- 90460 x 2 (Immunization administration through 18 years of age via any route of administration, with counseling by physician... first component of each vaccine)
- 90461 x 3 (Each additional compon... | |
Code an outpatient telehealth visit via synchronous audio-video interaction for an established patient with controlled hypertension and hypothyroidism. Medical decision making was low complexity, lasting 22 minutes. | CPT Code:
- 99213-95 (Office or other outpatient visit, established patient, low MDM; modifier 95 indicates synchronous telemedicine service)
ICD-10-CM Codes:
- I10 (Essential (primary) hypertension)
- E03.9 (Hypothyroidism, unspecified)
Reasoning: Low MDM for an established patient maps to CPT 99213. Telehealth serv... | |
Assign CPT and ICD-10 codes for an arthroscopic partial medial meniscectomy of the left knee. | Surgical note: Left knee diagnostic arthroscopy performed, revealing a complex tear of the posterior horn of the medial meniscus. Partial medial meniscectomy performed using punch shaver. Lateral compartment intact. | CPT Code:
- 29881-LT (Arthroscopy, knee, surgical; with meniscectomy [medial OR lateral, including any meniscal shaving], left side)
ICD-10-CM Code:
- M23.22 (Derangement of meniscus due to old tear or injury, medial meniscus, left knee)
Reasoning: CPT 29881 describes surgical knee arthroscopy with single-compartment... |
Explain how routine, uncomplicated prenatal care, vaginal delivery, and postpartum care should be billed for a pregnant patient seen by the same OB-GYN group throughout pregnancy. | CPT Code:
- 59400 (Routine obstetric care including antepartum care, vaginal delivery, and postpartum care)
ICD-10-CM Codes:
- Z34.00 (Encounter for supervision of normal first pregnancy, unspecified trimester)
- Z37.0 (Single live birth)
Reasoning: Global OB package code 59400 incorporates routine antepartum visits ... | |
Assign ICD-10-CM codes for a patient presenting with iron deficiency anemia secondary to chronic blood loss from uterine leiomyomas (fibroids). | ICD-10-CM Codes:
- D50.0 (Iron deficiency anemia secondary to blood loss (chronic))
- D25.9 (Leiomyoma of uterus, unspecified)
Reasoning: ICD-10-CM code D50.0 specifically identifies iron deficiency anemia due to chronic blood loss. Underlying etiology (uterine fibroids - D25.9) must be coded as additional diagnosis t... | |
Code debridement of 6 fingernails affected by severe fungal onychomycosis. | CPT Code:
- 11721 (Debridement of nail(s) by any method(s); 6 or more)
ICD-10-CM Code:
- B35.1 (Tinea unguium [Onychomycosis])
Reasoning: CPT code 11720 covers nail debridement of 1 to 5 nails. CPT 11721 covers 6 or more nails. Since 6 fingernails were debrided, 11721 is the correct code. | |
A hospitalist admits a patient with acute decompensated heart failure requiring intravenous furosemide and continuous monitoring. Medical Decision Making is of moderate complexity. What CPT code is used for the initial inpatient hospital care? | CPT Code:
- 99222 (Initial hospital inpatient or observation care, per day, for evaluation and management of a patient, moderate level MDM)
ICD-10-CM Code:
- I50.21 (Acute systolic (congestive) heart failure)
Reasoning: Per updated 2023 E/M guidelines, Initial Hospital Care (99221-99223) codes apply to both inpatient... | |
Code a flexible fiberoptic bronchoscopy with transbronchial lung biopsy of a single lobe. | Procedure report: Bronchoscope inserted into right lower lobe. Transbronchial biopsy taken under fluoroscopic control. No bleeding noted. | CPT Code:
- 31628 (Bronchoscopy, rigid or flexible, including fluoroscopic guidance when performed; with transbronchial lung biopsy(ies), single lobe)
ICD-10-CM Code:
- R91.8 (Other nonspecific abnormal finding of lung field)
Reasoning: CPT 31628 includes flexible bronchoscopy with single-lobe transbronchial biopsy A... |
A 40-year-old female undergoes laparoscopic cholecystectomy for symptomatic cholelithiasis with acute cholecystitis. | CPT Code:
- 47562 (Laparoscopy, surgical; cholecystectomy)
ICD-10-CM Code:
- K80.00 (Calculus of gallbladder with acute cholecystitis without obstruction)
Reasoning: Surgical laparoscopic cholecystectomy is coded as 47562. ICD-10 code K80.00 captures both gallbladder calculus (cholelithiasis) and acute cholecystitis ... | |
Code Mohs micrographic surgery on the nose for basal cell carcinoma, first stage, up to 5 tissue blocks. | CPT Code:
- 17311 (Mohs micrographic technique... head, neck, genitalia; first stage, up to 5 tissue blocks)
ICD-10-CM Code:
- C44.311 (Basal cell carcinoma of skin of nose)
Reasoning: CPT 17311 covers Stage 1 Mohs surgery on high-risk anatomic locations (head, neck, genitalia) for up to 5 blocks. Secondary stages or... | |
How should an excisional wound debridement down to open bone (3 cm²) be coded? | Operative note: Sacral pressure ulcer debrided with rongeur and curette down to and including viable bone. Surface area debrided: 3 sq cm. | CPT Code:
- 11044 (Debridement, bone (includes bone removal, lambeau, subcutaneous tissue and muscle, if performed); first 20 sq cm or less)
ICD-10-CM Code:
- L89.154 (Pressure ulcer of sacral region, stage 4)
Reasoning: CPT debridement depth determines code level. Debridement including bone is reported with 11044 fo... |
Code an incision and drainage (I&D) of a complex, infected pilonidal cyst. | CPT Code:
- 10081 (Incision and drainage of pilonidal cyst; complicated)
ICD-10-CM Code:
- L05.01 (Pilonidal cyst with abscess)
Reasoning: Simple pilonidal I&D is coded as 10080. When documented as complicated (requiring marsupialization, extensive packing, or secondary closure), code 10081 is appropriate. | |
Code a cystourethroscopy with transurethral resection of a bladder tumor (TURBT) measuring 1.5 cm. | Op note: Cystoscope passed. Identified a 1.5 cm papillary lesion on posterior bladder wall. Resected lesion completely using resectoscope down to detrusor muscle. | CPT Code:
- 52234 (Cystourethroscopy, with fulguration (including cryosurgery or laser surgery) and/or resection of; small bladder tumor(s) (0.5 up to 2.0 cm))
ICD-10-CM Code:
- C67.9 (Malignant neoplasm of bladder, unspecified)
Reasoning: CPT TURBT selection is based on tumor size: minor <0.5 cm (52224), small 0.5-2... |
Explain how Medicare prolonged outpatient E/M services are billed when direct patient contact time exceeds the maximum threshold for CPT 99215. | Provider Note: Spent 70 total minutes on date of encounter for an established outpatient visit including face-to-face and non-face-to-face review on same day. | CPT/HCPCS Codes:
- 99215 (Office or other outpatient visit, established patient, high MDM, 40-54 minutes)
- G2212 x 1 (Prolonged coverage of evaluation and management services... each additional 15 minutes, Medicare specific)
Reasoning: For Medicare claims, prolonged time is reported using HCPCS G2212 once total time ... |
Assign ICD-10-CM codes for Hypertensive Heart and Chronic Kidney Disease with Stage 3b CKD and no heart failure. | ICD-10-CM Codes:
- I12.9 (Hypertensive chronic kidney disease with stage 1 through 4 chronic kidney disease, or unspecified chronic kidney disease)
- N18.32 (Chronic kidney disease, stage 3b)
Reasoning: ICD-10 guidelines assume a causal relationship between hypertension and chronic kidney disease. Category I12 is used... | |
Code a bilateral tympanostomy with ventilating tube insertion under general anesthesia. | CPT Code:
- 69436-50 (Tympanostomy [requiring insertion of ventilating tube], local or general anesthesia; modified for bilateral procedure)
ICD-10-CM Code:
- H65.33 (Chronic mucoid otitis media, bilateral)
Reasoning: CPT 69436 applies when myringotomy with tube placement requires general anesthesia. Modifier 50 indi... | |
Code a diagnostic lumbar puncture performed on an adult patient with severe intractable headache. | Procedure report: Lumbar spine prepped. 22G spinal needle inserted at L3-L4 space. CSF fluid drawn clear and sent for analysis. Opening pressure measured. | CPT Code:
- 62270 (Spinal puncture, therapeutic or diagnostic; lumbar)
ICD-10-CM Code:
- R51.9 (Headache, unspecified)
Reasoning: CPT 62270 covers diagnostic or therapeutic lumbar punctures. If fluoroscopic or ultrasound guidance is utilized, it is billed separately (e.g., 77003) unless bundled by payer rules. |
Assign surgical CPT code for a total abdominal hysterectomy with bilateral salpingo-oophorectomy (TAH-BSO). | CPT Code:
- 58150 (Total abdominal hysterectomy [corpus and cervix], with or without removal of tube(s), with or without removal of ovary(ies))
ICD-10-CM Code:
- D25.9 (Leiomyoma of uterus, unspecified)
Reasoning: CPT 58150 explicitly includes removal of the uterus, cervix, fallopian tubes, and ovaries via abdominal ... | |
Code initial setup, patient training, and sensor placement for Personal Continuous Glucose Monitoring (CGM). | CPT Code:
- 95249 (Ambulatory continuous glucose monitoring of interstitial tissue fluid via a subcutaneous sensor... patient-provided equipment, sensor placement, hook-up, calibration, and patient training)
ICD-10-CM Code:
- E11.9 (Type 2 diabetes mellitus without complications)
Reasoning: CPT 95249 covers initial e... | |
Code a shoulder arthroscopy with rotator cuff repair and subacromial decompression (acromioplasty). | CPT Codes:
- 29827 (Arthroscopy, shoulder, surgical; with rotator cuff repair)
- 29826 (Arthroscopy, shoulder, surgical; decompression of subacromial space with partial acromioplasty; add-on code)
ICD-10-CM Code:
- M75.121 (Complete rotator cuff tear or rupture of right shoulder, not specified as traumatic)
Reasoning... | |
A physician excises a benign seborrheic keratosis measuring 0.8 cm on the chest. Simple closure performed. | CPT Code:
- 11401 (Excision, benign lesion including margins, except skin tag, trunk, arms or legs; excised diameter 0.6 to 1.0 cm)
ICD-10-CM Code:
- L82.1 (Other seborrheic keratosis)
Reasoning: Benign skin lesion excision on trunk measuring 0.8 cm falls into code category 11401 (0.6 cm to 1.0 cm). Simple repair is ... | |
Code a Diagnostic Transesophageal Echocardiography (TEE) including probe placement, image acquisition, interpretation, and report. | CPT Code:
- 93312 (Echocardiography, transesophageal, real-time with image documentation; including probe placement, image acquisition, interpretation and report)
ICD-10-CM Code:
- I35.0 (Nonrheumatic aortic valve stenosis)
Reasoning: CPT 93312 represents the complete TEE service (probe insertion, acquisition, and in... | |
Code foreign body removal embedded in the cornea of the right eye using a slit lamp. | Op note: Metallic foreign body noted embedded in right corneal stroma. Removed cleanly under slit lamp magnification using a 25-gauge needle. | CPT Code:
- 65222-RT (Removal of foreign body, external eye; corneal, with slit lamp, right eye)
ICD-10-CM Code:
- T15.01XA (Foreign body in cornea, right eye, initial encounter)
Reasoning: CPT 65222 specifies corneal foreign body removal WITH slit lamp utilization. Modifier RT designates right eye, matching ICD-10 c... |
An established patient presents for follow-up of two chronic stable conditions (hypertension and hyperlipidemia) and one new acute self-limited problem (acute mild allergic rhinitis). Prescription medications were reviewed and adjusted. What level of E/M service is warranted? | CPT Code:
- 99214 (Office or other outpatient visit for the evaluation and management of an established patient, moderate complexity MDM)
ICD-10-CM Codes:
- I10 (Essential (primary) hypertension)
- E78.5 (Hyperlipidemia, unspecified)
- J30.9 (Allergic rhinitis, unspecified)
Reasoning: MDM evaluation under 2021/2023 g... |
Medical Billing & ICD-10 Synthetic Dataset (Sample
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Dataset Description
This dataset provides structured QA pairs for training open-source LLMs (Llama 3, Qwen 2.5, Mistral) on medical billing resolution, code compliance, and claims processing.
Sample Structure
{
"instruction": "Determine the correct ICD-10 code for a patient diagnosed with Type 2 diabetes with kidney complications.",
"input": "Patient notes: 58-year-old male presenting with diabetic nephropathy.",
"output": "The primary ICD-10 code is E11.22 (Type 2 diabetes mellitus with diabetic nephropathy)."
}
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