A 61-year-old female patient is seen for a complaint of
severe heartburn, lightheadedness, skin reddening, and
shortness of breath. The physician renders a diagnosis of
paralysis. What code(s) should be assigned?
2. A 37-year-old patient comes in complaining of swollen
joints and headaches. The physician’s diagnosis is SLE.
The patient also has rheumatoid arthritis and asthma
with status asthmaticus. What code(s) are assigned?
3. A 52-year-old patient is seen for mouth pain, knee pain,
and fluid buildup in the chest. The physician renders a
diagnosis of pulp degeneration, old disruption of the posterior
cruciate ligament, and pleural effusion. The
physician also performed a chest tube insertion (draining
the right pleural cavity with a drainage device using a
percutaneous approach) prior to diagnosing the patient’s
pleural effusion. What diagnosis and procedure code(s)
4. A 30-year-old male is admitted to the hospital with
lymphadenitis, acute lymphoid leukemia in relapse, and
von Willebrand disease. What code(s) are reported?
5. A 47-year-old male is involved in a motor vehicle accident.
He was driving on the highway when his car
collided with another vehicle. He was brought to the hospital
with a lower arm injury. The physician obtained an
x-ray of the arm and, after careful review and interpretation
of the x-ray, rendered a diagnosis of lower arm
fracture. The physician repaired the arm fracture using
open reduction and internal fixation (reposition of the
right radius with internal fixation using a percutaneous
endoscopic approach). What diagnosis and procedure
code(s) are reported?
Review each of the following medical coding scenarios. Assign
the CPT code for the services and procedures indicated in
1. A 48-year-old male patient comes to the emergency room
with complaints of GERD. The physician performs a
laparoscopic fundoplasty with a Collis gastroplasty. What
CPT code(s) should be assigned?
2. A 40-year-old female patient is diagnosed with cervical
cancer. She also complains about difficulty breathing.
She is admitted to the hospital, where the physician
begins to perform a bronchoscopy after anesthesia
administration. However, the procedure is discontinued
due to unforeseen complications. Later the same day, a
bilateral cervical lymphadenectomy is performed to
address the patient’s cervical cancer. What CPT code(s)
3. A 50-year-old patient is admitted for a repair of a laceration
to the diaphragm resulting from an accident
involving a bus that ran into a ditch. She also received
eight trigger point injections into the transverse abdominus
muscle due to pain resulting from the accident.
What CPT code(s) are assigned?
4. A 23-year-old patient comes to the emergency room after
being physically assaulted by her boyfriend. She complains
of nasal pain and bleeding from the left nostril.
The physician obtains an x-ray of the nasal cavity, and
the x-ray confirms a nasal septum fracture. The physician
performs an open treatment of the nasal fracture
with a concomitant open treatment of the fractured septum.
What CPT code(s) should be assigned?
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