A patient underwent a colonoscopy, where the gastroenterologist biopsied two polyps from the colon. Each polyp was sent to pathology as separately identified specimens. The gastroenterologist was requesting a pathology consult while the patient was still on the table. Tissue blocks and frozen sections were then prepared and examined as follows:
Specimen 1: First Tissue Block-Three Frozen Sections Second Tissue Block-One Frozen Section Specimen 2: First Tissue Block-Two Frozen Sections Second Tissue Block-One Frozen Section What CPTcoding is reported?

A 46-year-old female is admitted to the hospital by her urologist for a left ureteral calculus. The urologist visits her again on day two and performs a low for number and complexity of problems addressed, minimal for amount and/or complexity of data to be reviewed and analyzed, and moderate for risk of complications.
What E/M service is reported for day two?

View MR 001394
MR 001394
Operative Report
Procedure: Excision of 11 cm back lesion with rotation flap repair.
Preoperative Diagnosis: Basal cell carcinoma
Postoperative Diagnosis: Same
Anesthesia: 1% Xylocaine solution with epinephrine warmed and buffered and injected slowly through a 30- gauge needle for the patient ' s comfort.
Location: Back
Size of Excision: 11 cm
Estimated Blood Loss: Minimal
Complications: None
Specimen: Sent to the lab in saline for frozen section margin control.
Procedure: The patient was taken to our surgical suite, placed in a comfortable position, prepped and draped, and locally anesthetized in the usual sterile fashion. A #15 scalpel blade was used to excise the basal cell carcinoma plus a margin of normal skin in a circular fashion in the natural relaxed skin tension lines as much as possible The lesion was removed full thickness including epidermis, dermis, and partial thickness subcutaneous tissues. The wound was then spot electro desiccated for hemorrhage control. The specimen was sent to the lab on saline for frozen section.
Rotation flap repair of defect created by foil thickness frozen section excision of basal cell carcinoma of the back. We were able to devise a 12 sq cm flap and advance it using rotation flap closure technique. This will prevent infection, dehiscence, and help reconstruct the area to approximate the situation as it was prior to surgical excision diminishing the risk of significant pain and distortion of the anatomy in the area. This was advanced medially to close the defect with 5 0 Vicryl and 6-0 Prolene stitches.
What CPTcoding is reported for this case?

(A patient presents for surgery due to recurrent lumbar radiculopathy at a previously operated spinal level.
The surgeon performs arepeat exploration laminotomywithbilateral foraminotomyto decompress nerve roots at theL1-L2 interspace. No additional spinal levels are treated. What CPTcoding is reported?)

(A patient training for a marathon collapsed due to heat exhaustion on a very hot day and is treated at a nonfacility urgent care center. The physician diagnoses heat exhaustion and dehydration and begins IV therapy of normal saline (pre-packaged fluid and electrolytes). The hydration lasts1 hour and 30 minutes.
What CPTcoding is reported?)

A 42-year-old male is diagnosed with a left renal mass. Patient is placed under general anesthesia and in prone position. A periumbilical incision is made and a trocar inserted. A laparoscope is inserted and advanced to the operative site. The left kidney is removed, along with part of the left ureter. What CPTcode is reported for this procedure?

A 52-year-old woman has been experiencing discomfort and itching In the vulvar area for several months.
She has a history of abnormal Pap smears and a recent biopsy revealed vulvar intraepithelial neoplasia (VIN III). Decision has been made to perform a vulvectomy.
Procedure: Under general anesthesia, the surgeon made an incision in the vulvar area and removed the vulva (more than 80%), including the affected skin and deep subcutaneous tissue.
What CPTand ICD-10-CM codes are reported?

A suppression study includes five glucose tests and five growth hormone tests.
What CPTcoding is reported?

(Full Case:Procedure:Excision of6.0 cm malignant lesionof theright forearmwithadjacent tissue transferusing arotation flap.Pre/Post-op Dx:Basal cell carcinoma, right forearm.Anesthesia:local (1% Xylocaine with epi).
Defect size:8 sq cm.Specimen:sent forfrozen section margin control; margins confirmed clear.Closure:rotation flap from adjacent healthy tissue,total area 8 sq cm, secured with layered closure (5-0 Vicryl/6-0 Prolene).
Question:What CPTcoding is reported?)