The Global Surgical Package applies to services performed in what setting?
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What surgical status indicator represents the Global Surgica…
What surgical status indicator represents the Global Surgical Package for endoscopic procedures (without an incision) where there is no postoperative period after the day of the surgery?
Tests in the Chemistry section of CPT® are what types of tes…
Tests in the Chemistry section of CPT® are what types of tests unless specified otherwise?
Hallux rigidus is a condition affecting what part of the bod…
Hallux rigidus is a condition affecting what part of the body?
A patient with hypertensive cardiovascular disease is admitt…
A patient with hypertensive cardiovascular disease is admitted by his primary care provider. What is the correct reporting of ICD-10-CM code(s) for this encounter?
The patient has a torn medial meniscus. An arthroscope was p…
The patient has a torn medial meniscus. An arthroscope was placed through the anterolateral portal for the diagnostic procedure. The patellofemoral joint showed grade 2 chondromalacia on the patellar side of the joint only, this was debrided with a 4.0-mm shaver. The medial compartment was also entered and a complex posterior horn tear of the medial meniscus was noted. It was probed to define its borders. A meniscectomy was carried out to a stable rim. What CPT® code(s) is/are reported?
Left ureteral stent placement and Extracorporeal Shock Wave…
Left ureteral stent placement and Extracorporeal Shock Wave Therapy or Lithotripsy (ESWL) of the left kidney are performed. What CPT® code(s) is/are reported for this service?
A preanesthesia assessment was performed and signed at 10:21…
A preanesthesia assessment was performed and signed at 10:21 am. Anesthesia start time is reported as 12:26 pm, and the surgery began at 12:37 pm. The surgery finished at 15:12 pm and the patient was turned over to PACU at 15:26 pm, which was reported as the ending anesthesia time. What is the anesthesia time reported?
Operative ReportPre-Operative and Post-Operative Diagnosis: …
Operative ReportPre-Operative and Post-Operative Diagnosis: Squamous cell carcinoma, left legOpen wound, right legPersonal history of squamous cell carcinoma, right legINDICATIONS FOR SURGERY: The patient is an 81-year-old white man with biopsy proven squamous cell carcinoma of his left leg. I marked the areas for excision with gross normal margins of 5 mm, and I drew my planned skin graft donor site from his left lateral thigh. He also had an open wound of his right leg from a squamous cell carcinoma excised four months ago; the skin graft had not taken. We plan on re-skin grafting the area. The patient is aware of all of these markings, and understands the surgery and location.DESCRIPTION OF PROCEDURE: The patient was taken to the operating room. IV Ancef was given. I used plain lidocaine for his local anesthetic throughout the procedure until the skin grafts were inset. The anterior of his leg and the thigh were infiltrated with local anesthetic. Both lower extremities were prepped and draped circumferentially, which included the left thigh on the left side. I excised the lesion on his left leg as drawn into the subcutaneous fat. Hemostasis achieved with the Bovie cautery. I then excised the wound on his right leg to lower the bacterial counts. I took a 1-2 mm margin around the wound and excised the granulation tissue as well. Hemostasis was achieved using the Bovie cautery. I then changed gloves. A split-thickness skin graft was harvested from the left thigh using the Zimmer dermatome. This was meshed 1:5:1. By this time, the pathology returned showing the margins were clear.Skin grafts were inset on each leg wound using the skin stapler. Xeroform and gauze bolster was placed over the skin graft using 4-0 nylon. The skin graft donor site was dressed with OpSite. The legs were further dressed with heavy cast padding and the double Ace wrap. The patient tolerated the procedure well.PROCEDURES: Excision squamous cell carcinoma, left leg with excised diameter of 2.5 cm, repaired with a split-thickness skin graft measuring 5.1 cm2. Excisional preparation of right leg wound repaired with a split-thickness skin graft measuring 3.2 cm2.What CPT® codes are reported?
EHR stands for:
EHR stands for: