Certified Professional Coder (CPC): AAPC-CPC

View MR 004397 MR 004397 Operative Report Preoperative Diagnosis: Calculi of the gallbladder Postoperative Diagnosis: Calculi of the gallbladder, chronic cholecystitis Procedure: Cholecystectomy Indications: The patient is a 50-year-old woman who has a history of RUQ pain, which ultrasound revealed to be multiple gallstones. She presents for removal of her gallbladder. Procedure: The patient was brought to the OR and prepped and draped in a normal sterile fashion. After adequate general endotracheal anesthesia was obtained, a trocar was placed and C02 was insufflated into the abdomen until an

adequate pneumoperitoneum was achieved. A laparoscope was placed at the umbilicus and the gallbladder and liver bed were visualized. The gallbladder was enlarged and thickened, and there was evidence of chronic inflammatory changes. Two additional ports were placed and graspers were used to free the gallbladder from the liver bed with a combination of sharp dissection and electrocautery. Cystic artery and duct are clipped. Dye is injected in the gallbladder. Cholangiography revealed no intraluminal defect or obstruction. Gallbladder is dissected from the liver bed. The scope and trocars are removed.

What CPT?coding is reported for this case?

A. 47562, 74300-26

B. 47563, 74300-26

C. 47605, 74300-26

D. 47600, 74300-26

Patient had polyps removed on a previous colonoscopy. The patient returns three months later for a follow-up examination for another colonoscopy. No new polyps are seen.

What diagnosis coding is reported for the second colonoscopy?

A. Z09, Z86.010

B. K63.5

C. Z86.010, K63.5

D. Z09, K63.5

View MT 004268

MT 004268

Operative Report

Preoperative Diagnosis: History of colon polyps

Postoperative Diagnosis: Sigmoid diverticulosis

Procedure: Diagnostic colonoscopy

Anesthesia: IV sedation

Technique: The patient was brought to the endoscopy suite and placed in the lateral decubitus position. Digital rectal examination was then performed The colonoscope was then inserted under videoscopic visualization with minimal insufflation. The scope went beyond the splenic flexure. The sigmoid colon did reveal some diverticulosis. Further advancement of the colonoscope was unable to be accomplished and did not reach the cecum due to retained stool in the transverse colon. It was decided not to advance the scope further due to poor prep. The colonoscope was then removed and the patient was given instruction to go back after one week for repeat colonoscopy.

How is the surgeon's service reported?

A. 45330

B. 45379-52

C. 45378-52

D. 45378-53