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Directions: Find the correct procedure codes and modifiers, if necessary. This assignment will reinforce what you have already learned about procedural coding because code numbers for the case scenarios presented are located in all the sections of the CPT code book. Also search for codes in the Medicine section, if necessary. La 3. Dr. Davis stated on his operative report that Mr. Allen was suffering from a complex, complicated nasal fracture. Dr. Davis debrided the wound because it was contaminated and performed an open reduction with internal fixation in a complex and complicated procedure Code Number a. Description Initial OV, complex history & examination, moderate complexity decision making Open tx nasal fracture, complicated Debridement, skin, subcutaneous tissue, muscle, and bone b. c. 4. A registered nurse (RN), an established patient, age 40 years, sees the doctor for an annual physical. A Pap (Papanicolaou) smear is obtained and sent to an outside labora- tory. The patient also has a furuncle on the right axilla at the time of the visit, which the doctor incises and drains (I & D). Code Number a. b. Description Periodic physical examination Handling of specimen I & D, furuncle, right axilla 5-mL penicillin IM injection c. d. 5. While making his roundscinatibe be pe alo debring the moon hour, Dr. James sees a new patient in the ED for a laceration of the forehead, 5-cm long. The doctor does a workup for a possible concussion. Code Number a. Description ED care, expanded problem-focused history, expanded problem-focused exami- nation, low-complexity decision making Repair of laceration, simple, face b. a. 6. The physician sees a new patient in the office with the same condition as the patient in Problem 5; however, an infection has developed, and the patient is seen for daily dressing changes. On day 11, the sutures are removed, and on day 12, a final dressing change is made, and the patient is discharged. Code Number Description Level 3, detailed history & examination with low-complexity decision making, initial new patient office visit b. Repair of laceration Tet tox (tetanus toxoid) 0.5 mL d. Administration intramuscular injection Minimal service, OV (suture removal) Minimal service, OV (dressing change) Note: Some fee schedules allow no follow-up days; Medicare fee schedule allows 10 follow-up days for the procedural code number for repair of laceration. C. e. f.
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