Medical Coding

1)     Assign CPT code(s) and appropriate modifiers to each statement.

The physician performed a complex repair during resection of the diaphragm and closed the residual defect with synthetic graft material.

2)      Mediastinotomy to remove foreign body using transthoracic approach, including median sternotomy.

3)      Patient underwent repair, laceration of diaphragm.

4)      Physician inserted a mediastinoscope through an incision in the sternal notch and performed a mediastinal lymph node biopsy.

5)      Physician  repaired an acute traumatic diaphragmatic hernia. 

    Patient underwent alveoloplasty to remove sharp areas or undercuts of alveolar bone, one quadrant.

      Surgeon used a scalpel to slice off a cancerous portion of the vermillion border of the patient’s lip: mucosal advancement was performed after excision.

      Surgeon made an incision through submucosal tissue and removed a lesion in the vestibule of the mouth. Wound repair was not required.

      Patient underwent simple incision of the lingual frenum to free the tongue.

      Patient underwent incision in the parotid gland to remove calcified stone.

    Surgeon repaired a tear at the pharyngeal esophageal junction.

      Physician drained and abscess near the tonsil.

     Surgeon removed an 8 year old patient’s tonsils and adenoids.

      Physician controlled secondary oropharyngeal hemorrhaging, status post tonsillectomy, by using cellulose sponges that expanded when placed in the tonsillar cavity.

  Physician performed a tonsillectomy on a 12 year old male patient.

    Physician inserted a flexible esophagoscope into the esophagus and destroyed a lesion, using snare technique.

   Surgeon made an incision in the left posterior chest wall into the esophagus to remove a foreign body from the esophagus.

  Physician inserted a balloon endoscopically for tamponade of bleeding esophageal varices.

    Dr. Smith performed a partial cervical esophagectomy while Dr. Jones performed a jejunum transfer with microvascular anastomosis.

   The physyician passed an endoscope through the patient’s mouth and visualized the entire esophagus, stomach, duodenum, and jejunum. One lesion was removed using biopsy forceps. Another was remove using snare.

      Patient underwent incision of the pyloric muscle.

      The physician performed an open revision of a previously performed gastric restrictive procedure and reversed the previously partitioned stomach to restore normal gastrointestinal continuity.

    Using fluoroscopic guidance, the physician repositioned a gastric feeding tube through the duodenum.

   The physician performed a laparoscopic surgical gastric restrictive procedure with gastric bypass and roux-en-Y gastroenterostomy.

 The physician percutaneously place a gastrostomy tube into the stomach under fluoroscopic guidance including contrast injection(s), image documentation.