Code 99215 is correct. The key elements are: 1) The patient is established. 2) The physician performed a comprehensive history and exam. 3) The medical decision making is of high complexity, as indicated by the review of external records (hospital summary), review of labs, and management of prescription medication. 4) The time of 45 minutes meets or exceeds the typical time for 99215 (40-54 minutes). While time can be used for code selection, the key components also support 99215. 99214 is for moderate complexity MDM. 99244 is for outpatient consultation. 99354 is for prolonged services and would be an add-on code, not a standalone E/M code for this scenario.

For excision of malignant lesions, the code is selected based on the excised diameter, which includes the size of the lesion plus the margins. The correct calculation is the greatest clinical diameter of the lesion (often the excised diameter provided by the physician) plus the margins required for complete excision (measured separately). Therefore, 1.5 cm + 0.3 cm margin on one side + 0.3 cm margin on the other side = 2.1 cm total excised diameter. This is a fundamental rule in integumentary system coding.

Lysis of adhesions (enterolysis) is not separately reportable when it is performed to access the surgical site, as it is considered an integral part of the primary procedure. However, when the lysis is extensive, significantly increases the complexity and time of the procedure, and is well-documented, the appropriate action is to append modifier 22 (Increased Procedural Services) to the primary cholecystectomy code. This alerts the payer that additional work was required, and supporting documentation must be submitted.

HCPCS code L5856 is used to report a knee joint, single axis, with a cemented prosthesis. L5857 is for an uncemented prosthesis. L8630 is for a synthetic cartilage implant, not a total knee. C1778 is a generic code for a joint device (used in the inpatient/outpatient hospital setting under the APC system), but for professional billing of the implant supplied by the physician, the more specific L-code is typically required. Knowing the specific HCPCS codes for orthotic and prosthetic devices is essential for accurate billing of supplied materials.

Code 63042 (Laminotomy, hemilaminectomy, with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc, including open and endoscopically-assisted approaches; 1 interspace, lumbar) accurately describes the entire procedure performed. It is a bundled code that includes all the components listed: laminotomy, facetectomy, foraminotomy, and discectomy at a single interspace. 63020 is for a laminotomy for exploration/decompression of nerve roots. 63030 is for a laminotomy for excision of herniated disc. 63047 is the code for each additional interspace, which is not needed here.

The correct codes are CPT 45385 (Colonoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps or bipolar cautery) and ICD-10-CM Z12.11 (Encounter for screening for malignant neoplasm of colon). The polyp was removed via snare polypectomy (hot), which makes 45385 appropriate. 45378 is for diagnostic colonoscopy. The primary reason for the encounter remains the screening (Z12.11), as the polyp was an incidental finding. K63.5 is for polyp of colon, which is not the reason for the encounter. D12.4 is for a benign neoplasm of the colon, which would be used if the encounter was for treatment of a known polyp.

This is a telephone evaluation and management service performed by a qualified non-physician healthcare professional (the nurse). CPT code 98966 (Telephone assessment and management service provided by a qualified nonphysician health care professional to an established patient, parent, or guardian; 11-20 minutes) is the correct code. 99441 is for physician telephone services. 99212 is for an office visit, which did not occur. Whether it’s included in the post-operative period depends on the specific procedure’s global period; however, telephone services are typically not included in the global surgical package and are separately reportable if they meet the criteria.

For the Medicare Initial Preventive Physical Exam (IPPE or “Welcome to Medicare” visit), a review of the patient’s functional ability and safety is a required element. CMS guidelines specify that this should be documented as a separate and distinct element within the medical record. While it may overlap with ROS or other areas, best practice is to clearly document it in its own section (e.g., “Functional Assessment”) to ensure it is easily identifiable for audit purposes and to confirm all required IPPE components were completed.

When a laparoscopic procedure is converted to an open procedure, you report only the code for the open procedure that was completed. The laparoscopic approach was attempted but not completed, so you do not report it separately. Modifier 52 (Reduced Services) or 53 (Discontinued Procedure) are not appropriate because a different, complete procedure (the open appendectomy) was performed. Therefore, the correct action is to report 44950 (Appendectomy; for ruptured appendix or other complication) or 44950-44960 for uncomplicated, depending on the findings, with no modifier to indicate the conversion. The operative report must clearly document the reason for conversion.

Code 99215 is correct. The key elements are: 1) The patient is established. 2) The physician performed a comprehensive history and exam. 3) The medical decision making is of high complexity, as indicated by the review of external records (hospital summary), review of labs, and management of prescription medication. 4) The time of 45 minutes meets or exceeds the typical time for 99215 (40-54 minutes). While time can be used for code selection, the key components also support 99215. 99214 is for moderate complexity MDM. 99244 is for outpatient consultation. 99354 is for prolonged services and would be an add-on code, not a standalone E/M code for this scenario.0