If a physician were to only review the most recent X-ray, the physician is only meeting one of the nvo categories in the amount and/or complexity of data reviewed and analyzed. Meeting only one ofthe categories contributes to a low level of medical decision-making. On the other hand, altering a drug management program, reviewing several unique tests, and/or addressing an exacerbation of a chronic illness, all contribute to a moderate level of medical decision-making.

The procedures performed on this encounter were the meniscectomy (removal of damaged meniscus from the lateral compartment) with a chondroplasty (shaving of articular cartilage,
29881) and loose body removal by means of an arthroscopy (29874). Because the removal of loose bodies is considered inclusive to the primary procedure, modifier 59 is appended as opposed to modifier 51 to indicate that it was a distinct procedural service due to the separate incision.
Answers A and D can be eliminated based on the diagnosis chosen. S83.203A indicates the location of meniscus is unspecified: however, the surgeon removed the damaged meniscus from the lateral compartment, leading the biller to S83.281A.

An E/M is always billed when a patient is seen in the emergency department because it is unscheduled and urgent. In this case, the documentation encompasses a straightforward level of decision-making (one acute, uncomplicated injury, minimal or no data reviewed, superficial dressings that result in minimal risk or morbidity of the patient), which lead the coder to 99282.
Modifier 57 is appended to indicate that the decision for surgery was made just prior to the procedure and is not bundled. CPT coding crosswalk confirms that a closed treatment of a dislocated elbow is CPT code 24600. Application ofa splint is represented by CPT code 29105 but is not applicable when performed with a surgery to correct the dislocation. ICD-IO-CM crosswalk for dislocation of left elbow is S53.105A.

A gastroscopy is a procedure that uses an endoscope to examine the stomach and some parts of the intestinal tract An endoscopy uses a thin tube through a natural opening in the body to examine the digestive tract. A laparotomy is a large incision in the belly to gain access into the abdominal cavity.

Surgical procedures on the nervous system are identified by where inside the skull they occur. A meningioma is being excised from above the tentorium cerebelli, otherwise known as supratentorial (CPT 61512). The removal of an extradural hematoma is inclusive to the primary craniectomy code because the finding is incidental and the same surgical site is used for its removal.
If the surgeon had to create a separate incision to access the extradural hematoma, that excision could be reported separately with modifier 59.