CPT 38120 is the removal of the spleen by means of a laparoscope. The physician performed a midline celiotomy (an abdominal incision), which is an open procedure, eliminating this option. CPT 43631 describes the removal of certain portions of the stomach and was not the procedure performed. An exploratory laparotomy (or abdominal exploration) is inclusive to a splenectomy procedure and should not be reported separately. Additionally, CPT 38102 is reported when the spleen is involved in an extensive disease such as malignancy. On the other hand, CPT
38100 fully describes the open splenectomy, and CPT 38999 is used for the removal of mesenteric lymph nodes because there is no specific code for this procedure.

The left coronary artery and the right common carotid artery would each be considered their own vascular family. Therefore, when the starting point of selective catheterization is the aorta, the left coronary artery would be considered first order (36215) in the vascular family and the right common carotid artery would be considered the second order (36216). Modifier 59 is appended to indicate that a different vascular family was examined in one session. Contrast materials and catheterization into the aorta are inclusive to the nvo procedures and are not to be separately coded.

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.

The CPT crosswalk for x-ray of knee directs the coder to 73560-73580. Because two views were obtained, the correct code would be 73560 (radiologic examination, knee; I or 2 views).
Modifier TC and modifier 26 indicate only technical and professional components: however, because the x-ray was performed in a physician's office, 73560 would be reported without either because the practice provided both components. In terms of diagnosis, the knee pain would not be reported because it is a symptom of a definitive diagnosis.

A level II HCPC code describes medical devices, supplies, medication, and/or other services that a provider and/or entity used during a service provided to a patient. Advanced life support (ALS) fits this description because it is a set of life-saving protocols administered in transit.
Radiation treatment management and a diagnostic colonoscopy describe a level I HCPC code, otherwise known as a CPT code. If the patient was asymptomatic and the colonoscopy was for screening purposes only, a level II HCPC code could be assigned. However, a diagnostic procedure implies a past medical/family history that puts the patient at risk and/or symptoms that warrant the procedure. A malignant neoplasm describes an ICD-IO-CM code because it is a diagnosis.