Catheter access, standard supplies such as a flush solution, and the flush at the end of the infusion are all considered necessary to facilitate the infusion and are inclusive to CPT codes
96360-96361. Declotting a catheter involves the injection of a thrombolytic agent to dissolve the clot and is separately reportable with CPT 36593.

To determine which services to report for this encounter, it is important to understand which services were rendered on the last. The patient had an open biopsy of the axillary lymph nodes (CPT 38525) last week This procedure has a postoperative 90-day global period. This means that any related services provided to the patient within that time are reported with zero-charge CPT
99024. Services such as biopsy results, follow-up incisional care, and any postoperative complications are all inclusive to this code. As the patient was given biopsy results, CPT 99024 should be reported for this encounter. However, CPT guidelines also state that when it comes to diagnostic procedures, "care of the condition for which the diagnostic procedure was performed...
is not included and may be listed separately." In this case, that care begins with the discussion of treatment options with their identified risks, and the decision to begin radiation. This level of moderate medical decision-making is reported by means of E/M CPT 99214. Modifier 24 is appended to indicate that is it unrelated to postoperative care, and modifier 25 is appended to indicate it is separately identifiable to CPT 99024. ICD-IO-CM crosswalk for lymphoma, diffuse large cell, is C83.34.

A urodynamics study is a diagnostic test to evaluate the function of the bladder. When performed using calibrated equipment, it becomes known as a complex cystometrogram (51726-
51729). In CPT code 51728, a complex cystometrogram is performed in conjunction with voiding pressure studies. In the provider's documentation, the bladder is filled with water, and voiding times and volume are recorded, thus fulfilling the requirements for this code. CPT code 51726 in answers A and B only describe a complex cystometrogram without the voiding pressure studies.
Electromyography (EMG) studies were performed without a needle to evaluate pelvic floor activity and are represented by 51784. An intraabdominal voiding pressure study (51797) can be inferred in that the provider had earlier inserted a rectal catheter and, after instructing the patient to cough, obtained an abdominal pressure measurement. A complex urinary flow study (51741) was performed in obtaining the maximum urinary flow rate through calibrated equipment. This procedure is missing in answers B and C. Modifier TC (indicating only a technical component) is amended on all the procedures because the provider is not interpreting the results to the patient.
Modifiers 51 and/or 59 is not amended on any procedure (A and B) because these are routinely billed together.

Modifier 53 is used to indicate that a procedure was terminated by the provider after anesthesia was given due to extenuating circumstances that affected the health of the patient.
Although option B is similar, the procedure that was discontinued was done so prior to anesthesia in the outpatient setting, in which case modifier 73 would be appended.

Acute trauma results from a single incident, whereas chronic trauma is repeated, usually over the course of months or years. In this scenario, the documentation does not specify, so the coder should assume acute trauma. There is no mention of obstruction, so ICD-IO-CM code selection is K44.9, followed by the cause of the hernia. Vvhen an exam shows evidence of abuse, the abuse is no longer considered suspected but confirmed.