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(A 5-year-old patient has a fractured radius. The orthopedist providesmoderate sedationand the reduction. The intra-service sedation time is documented as21 minutes. What CPT® code is reported for the moderate sedation?)
A woman who is 19 weeks pregnant is taken to the hospital from her doctor ' s office due to the detection of no fetal heartbeat and the death of the fetus. Due to the stage of pregnancy, labor is initiated, and the fetus is delivered.
What CPT® and ICD-10-CM codes are reported for the delivery of the fetus on the maternal record?
(Full Case:Preoperative diagnosis:Low back pain; possible spinal stenosis L3–4.Postoperative diagnosis:No evidence of discogenic pathology or spinal stenosis at L3–4; normal discography L3–4.Procedure:Awake discography and injection, L3–4.Anesthesia:IV narcotic with reversal and local; propofol given transiently, then patient alert/responsive for pain response during injection.Technique:Patient to OR; right decubitus; sterile prep/drape; C-arm used to mark entry; local ethyl chloride + 1% Xylocaine; docking needle placed posterolateral at L3–4 under AP/lateral; inner needle advanced to disc nucleus center; contrast injected while monitoring patient response; normal bilocular pattern; 1.5 cc volume; no pain with pressurization.Documentation:No videotape; plain films available; post-discography CT planned/reviewed for other causes.Question:What CPT® and ICD-10-CM coding is reported?)