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An air bag deployed when a driver lost control of the car and crashed into a guardrail on the side of the highway. The driver suffers partial impact resulting in a skull fracture of the anterior
cranial base. The fracture is diagnosed using the MRI scanner and cerebrospinal fluid is noted dripping via the sphenoid sinus into the right nasal passage. The patient requires a surgical nasal
sinus endoscopy to assess and repair the injury.
What is the correct procedure and diagnosis coding combination to report this service?
View MR 004397
MR 004397
Operative Report
Preoperative Diagnosis: Calculi of the gallbladder
Postoperative Diagnosis: Calculi of the gallbladder, chronic cholecystitis
Procedure: Cholecystectomy
Indications: The patient is a 50-year-old woman who has a history of RUQ pain, which ultrasound revealed to be multiple gallstones. She presents for removal of her gallbladder.
Procedure: The patient was brought to the OR and prepped and draped in a normal sterile fashion. After adequate general endotracheal anesthesia was obtained, a trocar was placed and C02 was insufflated into the abdomen until an adequate pneumoperitoneum was achieved. A laparoscope was placed at the umbilicus and the gallbladder and liver bed were visualized. The gallbladder was enlarged and thickened, and there was evidence of chronic inflammatory changes. Two additional ports were placed and graspers were used to free the gallbladder from the liver bed with a combination of sharp dissection and electrocautery. Cystic artery and duct are clipped. Dye is injected in the gallbladder. Cholangiography revealed no intraluminal defect or obstruction. Gallbladder is dissected from the liver bed. The scope and trocars are removed.
What CPT® coding is reported for this case?
A 45-year-old female presents to the ED with chest pain. The provider has an Albumin Cobalt Binding Test to determine if the chest pain is ischemic in nature.
That lab test is reported?