Coding guide Immune Globulin and Vaccine Codes 2024

Four new vaccine product codes and two new immune globulin codes were established in the Current Procedural Terminology (CPT) 2024 code set. This article provides an overview of these new codes. Immune Globulins, Serum or Recombinant Products  90380 Respiratory syncytial virus, monoclonal antibody, seasonal dose; 0.5 mL dosage, for intramuscular use  903811 mL dosage, for intramuscular use Vaccines, Toxoids  90589 Chikungunya virus vaccine, live attenuated, for intramuscular use  90679 Respiratory syncytial virus vaccine, preF, recombinant, subunit, adjuvanted, for intramuscular use  90683 Respiratory syncytial virus vaccine, mRNA lipid nanoparticles, for intramuscular…

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Remote Multi-Day Complex Uroflowmetry (0811T, 0812T)

Two new Category III codes (0811T, 0812T) were added to the CPT 2024 code set for reporting remote multi-day complex uroflowmetry services. Uroflowmetry is the measurement of urine flow during urination. Other existing uroflowmetry codes describe simple uroflowmetry using nonautomated (eg, stop-watch flow rate, mechanical uroflowmeter) equipment (51736) and complex uroflowmetry using automated (eg, calibrated electronic) equipment (51741). These two new codes are used to report remote (eg, at home) multi-day complex uroflowmetry services. This article provides an overview of these changes. Description of code 0811T, 0812T 0811T Remote multi-day…

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Coding tips for Cystourethroscopy (CPT code 52284) & Radiofrequency Ablation (CPT code 58580)

For the CPT 2024 code set, a new code (52284) was established in the Bladder subsection of the Urinary section to describe cystourethroscopy with mechanical urethral dilation and therapeutic drug delivery via coated balloon. In addition, a new code (58580) was added to the Female Genital System subsection of the Surgery section to report radiofrequency (RF) transcervical fibroid ablation (TFA), including intraoperative guidance and monitoring. Guidelines and parenthetical notes were revised and added to assist with the correct reporting of these services. This article provides an overview of these changes.…

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Sample coded report for Radical Prostatectomy Robotic Assisted CPT code

Pre-op Diagnosis: Prostate cancer (CMS/HCC) [C61] Post-op Diagnosis: Same as Pre-op Procedure(s):  RADICAL PROSTATECTOMY ROBOTIC ASSISTED WITH BILATERAL PELVIC LYMPH NODE DISSECTION – Wound Class: Clean Contaminated Proc. Description(s) & CPT Code(s): RADICAL PROSTATECTOMY ROBOTIC ASSISTED WITH BILATERAL PELVIC LYMPH NODE DISSECTION: Anesthesia: General Estimated Blood Loss: less than 100 mL Quantitative Blood Loss: No data recorded Implants: * No implants in log * Complications: None Findings: Dictated Technique: RADICAL PROSTATECTOMY ROBOTIC ASSISTED WITH BILATERAL PELVIC LYMPH NODE DISSECTION  Technique: Drains: 1) 18 French Foley catheter, 2) 19 French JP drain Procedures: 1) robotic-assisted laparoscopic radical prostatectomy with bilateral nerve sparing…

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Sample coded report for Gastrectomy Robotic Assisted cpt code

Pre-op Diagnosis: Morbid obesity (CMS/HCC) [E66.01] Body mass index is 43.75 kg/m². Essential hypertension, OSA with cpap Post-op Diagnosis: Same as Pre-op Procedure(s):  Procedure(s): SLEEVE GASTRECTOMY ROBOTIC ASSISTED Proc. Description(s) & CPT Code(s): SLEEVE GASTRECTOMY ROBOTIC ASSISTED:  Anesthesia: General Estimated Blood Loss: None Quantitative Blood Loss: No data recorded   Drain: None  Complications: none Findings: Liver appeared fatty Technique:  Tonie Williams is electively admitted for robotic sleeve gastrectomy today for obesity and health problems directly related to obesity. The patient has been extensively informed of the risks, benefits, limitations, and alternatives to surgery as a means of aggressive weight control through discussions in the…

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Sample Coded report for Spinal Cord Stimulator Battery Replacement Exam

Pre-op Diagnosis: Chronic pain syndrome [G89.4] Mechanical breakdown of implanted electronic neurostimulator of spinal cord, initial encounter (CMS/HCC) [T85.112A]    Post-op Diagnosis: Same as Pre-op Procedure(s): Spinal Cord Stimulator Battery Replacement – Wound Class: Clean Anesthesia: Monitor Anesthesia Care Estimated Blood Loss: None Drain:  None   Total IV Fluids:  Per anesthesia record   Specimens: No specimens Complications:  None Findings:  None      Disposition: aroused from sedation, and taken to the recovery room in a stable condition     Condition: doing well without problems Technique:  The patient was placed prone on the operating room table, with monitored anesthesia care.  Lumbar region sterilely prepared and draped in usual fashion.  Local…

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Sample Coded report for Shoulder Arthroplasty CPT code

Pre-op Diagnosis: Arthritis of left shoulder region [M19.012] Left shoulder rotator cuff tear arthropathy and severe degenerative changes at the level of the glenohumeral joint with inferior humeral head osteophyte formation. Post-op Diagnosis: Same as Pre-op Procedure(s):  Left – LEFT REVERSE TOTAL SHOULDER ARTHROPLASTY Anesthesia: General and interscalene regional nerve block. Estimated Blood Loss: 200 mL Specimens:  Standard arthroplasty specimens. Implants: DJO reverse total shoulder arthroplasty   –     glenoid base plate with 30 mm screw length.  Circumferential screw x3-22 mm, 14 mm, 22 mm.  Glenoid head with retaining screw size 32 mm -4 mm.  Humeral stem, small shell, 6 mm x 108 mm.…

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List of New HCPCS Level II codes effective 1st April 2024

Their are many new HCPCS level II codes will be used effectively 1st April 2024. Also, you will get to see some changes or revision on some codes from April 2024. With some additions and revision their are some deletion of codes as well which will not be used after 1st April 2024. These all are the quarterly updates about HCPCS codes by CMS. The Medical coders have to follow the new updates and used codes accordingly to get paid for all the services provided based on the documentation. New…

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Sample Coded report for CYSTOSCOPY LITHOTRIPSY CPT code

Pre-op Diagnosis: Uric acid nephrolithiasis [N20.0] Post-op Diagnosis: Left nephrolithiasis Procedure(s):  Left – URETEROSCOPY – Wound Class: Clean Contaminated  – Incision Closure: No Incision / NA Left – CYSTOSCOPY LITHOTRIPSY URETERAL and renal STONEs – Wound Class: Clean Contaminated  – Incision Closure: No Incision / NA Left – CYSTOSCOPY, URETERAL STENT EXCHANGE – Wound Class: Clean Contaminated  – Incision Closure: No Incision / NA Proc. Description(s) & CPT Code(s): URETEROSCOPY: CYSTOSCOPY LITHOTRIPSY URETERAL STONE: CYSTOSCOPY, URETERAL STENT EXCHANGE:  Anesthesia: General Complications:  None Findings:  The patient had a large stone burden in the left kidney.  Another calyx was obstructed by a…

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Sample Coded report for skin Excision CPT code

Pre-op Diagnosis: Excess skin [L98.7] Post-op Diagnosis: excess skin of upper arms ( bat wing deformity) bilateral Excess skin of chest wall right and left lateral chest35x10 cm, 38×12 cm right chest Painful scar abdomen 21 cm horizontal scar and 19 cm vertical component Procedure(s):  Bilateral – BRACHIOPLASTY excision bilateral excess soft tissue lateral chest Right 38×12 cm Left 35×10 cm Painful scar abdomen excision and closure  21 cm horizontal component and 19 cm vertical component or 40 cm total length Anesthesia: General Findings:excess skin with poor skin elasticity secondary to massive weight loss…

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