Step 1:Review Code Set 1 (Last Name beginning in A - M) or Code Set 2 (Last Name beginning in N-Z)

Step 2:Review the Code Set you are assigned to. Use your coding manual(s) to assign the correct code(s) in the proper sequence. In addition to assigning the code(s), explain how you arrived at the code(s). Your explanation should include what you determined to be the diagnoses/procedures, how you looked these up in the coding manual, and any guidelines you followed to assign the correct code(s).

Step 3:Share your answers using this forum with your assigned classmate and review codes assigned by your classmate. Provide a written review and discussion response that answers the following questions:

1. Are all the questions answered correctly? If not, which questions are incorrect?
2. For any answers that were incorrect, please explain the correct answer.
3. What did you learn from completing this code audit?
4. Do you have any helpful ideas or strategies to assist your peer in identifying correct codes related to this topic?

Code Set 1 (Last Name beginning with A - M)

1. Mr. Lahey is seen in the same-day surgery unit for an arthroscopy to remove some loose bodies in his shoulder area. What CPT code is reported?
2. A 37-year-old patient presents with right-side thoracic myofascial pain. A 25-gauge 1.5-inch needle on a 10-cc controlled syringe with 0.25% bupivacaine was used. A total of 8-cc of bupivacaine was used on the rhomboid major, rhomboid minor, and levator scapular muscles for a total of four trigger points. What CPT code(s) is/are reported for this procedure?
3. Mr. Jackson fell off a ladder and fractured his left femoral shaft in three places. The fracture is treated with an ORIF of the left femur with an intramedullary nail and interlocking screws (peritrochanterically). The orthopedist also places the leg in a plaster splint prior to leaving the OR. What CPT code(s) is/are reported?

Code Set 2 (Last Name beginning with N - Z)

1. A 53-year-old patient is given a local anesthetic, by injection in the thigh above the site to be biopsied. A small-bore needle is then introduced into the muscle, about 3 inches deep, and a muscle biopsy is taken. What CPT code is reported for this service?
2. Mr. Long presents today for a closed reduction of a nasal fracture. The depressed right nasal bone was elevated using heavy reduction forceps while the left nasal bone was pushed to the midline. This resulted in good alignment of the external nasal dorsum. What CPT code is reported for this procedure?
3. A 17-year-old patient presents with recurrent left wrist pain from an injury to her wrist over one year ago. The patient was taken to the operating room and placed under general anesthesia. She was placed in wrist traction. The radiocarpal joint was entered endoscopically through sharp skin incisions and blunt dissection into the joint. Mild synovitis was found in the dorsal ulnar aspect of the wrist. This was debrided arthroscopically with a shaver. There was a peripheral tear of the triangular fibrocartilage. This area was shaved to promote healing. There was synovitis within the midcarpal joint. All instruments were removed, and the wounds were closed with interrupted nylon sutures. What CPT code(s) is/are reported?