1. Roberta Sleether is a new patient who saw Dr. Morganstern to report feeling tired all the time. She stated that she
was exhausted even after a full 8 hours of sleep at night. Roberta said that she did not have much of an appetite and
that she had been eating mostly salads and chicken with a bowl of fruit as snacks. She is not overweight and her
blood pressure and other vital signs were normal. Dr. Morganstern decided to perform a complete blood count, an
electrolyte panel, and a lipid panel. He also ordered a urinalysis, an iron-binding capacity, and a vitamin B₁2 test.
The physician asked if she had noticed any blood in her urine or stool, and she denied blood in the urine but did
mention she had several episodes of diarrhea. Dr. Morganstern added an occult blood test and a stool culture to check
for pathogens. The physician placed Roberta on multivitamin therapy and told her to return in 1 week to discuss her
laboratory test results. He spent approximately 30 minutes with Roberta, taking a detailed history and performing a
detailed examination, making low-complexity medical decisions. Roberta scheduled her appointment for the follow-
ing week and left the clinic.
2. Diagnosis: Left cheek laceration
Procedure: Repair left cheek laceration
After the patient was prepped with local anesthetic to the left cheek area, the cheek was dressed and draped with
Betadine. The 1.7 cm chin laceration of the skin was closed with three interrupted 6-0 silk sutures. Gentamicin
ointment was applied to the lacerations and a dressing was placed on the left cheek. The patient tolerated the
procedure well.
What is the appropriate CPT code for this procedure?
Can a modifier be used for this procedure? If so, what would be the most appropriate?
Because anesthesia was used, can an appropriate anesthesia CPT code be used?
3. Diagnosis: Abdominal pain
Procedure: Esophagogastroduodenoscopy with biopsy
The patient was premedicated and brought to the endoscopy suite where his throat was anesthetized with Cetacaine
spray. He then was placed in the left lateral position and given 2 mg Versed, IV.
An Olympus gastroscope was advanced into the esophagus, which was well visualized with no significant spasms.
Subsequently the scope was advanced into the distal esophagus, which was essentially normal. Then the scope
was advanced into the stomach, which showed evidence of erythema and gastritis. The pylorus was intubated and the duodenal bulb visualized . The duodenal bulb showed severe erythema suggestive of duodenitis .Biopsies of both the duodenum and the stomach were obtained .the scope was withdrawn the pariente tolerated the procedure well
I need the coding of cpt please helppp me
