Exam 26: Coding for Surgical Procedures on Digestive, Urinary, Male and Female Reproductive Systems, Maternity Care, Nervous System, and Eyes, Ears, and Endocrine System

Operative Report Preoperative diagnosis: Internal hemorrhoids Postoperative diagnosis: Internal hemorrhoids, anal fistula Procedure performed: Hemorroidectomy and repair of anal fistula Operative note: The patient presented today for an inpatient procedure to repair an anal fistula and remove internal hemorrhoids. The patient was put under general anesthesia, prepped, and draped. The physician entered the anus using an endoscope to determine placement of internal hemorrhoids and, upon entering, identified an intersphincteric anal fistula that had occurred since the last visit by the patient. The procedure was initiated, and removal of two columns of internal hemorrhoids was performed using rubber band ligation. Once that procedure was performed, an endoscopic repair of the anal fistula took place, using fibrin glue to seal the fistula. With this accomplished, the patient was awakened from anesthesia and taken to an inpatient room for an overnight stay. Select the appropriate CPT and ICD-10-CM codes:

A 25-year-old male patient presents for outpatient surgery today on penile genital warts that previously were treated with medication and have not subsided. The patient is having the genital warts removed using a cryosurgery technique. What are the correct CPT and ICD-10-CM codes?

A 39-year-old female presents with an ectopic pregnancy. Due to previous abdominal surgeries, the surgeon is unable to perform a laparoscopic fallopian tube removal and must use an open procedure to successfully perform the removal. The physician elects to surgically treat this patient by using an open approach to her abdomen to remove her left fallopian tube and ovary, along with the products of conception. Select the appropriate CPT and ICD-10-CM codes:

The patient is a 35-year-old female who has been having prolonged and heavy bleeding during menstruation. After other testing, the patient opted to have an elective uterine ablation using NovaSure. Procedure: After the patient was put under general anesthesia, the patient was placed in the dorsolithotomy position, after which the perineum and the vagina were prepped, the bladder was straight catheterized, and the patient was draped. After a bimanual exam was performed, a speculum was placed and the cavity integrity assessment performed. The NovaSure system uses a small amount of CO2 to verify cavity integrity prior to performing the procedure. The NovaSure thermal endometrial ablation procedure then delivered radiofrequency energy until tissue impedance reached 50 ohms; the electrode array was retracted for easy removal, leaving the uterine lining desiccated down to the superficial myometrium. The patient was awakened from anesthesia and sent home to recover. Select the appropriate CPT and ICD-10-CM codes:

An endoscopy procedure was started on a patient who was scheduled and prepped for a total colonoscopy. The physician was unable to advance the scope beyond the splenic flexure due to unforeseen circumstances. Which of the following modifiers is appended to the colonoscopy code?

Operation: LEEP procedure Diagnosis: Cervical polyp Procedure: With the patient in the supine position, general anesthesia was administered. The patient was put in the dorsal lithotomy position and prepped and draped for dilation and curettage in a routine fashion. An insulated posterior weighted retractor was put in. Using the LEEP tenaculum, we were able to grasp the anterior lip of the cervix with a large wire loop at 35 cutting, 30 coagulation. The cervical polyp on the posterior lip of the cervix was excised. Then changing to a 40 of coagulation and 4 cutting, the base of the polyp was electrocoagulated, which controlled all the bleeding and then it was closed with figure-of-eight 3-0 Vicryl sutures. Rechecking the cervix, no bleeding was noted. The patient was laid flat on the table, awakened, and moved to the recovery room bed and sent to the recovery room in satisfactory condition. Select the appropriate CPT and ICD-10-CM codes:

An elderly gentleman has worsening bilateral hydronephrosis. He did not have much of a postvoid residual on bladder scan. He is taken to the OR to have a bilateral cystoscopy and retrograde pyelogram. The results come back as gross prostatic hyperplasia. Select the appropriate CPT and ICD-10-CM codes:

Preoperative diagnosis: Bladder tumor, 3.4 cm Postoperative diagnosis: Bladder tumor, 4.2 cm Procedure: The patient was placed in the lithotomy position after receiving IV sedation. He was prepped and draped. A 21-French cystoscope was passed into the bladder; a previous CT scan of the bladder indicated a tumor of approximately 3.4 cm. After inspection of the bladder with the cystoscope, the findings were consistent with a bladder tumor but the size was inconsistent; the actual finding was a size of 4.2 cm. A biopsy was taken, and laser surgery was performed with fulguration on the removal of the tumor. The patient tolerated the procedure well. Code only the procedure:

Select the appropriate CPT and ICD-10-CM codes to report the removal of 35 percent of the left thyroid lobe through an isthmusectomy. The patient's diagnosis is benign thyroid neoplasm.

The patient is a female transgender patient who has undergone hormonal therapy, along with other services, to prepare her for her sex change to a male. The patient is counseled on the adverse effects of surgery, as well as complications that may occur. The patient signs the consent for surgery and is taken to the operating room, prepped for surgery, and placed under general anesthesia. The patient successfully comes through surgery. Select the appropriate CPT code:

An endoscopy procedure was started on a patient who was scheduled and prepped for a total colonoscopy. The physician was unable to advance the scope beyond the splenic flexure due to unforeseen circumstances. Which of the following modifiers is appended to the colonoscopy code?

Which of the following is the gland that secretes a factor that causes T cells to mature and is larger in infants?

A patient is seen in the outpatient clinic for a colonoscopy due to a family history of colon cancer. The patient has no personal history of gastrointestinal disease and is currently without signs and symptoms. The colonoscopy revealed a colonic polyp that was removed by hot biopsy forceps. What should the CPT and diagnosis codes for this case be?

Which of the following terms refers to an abnormal accumulation of fluid in the peritoneal cavity that is often a complication of a malignancy?

The medical term that can be used for pain in the head is:

Preoperative diagnosis: (1) Cholelithiasis, (2) acute cholecystitis Postoperative diagnosis: (1) Cholelithiasis, (2) acute cholecystitis Name of operation: Laparoscopic cholecystectomy Anesthesia: General Findings: The gallbladder was thickened and showed evidence of chronic cholecystitis. There was a great deal of inflammatory reaction around the cystic duct. The cystic duct was slightly larger. There were nine stones impacted in the cystic duct. The gallbladder contained numerous stones, which were small. With the stones impacted in the cystic duct, it was felt that probably none were within the common duct. Other than rather marked obesity, no other significant findings were noted on limited exploration of the abdomen. Procedure: Under general anesthesia after routine prepping and draping, the abdomen was insufflated with the Veress needle and the standard four trocars were inserted uneventfully. Inspection was made for any entry problems, and none were encountered. After limited exploration, the gallbladder was then retracted superiorly and laterally, and the cystic duct was dissected out. This was done with some difficulty due to the fibrosis around the cystic duct, but care was taken to avoid injury to the duct and to the common duct. In this manner, the cystic duct and cystic artery were dissected out. Care was taken to be sure that the duct that was identified went into the gallbladder and was the cystic duct. The cystic duct and cystic artery were then doubly clipped and divided, taking care to avoid injury to the common duct. The gallbladder was then dissected free from the gallbladder bed. Again, the gallbladder was somewhat adherent to the gallbladder bed due to previous inflammatory reaction. The gallbladder was dissected free from the gallbladder bed utilizing the endo shears and the cautery to control bleeding. The gallbladder was extracted through the operating trocar site, and the trocar was reinserted. Inspection was made of the gallbladder bed. One or two bleeding areas were fulgurated, and bleeding was well controlled. Select the appropriate CPT and ICD-10-CM codes:

Preoperative diagnosis: Right eustachian tube dysfunction Postoperative diagnosis: Right eustachian tube dysfunction Anesthesia: General mask Name of operation: Eustachian tube catheterization Procedure: The patient was taken to the operating room and placed in the supine position. After general anesthesia was given, the operating microscope was brought in for full use throughout the case. The right tympanic membrane was approached using a transnasal approach. An anterior-inferior radial incision was made in the right tympanic membrane. Suction revealed a substantial amount of mucopurulent drainage. A Sheehy pressure equalization tube was placed in the site. Floxin drops were added. The patient tolerated the procedure well and returned to the recovery room awake and in stable condition. Select the appropriate CPT and ICD-10-CM codes:

Preoperative diagnosis: Bladder tumor, 3.4 cm Postoperative diagnosis: Bladder tumor, 4.2 cm Procedure: The patient was placed in the lithotomy position after receiving IV sedation. He was prepped and draped. A 21-French cystoscope was passed into the bladder; a previous CT scan of the bladder indicated a tumor of approximately 3.4 cm. After inspection of the bladder with the cystoscope, the findings were consistent with a bladder tumor but the size was inconsistent; the actual finding was a size of 4.2 cm. A biopsy was taken, and laser surgery was performed with fulguration on the removal of the tumor. The patient tolerated the procedure well. Code only the procedure:

The medical term that can be used for pain in the head is:

A 35-year-old patient is brought to the operating room for an outpatient surgery for a hiatal hernia repair. The surgeon is able to repair the hernia laparoscopically by placing sutures in the crus diaphragmatic muscles below the esophagus and bringing them together to close the hiatal hernia. The anterior and posterior walls of the fundus are wrapped and stitched around the esophagus to complete the procedure. Select the appropriate CPT and ICD-10-CM codes for this procedure: