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

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 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ablation procedure then delivered radiofrequency energy until tissue impedance reached 50 ohms; the electrode array was retracted for easy removal, leaving the uterine lining desiccated down to the superficial myometrium.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?

The termsalpingo-oophorectomy refers to:

There are two main types of glaucoma. Which type of glaucoma describes when fluid does not flow through the orbicular meshwork properly?

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

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:

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

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

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.

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?

To accurately identify that a procedure was performed on the second lumbar vertebra, which of the following would be documented in the operative report?

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:

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.

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

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?

Postoperative diagnosis: Ovarian cyst, right Anesthesia: General Name of operation: Open drainage of cyst Procedure: The patient was taken to the operating room and prepped and draped in the usual manner, and adequate anesthesia was induced. An infraumbilical incision was made, and abdominal entrance was made. Gas was entered into the abdomen at 2 liters. The abdomen was visualized. The cyst was noted on the right, a 4-cm ovarian cyst. This was needled, and a hole was cut in it with the scissors. Hemostasis was intact. The instruments were removed. The patient was awakened and taken to the recovery room in good condition. Select the appropriate CPT and ICD-10-CM codes:

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 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:

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?