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:

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:

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:

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:

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

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:

A 55-year-old male patient is coming to the hospital for an outpatient service for a prostate biopsy. The patient has a family history of prostate cancer, had recent blood work showing elevated PSA levels, and has problems urinating. The patient presents and is placed under anesthesia and prepped and draped. Ultrasonic guidance is used for needle placement, and a needle biopsy is taken. The biopsy is sent to pathology, and the patient is awaiting the results. Select the appropriate CPT and ICD-10-CM codes:

When multiple surgeons perform the complete skull base procedure (approach procedure, definitive procedure, reconstruction/repair), each surgeon reports only the code for the specific procedure each performed. If one surgeon performs all of the procedures, then all the applicable codes are reported and a modifier is added to the secondary procedure code(s). Which modifier is added?

The termsalpingo-oophorectomy refers to:

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:

The nervous system is divided into two major systems. Which system includes the brain and the spinal cord?

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

A 55-year-old male patient is coming to the hospital for an outpatient service for a prostate biopsy. The patient has a family history of prostate cancer, had recent blood work showing elevated PSA levels, and has problems urinating. The patient presents and is placed under anesthesia and prepped and draped. Ultrasonic guidance is used for needle placement, and a needle biopsy is taken. The biopsy is sent to pathology, and the patient is awaiting the results. Select the appropriate CPT and ICD-10-CM codes:

A 55-year-old male patient is coming to the hospital for an outpatient service for a prostate biopsy. The patient has a family history of prostate cancer, had recent blood work showing elevated PSA levels, and has problems urinating. The patient presents and is placed under anesthesia and prepped and draped. Ultrasonic guidance is used for needle placement, and a needle biopsy is taken. The biopsy is sent to pathology, and the patient is awaiting the results. Select the appropriate CPT and ICD-10-CM codes:

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:

The nervous system is divided into two major systems. Which system includes the brain and the spinal cord?

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:

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?

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

A 23-year-old patient, is seen by Dr. Johnson for a cough with wheezing and green-colored mucus for the past four days, as well as four days of external bleeding hemorrhoids and diarrhea. Dr. Johnson gives her Augmentin for acute viral bronchitis, instructions on the care of external hemorrhoids, and a diet plan to assist with the diarrhea. What diagnoses should Dr. Johnson use for this encounter?