Exam 27: Coding and Surgical Procedures

With the patient under general anesthesia, the ENT used a surgical microscope to perform a myringotomy to release pressure and a tympanoplasty to repair the perforated eardrum of a 6-year-old boy with chronic ear infections who stuck the end of his glasses in his ear. Select the appropriate CPT and ICD-10-CM codes.

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Roger was in an altercation with his neighbor and he has 3 wounds. The first is a 15.5cm wound on the face that required a single layer closure, the second is a 25.5cm laceration of the left forearm that required a layered closure of the subcutaneous tissue, and the third laceration is a 10cm wound on the right external ear that required a layered closure. Select the appropriate CPT and ICD-10-CM codes.

A 43 year old patient has an in situ malignant neoplasm of the left kidney. He is scheduled for a left nephrectomy with partial ureterectomy by open approach. Select the appropriate CPT and ICD-10-CM codes.

Julia was playing baseball in her hardball league and was hit in the face with a line drive. Upon waking she was taken directly to the hospital. She has a fractured mandible, and the orthopedic surgeon is performing a closed treatment with interdental fixation. Select the appropriate CPT and ICD-10-CM codes.

Jim went to the doctor for removal of his skin tags. The physician noted 32 skin tags on his back. Using a scalpel the physician removed all of the skin tags and gave Mr. Evans an antibiotic cream prescription to use for the next 7-10 days. Select the appropriate CPT and ICD-10-CM codes.

Preoperative Diagnosis: Upper gastrointestinal bleeding Postoperative Diagnosis: Gastritis Operation: EGD Operation Description: Patient admitted for upper gastrointestinal bleeding. Patient was informed that an EGD would be completed and understands the risks involved. Consent was obtained. Patient was prepped in the usual sterile fashion. The endoscope entered the oropharynx and the esophagus inspected and revealed no ulcerations or other abnormalities. Coffee ground material was present but no fresh blood noted. Area was biopsied and then scope removed. Patient went to the recovery room in stable condition. Select the appropriate CPT and ICD-10-CM codes

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McKenna was born at 36 weeks and is now 1 month old. She presented with a reducible right inguinal hernia and hydrocele. She was taken to the OR for a repair. Select the appropriate ICD-10-CM and CPT code(s):

Procedure: This 10-year-old female is referred for a 16-channel electroencephalogram due to unexplained seizures. During wakefulness, the posterior background is comprised predominately of 9 Hertz alpha activity, which is well modulated, symmetric, and responsive to eye opening. The anterior background contains 15-20 Hertz low voltage beta activity. With drowsiness there is attenuation of the posterior alpha rhythms, and 5-7 Hertz bi-temporal and sensual beta rhythms are noted. With early stage 2 sleep, there is 3-4 Hertz slowing of the record with occasional midline vertex waves and synchronous sleep spindle formation. No lateralizing asymmetries or epileptiform discharges are noted. Total duration was 4 hours. Impression: This is an unremarkable awake, drowsy, and stage 2 sleep electroencephalogram. No evidence of ictal discharges or lateralizing asymmetries. Select the appropriate CPT and ICD-10-CM codes.

A patient with a benign tumor on the parotid gland had a parotidectomy. Nerves were dissected off the gland and left intact. A suction drain was inserted, which will be removed in two days. Select the appropriate CPT and ICD-10-CM codes.

CT Scan of the Abdomen and Pelvis History: Malignant testicular neoplasm Technique: Axial CT images of the abdomen and pelvis were obtained with intravenous and oral contrast. Findings: Images of the lung bases are normal. Images of the abdomen show the liver, spleen, gallbladder, pancreas, and adrenal glands to be normal. No mass is seen. There is no evidence of cholelithiasis. A retroaortic left renal vein is seen. No obvious mass or enlarged lymph nodes are noted in the retroperitoneum. Mesenteric structures appear normal. A prominent inferior vena cava is seen. Gas is identified in the left inguinal structures, likely representing previous left orchidectomy and removal of the inguinal ring. No enlarged lymph node is identified in the pelvis. Impression: Left retroaortic renal vein is seen. No adenopathy is noted within the abdomen or pelvis. No enlarged lymph node is seen; no mass is identified. Select the appropriate ICD-10-CM and CPT code(s):

A patient presents to his physician today complaining of pain in the left gluteal area. The physician gathers an expanded problem-focused history and performs an expanded problem-focused examination and decision making of straightforward complexity, determining that the cause of the pain is an infected sebaceous cyst in this area. An incision and drainage of the cyst is performed. Select the appropriate ICD-10-CM and CPT code(s):

Tina, age 31, gravida 2, Para 1, is pregnant with twins and has been seeing Dr. Smidley. At 41 weeks she experiences labor and is taken directly to the hospital by her husband. After 14 hours of extremely hard labor the first twin is born; it is a male weighing 6lbs 3ozs. Dr. Petrowski, the attending OB-GYN, orders a cesarean section because the second twin is large for dates, causing cephalopelvic disproportion. The second twin, a female weighing 9lbs 2ozs, was delivered via C-section. Select the appropriate CPT and ICD-10-CM codes.

A 40-year-old patient had 27 skin tags removed in the physician's office. Patient tolerated the procedure well and was instructed to return for a follow up visit in ten days. Select the appropriate CPT and ICD-10-CM codes.

Preoperative Diagnosis: Dysfunctional Uterine Bleeding Postoperative Diagnosis: Dysfunctional Uterine Bleeding Operation: Dilation and Curettage Operation Description: A 32-year-old woman was diagnosed with dysfunctional uterine bleeding. The physician ordered a dilation and curettage (D&C) to be performed. Risks of the operation, such as infection, were discussed. The patient understood all risks and wanted to proceed with the operation. Consent was obtained. The patient was prepped and draped in the usual sterile fashion in the operating room. The D&C procedure was performed. The patient was in good stable condition and brought to the recovery room. Select the appropriate CPT and ICD-10-CM codes.

George presented with chronic intractable pain of unknown origin in his left leg. The neurologist used stereotaxis to create a lesion in the spinal cord in order to attempt to block the pain and provide sustainable relief. Select the appropriate ICD-10-CM and CPT code(s):

Tommy was climbing the tree in front of his house, fell, and sustained a greenstick fracture of the ulna of his left arm. The orthopedic surgeon performed a closed manipulation and applied a short arm cast. Select the appropriate ICD-10-CM and CPT code(s):

Dr. Black, a cardiologist, today is seeing Mrs. Smythe, a 72-year-old Medicare patient, at the request of her internist regarding her chronic atrial fibrillation. After a comprehensive history, comprehensive cardiology-specific examination, and decision making of moderate complexity, Dr. Black prescribes some adjustments to her medications and sends a letter to her internist with his findings and suggested follow-up. Select the appropriate CPT and ICD-10-CM codes.

Preoperative diagnosis: Right subdural hematoma Postoperative diagnosis: Right subdural hematoma Procedure performed: Right temporoparietal craniotomy for evacuation of subdural hematoma Anesthesia: General endotracheal Complications: None Conditions: Stable Indications for procedure: Mr. Green is a 45-year-old male with a known history of alcoholism. He reported falling today, with loss of consciousness for about 20 minutes. Upon arrival at the ED, he was minimally responsive, with some spontaneous movement on the right side. He was intubated and taken to CT, which demonstrated a large right temporal subdural hematoma with 2.5-cm midline shift and effacement of the right lateral ventricle. Description of procedure: The patient was brought to the OR already intubated. General anesthesia was induced. He was given Ancef for preoperative prophylactic IV antibiotics. Lacri-Lube was placed in both eyes, which were then taped shut. A Foley was placed. The patient was positioned supine on the operating room table with the right side elevated with a gel roll. The head was secured in the three-point Mayfield head-holder with the right side up. All pressure points were inspected and padded adequately. The patient's scalp was clipped, prepped, and draped in standard sterile surgical fashion. Local anesthetic was infiltrated along the line of the planned skin incision. A right temporoparietal inverted-question-mark incision was performed with a #10 blade down to the level of the periosteum. The scalp flap, along with the muscle and periosteum, was elevated and reflected anteriorly and held in place with fishhooks. Raney clips were applied to the skin edges. Using the high-speed Midas Rex drill with the perforator bit, burr holes were placed in the temporoparietal region, and they were connected with the B1 and footplate. The bone flap was elevated from the dura and set aside. The underlying brain appeared to be tense. The dura was opened with a 15-blade, and a large amount of subdural hematoma was immediately released. The subdural space was copiously irrigated, and hemostasis was achieved. Select the appropriate ICD-10-CM and CPT code(s):