Exam 27: Coding and Surgical Procedures

A 65-year-old male with severe droopy upper eyelids that also have severe spider veins along with skin plaques presents to the ambulatory surgery center for a non-cosmetic blepharoplasty of his upper eyelids. The diagnosis was pseudoptosis causing visual impairment along with a severe case of acne rosacea. Select the appropriate CPT and ICD-10-CM codes.

John, age 45, was seen in the office today for interim medical evaluation and management of his type II diabetes. The physician performed an expanded problem-focused history and examination. At the same visit, the physician also administered a flu shot, split virus 0.5ml, intramuscularly. Select the appropriate CPT and ICD-10-CM codes.

The doctor performs repair of entropion left and right with tarsal strip repair. Select the appropriate CPT and ICD-10-CM codes.

The doctor performs median tarsorrhapy severing for left eye for a patient with conjunctival edema and mucopurulent discharge with corneal infiltrate. Select the appropriate CPT and ICD-10-CM codes.

The small air-filled cavity that contains the ossicles is the

Preprocedure diagnosis: Lumbar radiculopathy Postprocedure diagnosis: Lumbar radiculopathy Procedure performed: Lumbar epidural steroid injection Anesthesia given: Local Indications for procedure: This 53-year-old female presents with symptoms consistent with a lumbar radiculopathy. Previous epidural steroid injections have resulted in significant improvement of her pain. This is the second in a series of three of those injections. Description of procedure: The patient was placed in the left lateral decubitus position. The L4-5 interspace was identified with deep palpation. Local infiltration was carried out with 3 cc of 1% lidocaine. The area was prepped and draped in the usual sterile fashion. An 18-gauge Tuohy needle was advanced to the epidural space with the loss-of-resistance technique. Then a mixture of Depo-Medrol 80 mg, normal saline 10 cc, and lidocaine 1% at 5 cc was injected. No complications were encountered, and the patient was returned to the outpatient surgery department in stable condition. Plan: To repeat this procedure in two weeks Select the appropriate ICD-10-CM and CPT code(s):

A patient is in the office today for continued instruction including programming and modification of a speech generating device. The patient is post laryngectomy for carcinoma of the larynx. Select the appropriate CPT and ICD-10-CM codes.

Patient Susie Jones, a 32-year-old female, was admitted to the intensive care unit for acute respiratory distress syndrome. She was given critical care services by her provider Dr. Mark Smith for an hour and twenty minutes. Select the appropriate CPT and ICD-10-CM codes.

Preoperative Diagnosis: Uterine Mass Postoperative Diagnosis: Uterine Mass Operation: Hysteroscopy Operation Description: A 43-year-old patient was diagnosed with a uterine mass as noted on an ultrasound. Patient was administered general anesthesia upon arrival to the operating room. The patient was prepped. The hysteroscope was introduced and biopsy was obtained. Specimen was sent to pathology. Patient tolerated the procedure well. Select the appropriate CPT and ICD-10-CM codes.

Jerry is a 55-year-old diabetic with ESRD. At the beginning of September, Jerry began home-based dialysis services. However, on September 18, he was admitted to the hospital where he remained until September 25 when he was discharged home. Dialysis continued on alternate days while he was in the hospital, and physician visits with expanded problem-focused history and examinations were done on those days in between. Select the appropriate CPT and ICD-10-CM codes.

A patient with chronic recurrent acute sinusitis and nasal polyps presented to the outpatient surgical center for endoscopic frontal sinus exploration with osteomeatal complex resection, anterior ethmoidectomy, and removal of nasal polyps. Select the appropriate CPT and ICD-10-CM codes.

Wanda is visiting her dermatologist to have a biopsy done on some lesions on her back. Dr. Trummel examined the lesions on her back and decided to biopsy 4 of them. The pathology report later came back as benign. Select the appropriate CPT and ICD-10-CM codes.

A 76-year-old female was admitted for intravenous antibiotic therapy to treat pneumonia due to pseudomonas bacteria, and a level 3 initial inpatient visit was provided. On the second and third days, the patient had not yet responded to treatment, which was noted after an expanded problem-focused examination and interval history. On day 4, the patient showed significant improvement and the doctor recorded a problem-focused history and examination. On day 5, the patient was discharged home and the doctor spent 30 minutes in discharge day management. Select the appropriate CPT and ICD-10-CM codes for the physician visits.

Distention of the renal pelvis due to excessive urine collection in the kidney is

Upon orders from Dr. Clyos, a portable x-ray machine was transported to the city nursing home for chest x-rays of a patient with possible tuberculosis. The diagnosis was nodular lesions and patchy infiltrates in the upper lobes. Select the appropriate ICD-10-CM and CPT code(s):

Clinical History: Patient with neuropathy and pain in arm. Diagnosed with possible cervical disc. Study performed: Cervical Myelogram -injection procedure and radiological supervision and interpretation. Impression: Moderate ventral extradural defect C5-6 with bilateral C-6 root encroachments. Select the appropriate CPT and ICD-10-CM codes.

Preoperative Diagnosis: Phimosis Postoperative Diagnosis: Phimosis Operation: Circumcision Operation Description: A four-year-old male who had spraying of urine when voiding was diagnosed with phimosis. It seemed the urine collected in the foreskin when voiding. Risks of the operation, such as infection and bleeding were discussed. In addition, the options of a dorsal slit were reviewed. The family 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. LMA general anesthesia applied. The extra foreskin was marked; 1x3 Gamco clamp used. Then, using 5-0 Monocryl, 4 stitches were placed and suturing was done. Hemostatis was good and dermabond applied. The patient was in good, stable condition and was brought to the recovery room. The entire procedure was completed as discussed with family. Select the appropriate CPT and ICD-10-CM codes.

Mrs. Jones is in the operating room today for repair of a nontraumatic tear of the rotator cuff of the right shoulder. The physician performs an arthroscopy subacromial decompression with an open repair of the rotator cuff. Select the appropriate ICD-10-CM and CPT code(s):

A 39-year-old female patient is seen at the ambulatory surgery center for excision for 6 uterine fibroid tumors. The tumors weighed a total of 268 grams. The OB-GYN used an abdominal approach. Select the appropriate CPT and ICD-10-CM codes.

Anesthesia is administered to a normal, healthy patient for a cesarean hysterectomy following neuraxial labor anesthesia. Select the appropriate CPT code(s):