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.

Mary was seen today for a surgical hysteroscopy with lysis of intrauterine adhesions. Select the appropriate ICD-10-CM and CPT code(s):

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):

Preoperative diagnosis: Left perihilar mass Postoperative diagnosis: Left perihilar mass, mucosal abnormality in the posterior subsegment of the left upper lobe Procedure performed: Bronchoscopy, transbronchial lung biopsy and bronchial lung biopsy, brushing and washing Assistant: None Anesthesia: MAC Description of procedure: With the patient in the supine position, under monitored anesthesia care, the scope was introduced through the mouth, and the larynx and the laryngeal area were inspected. All of them were normal. The scope was then inserted through the trachea into the carina, which was sharp and clear. There was a moderate amount of thick-thin secretions that were suctioned through both right and left main bronchi. The scope was then directed into the right main bronchus, and then the right upper-lobe bronchus with its subsegments was inspected. All of them were normal. Right middle-lobe and right lower-lobe bronchi with their subsegments were also inspected and were normal. The scope was then directed into the left side, where the left main bronchus was normal. Left lower-lobe and middle-lobe bronchi with their subsegments were normal. The left upper-lobe bronchus, anterosuperior segment, showed an anterior subsegment to have a bulging in one of its subbronchi. Under fluoroscopy, biopsy forceps were inserted, and several pieces of lung tissue were obtained from the area of the left perihilar lesion. Then brushing was done in the same area. Washing was also done in the same area. Then, in a separate container, several pieces of bronchial tissue were taken from the area that was bulging, anterosuperior subsegment of the left upper-lobe bronchus. All specimens were submitted for cytology, pathology, and/or culture. The patient tolerated the procedure well, with no apparent complications. Chest x-ray is pending. Select the appropriate ICD-10-CM and CPT code(s):

Joey, a 5-year-old boy, was seen today for immunizations prior to beginning school. After counseling by the PA, he received diphtheria, tetanus toxoid, acellular pertussis, haemophilus influenza Type B, and polio virus as a single injection. Additionally, he received MMRV subcutaneously. Select the appropriate CPT and ICD-10-CM codes.

Mary Torres presents at her endocrinologist's office for IDDM. She states that she ran out of insulin the day before her visit. A blood glucose is performed and the result is 415. The physician writes an order for his nurse to give Mary 13 units of regular insulin. Select the appropriate HCPCS code for the medication only.

A 55-year-old female was having a problem with menopause. Because of the reported concerns about hormone replacement therapy, she decided to try acupuncture. After discussing her symptoms and discussing a treatment plan, Dr. Kind inserted several needles; the needles were removed 20 minutes later. Dr. Kind reviewed the follow-up plan and made an appointment for the patient's next visit. Dr. Kind spent 30 minutes in total face-to-face with Charlene. Select the appropriate ICD-10-CM and CPT code(s):

Jeremy is seen at the clinic today by his regular physician for a rash on his arm that developed while camping in the woods this past weekend. After the problem-focused history and examination the physician determines that the problem was caused by poison oak, and Jeremy is diagnosed with allergic contact dermatitis and prescribed corticosteroid skin cream to reduce the inflammation. Select the appropriate ICD-10-CM and CPT code(s):

_____ is defined as making false statements or representations of material facts to obtain some benefit or payment for which no entitlement would otherwise exist.

June was admitted to the hospital with atrial fibrillation by her PCP, and cardiology was consulted at the time of admission. On the next day, the cardiologist made rounds and checked on Mary's progress. An expanded problem-focused interval history was obtained, and an expanded problem-focused exam was performed. Mary has been on IV therapy and is showing improvement. Select the code for the cardiologist encounter on the second day.

Preoperative Diagnosis: Knee pain Postoperative Diagnosis: Juvenile Arthritis of the knee Operation: Arthroscopy of the right knee Operation Description: A 33-year-old patient was diagnosed with right knee pain. Patient is admitted to have an arthroscopy of the right knee. The risks were discussed with the patient and consent obtained. Select the appropriate CPT code for the anesthesia service, as well as the ICD-10-CM code.

A patient presented to the oncology clinic with a diagnosis of testicular tumor of uncertain behavior. The patient brought slides from his orchiectomy which was sent to the pathologist for review and report including a review of the medical records with written report requiring moderate level of decision making to confirm a diagnosis of testicular carcinoma. Select the appropriate CPT and ICD-10-CM codes.

A patient underwent a 2D echocardiogram including M-mode recording without color Doppler echocardiography for hemorrhagic pericarditis. The report was sent out for interpretation. Select the appropriate CPT and ICD-10-CM codes for the interpreting physician.

Mary Torres presents at her endocrinologist's office for IDDM. She states that she ran out of insulin the day before her visit. A blood glucose is performed and the result is 415. The physician writes an order for his nurse to give Mary 13 units of regular insulin. Select the appropriate HCPCS code for the medication only.

The jellylike substance found inside the eye is called the:

The patient is admitted to the ER for excessive weight loss and dehydration. The patient has a history of HIV-2 and has been taking nucleoside reverse transcriptase (RT) inhibitors. Assign the appropriate ICD-10-CM codes:

The patient undergoes simple mastectomy today for adenocarcinoma of the R breast. While the patient was still on the table, and immediately after the removal of the breast, the patient received a concentrated dose of radiation to the tumor site using IORT electron methodology. Select the appropriate CPT and ICD-10-CM codes.

Preoperative diagnosis: Carcinoma of the lung with right neck metastasis Postoperative diagnosis: Carcinoma of the lung with right neck metastasis Operative procedures: Cervical esophagoscopy, microlaryngoscopy, and biopsy Procedure and findings: With the patient under general anesthesia, the 10I 14 × 23 Roberts esophagoscope was passed. It was noticed that the left piriform sinus was of normal appearance. There was edema of the free tip of the epiglottis. The scope was advanced through the left piriform sinus into the cervical esophagus, and the cervical esophagus and postcricoid area were essentially normal. Also, the upper cervical esophagus was normal. The scope was slowly withdrawn through the right piriform sinus. It was noticed that there was a tumor involving the anterior wall of the right piriform sinus, extending approximately 1 cm below the pharyngeal epiglottic fold. This tumor then also involved the lateral hypopharyngeal wall to a minor degree. The scope was removed. The Dedo microlaryngoscope was passed. It was now noticed that the above findings were further defined. It was noticed that there was an exit through the tumor involving the vallecula on the right side going into the base of the tongue for a distance of approximately 0.5 cm. This tumor was quite exophytic, and it extended laterally above the pharyngeal epiglottic fold, extending, therefore, approximately 0.75 cm to the lateral hypopharyngeal wall. It also involved heavily the medial wall of the right piriform sinus without crossing over onto the laryngeal surface of the epiglottic fold. The vocal cords were of normal appearance. The right vocal cord was fixed in the midline. Inferiorly the tumor extended onto the medial wall of the piriform sinus just about 0.5 cm below the level of the right vocal cord. The scope was suspended. These findings were confirmed, and under 10 × magnification, several biopsies were obtained. The scope was removed. The neck was carefully palpated. The endoscopy had been preceded by a tracheostomy. The patient was initially prepared with Betadine solution and draped in the usual manner. A horizontal incision was made approximately 2 cm above the sternal notch and carried through the subcutaneous tissue down to the strap muscles. The strap muscles were divided in the midline. The cricoid cartilage was identified, the trach ties were tied securely into place, and the cuff was inflated to a comfortable pressure. The patient then received further ventilation through the newly placed trach tube. The patient tolerated all procedures well. Select the appropriate ICD-10-CM and CPT code(s):

A patient with type II diabetes under control was at laboratory today for HbA1C to determine control of sugar over time. Results reported at 8.9%. Select the appropriate CPT and ICD-10-CM codes.

A patient with schizophreniform disorder, who participated in a partial hospitalization program, was seen for 30 minutes of individual psychotherapy and 10 minutes of medication evaluation and management, which required a problem-focused history and straightforward medical decision making. The physician spent 30 minutes face-to-face with the patient. Select the appropriate CPT and ICD-10-CM codes.