Exam 27: Coding and Surgical Procedures

The final section of the small intestine is the

Preoperative diagnosis: Left hydrocele Postoperative diagnosis: Left hydrocele Procedure performed: Left hydrocelectomy Procedure description: The initial incision was made, and the left hydrocele was delivered out of the wound and incised. The hydrocele was emptied of about 500 mL and then incised completely. About 90% of the hydrocele sac was removed with the Bovie. The hydrocele sac was involuted and sewn to itself using running 3-0 Vicryl in the manner of Jaboulay. The testicle was replaced in the left scrotum, and the patient tolerated the procedure well. Select the appropriate ICD-10-CM and CPT code(s):

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.

Which of the following is considered an inhalation drug?

Patient was admitted with chest pain, R/O MI. The physician ordered the following laboratory tests: Comprehensive metabolic panel, CBC w/differential, Sedimentation rate, PT, troponin level, automated urinalysis w/microscopy. Select the appropriate CPT and ICD-10-CM codes for the laboratory tests.

George, a 59-year-old diabetic man with polyneuropathy, is prescribed a four-lead TENS unit as a method to provide a non-invasive, low-risk approach to reduce his pain. Select the appropriate CPT and ICD-10-CM codes for the unit.

A mother brings in her 3-year-old son for a well-child checkup. In addition to the physical examination for this established patient, the physician administers the DTP vaccine via IM injection and discusses the vaccines and possible side effects with the mother. Select the appropriate CPT and ICD-10-CM codes.

Specimen site: Gastric biopsy Gross description: Gastric biopsy: Received in formalin, the specimen consists of two fragments of gray-brown mucosa, each measuring approximately 0.3 centimeter in diameter. Totally submitted for routine and special stains and additional levels. Microscopic description: Sections show benign-appearing gastric mucosa with acute and chronic inflammatory cells within the lamina propria. The surface and pit-lining epithelium are also infiltrated with neutrophils. There is no dysplasia or malignancy. Special stains for H. pylori are positive. Final diagnosis: Gastric biopsy: ? Chronic active gastritis. ? Warthin-Starry stain positive for H. pylori. ? Negative for intestinal metaplasia, dysplasia, or malignancy. 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.

Dr. Mathis has been called to the ICU to provide care for a 37-year-old male patient who has received second-degree burns over 50% of his body. Dr. Mathis provides support from 1 p.m. to 3 p.m. After leaving the unit to do his rounds, Dr. Mathis is called back around 5 p.m., and he provides critical care support to the patient until 6 p.m. Select the appropriate CPT codes.

A 54-year-old patient presents to his primary physician office for a preoperative evaluation for a bilateral vasectomy. The patient's past history consists of controlled diabetes with no other known conditions. Identify which physical status modifier will be used for the surgery.

History: 76-year-old female with colonic mass Diagnosis: Invasive adenocarcinoma, 3.4 × 3.0 cm, involving muscularis propria All margins negative. No lymphatic invasion. No metastatic tumor identified. Gross description: Received fresh is a right colon, 32 cm in length. Upon opening of the specimen, there is a 3.4- × 3.0-cm nodular mass. 36 lymph nodes were retrieved. Representative sections are submitted. Microscopic description: Microscopic examination performed Select the appropriate ICD-10-CM and CPT code(s):

ESWL was performed on Mrs. Wilson's left kidney 1 week ago; now ESWL is being performed on her right kidney. She has 4 stones being removed today: 2 in the renal pelvis and 2 in the calyx. Under local anesthesia, the ESWL is performed and all 4 stones are successfully destroyed. Select the appropriate CPT and ICD-10-CM codes.

A 75-year-old female recently underwent a stroke assessment of her aphasia. The following assessments were performed using Boston diagnostic aphasia examination: expressive and receptive speech, language function, language comprehensive, speed production ability, reading, spelling, and writing skills. Total time 60 minutes. Select the appropriate ICD-10-CM and CPT code(s):

A patient underwent tympanoplasty with a mastoidectomy and ossicular chain reconstruction for removal of a cholesteatoma of the right ear Select the appropriate ICD-10-CM and CPT code(s):

What is a term for the inflammation of the membrane surrounding the brain and spinal cord?

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):

A patient with psoriasis was seen for laser treatment of 300 square centimeters. 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):

History: A 62-year-old woman (height, 1.7 m; weight, 61 kg) was scheduled for resection of a sigmoid colon carcinoma. Her medical history revealed hypothyroidism, vitamin B12 deficiency, and stiff person syndrome. This syndrome started with low back pain, which rendered her unable to walk. She was experiencing stiffness, involuntary jerks, and painful cramps. Neurologic examination revealed extreme hypertonia of the body and proximal legs, with intercurrent, painful spasms. Reflexes were symmetrical without Babinski signs. Laboratory findings showed positive glutamic acid decarboxylase (GAD) and negative amphiphysin antibodies. The patient was successfully treated with baclofen and diazepam. Subsequently, prednisone as immunosuppressive therapy was started. The stiffness diminished, and the patient was able to walk unaided. The neurologic examination was unremarkable, except for a slight stiffness in the legs. Her medication at admission was prednisone 20 mg once a day, baclofen 12.5 mg twice a day (daily dose = 25 mg), diazepam 7.5 mg twice a day (daily dose = 15 mg), levothyroxine 25 ?g once a day, and vitamin B12 injections. Her medical history included urologic and gynecologic surgery under general anesthesia before she experienced SPS. Procedure: No premedication was given. Anesthesia was induced with propofol (2.5 mg/kg) and sufentanil (0.25 ?g/kg). After the administration of atracurium (0.6 mg/kg), the trachea was intubated, and anesthesia was continued with isoflurane (0.6-1.0 vol %) and oxygen/air for the duration of the procedure. Cefuroxime 1,500 mg, clindamycin 600 mg, and dexamethasone 10 mg were administered IV. In the following 2 hours, additional atracurium (35 mg), sufentanil (10 ?g), and morphine (8 mg) were administered. At the end of the procedure, which was uneventful, neuromuscular monitoring showed four strong twitches. Although the patient was responsive, she could not open her eyes, grasp with either hand, or generate tidal volumes beyond 200 mL. Neostigmine 2 mg (0.03 mg/kg) and glycopyrrolate 0.2 mg did not alter the clinical signs of muscle weakness. The patient was sedated with propofol and further mechanically ventilated in the recovery room. After 1 hour, the sedation was stopped and mechanical ventilation was terminated. At that time, baclofen 12.5 mg was administered into the gastric tube. Two hours later she was in a good clinical condition, and her trachea was extubated. Select the appropriate ICD-10-CM and CPT code(s):