Exam 27: Coding and Surgical Procedures

Which CPT code(s) should be reported for a fine needle aspiration of the prostate performed by an urologist?

CPT code range 90281-99607 is located in which section of the CPT manual?

PSA is a blood test performed to screen for

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):

Jane is seen by the plastic surgeon today for injection of three units of Botox into her face, including her forehead and glabellar frown lines for cosmetic reasons. Select the appropriate CPT and ICD-10-CM codes for the injections and medication.

A 48-year-old female with blepharoptosis of the L eyelid presents today for visual field testing using the Humphrey field analyzer testing 3 isopters. Select the appropriate CPT and ICD-10-CM codes.

The patient was seen for complaints of persistent cluster headaches and blurring vision. As part of the workup, a lumbar puncture was performed, the pressure of the spinal fluid was measured, and some fluid was removed for analysis. Select the appropriate ICD-10-CM and CPT code(s):

Mrs. Mustin undergoes insertion of a left custom breast prosthesis 3 months after a mastectomy for breast cancer. The patient needed to undergo radiation to that area prior to the insertion of the prosthesis. Select the appropriate ICD-10-CM and CPT code(s):

A patient underwent fine needle aspiration of a cyst on the L breast and another on the R breast. Both aspirates were properly labeled and sent to cytopathology for interpretation and report. Pathology report demonstrated cells consistent with fibrocystic breast disease; no malignancy was noted. Select the appropriate CPT and ICD-10-CM codes.

CT Scan of the Chest and Adrenals History: Left pulmonary nodule on chest x-ray Technique: Helical transaxial images, 7 mm, of the chest were obtained after the administration of oral and intravenous contrast. Findings: The patient's chest x-rays from February 24 and 25 were reviewed. There is an ill-defined opacity suggested in the left midlung zones on those studies, including oblique views. Within the left lower lobe laterally, there is an approximately 2-cm area of parenchymal density that has the appearance of interstitial changes without findings of a significant nodule or mass. This finding can relate to scarring. There is no other nodule, mass, or effusion. Within the mediastinum, there is no evidence of adenopathy seen. The heart and great vessels are normal in appearance. There is a suggestion of minimal pericardial thickening anteriorly that is not specific. Osseous structures show degenerative changes with osteophyte formation at multiple levels in the thoracic spine. Visualized upper abdominal structures, including liver, spleen, kidneys, pancreas, aorta, and para-aortic retroperitoneum, show no specific finding. The adrenal glands are not enlarged. Impression: There is a small focal area of increased parenchymal density that has an interstitial pattern. There is no significant nodule or mass. This is suggestive of scarring. There is no nodule, mass, effusion, or adenopathy seen. Consider chest x-ray follow-up of this lesion to assess stability. 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.

Clinical diagnosis: Cholecystitis and Chronic Calculi Operation: Cholecystectomy Specimen: Gall bladder Pathology Report: Microscopic analysis of specimen measuring 9.0 X 3.0cm. Diagnosis: Chronic cholecystitis, cholelithiasis Select the appropriate CPT and ICD-10-CM codes.

Holter Monitor Report History: This is a 36-year-old male referred for evaluation of syncope episodes and dizziness. He also has a history of depression and anxiety. A Holter monitor was placed on April 2 for 24 hours. Recording revealed sinus rhythm with three VPCs and three isolated APCs. There were no SVTs, no VTs, and no pauses. The patient had multiple complaints of dizziness, anxiety, panic, and feeling near syncopal. Rhythms at these times documented normal sinus rhythm at rates between 80 and 104 beats per minute. No significant arrhythmias. Impression: Normal Holter Select the appropriate ICD-10-CM and CPT code(s):

A 45-year-old patient with BCBS is seen by a consultant at the request of her internal medicine physician for opinion and management recommendations regarding her subacute bronchitis. The consultant performs a comprehensive history and exam with decision making of moderate complexity. He returns the patient to her primary physician and sends a report discussing his findings and recommendations. Select the appropriate CPT and ICD-10-CM codes.

The patient undergoes repair of the renal pelvis to treat an ureteropelvic junction obstruction the patient has had since birth. An incision is made and an excision is performed on the (right) congenital kidney abnormality; a secondary pyeloplasty, solitary kidney or calycoplasty is performed on the left kidney. Select the appropriate CPT and ICD-10-CM codes.

A patient who is suffering from osteosarcoma located above the right knee begins chemotherapy treatment at today's encounter. Select the appropriate ICD-10-CM codes to be reported for this encounter:

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.

Which of the following CPT codes is NOT a method of drawing blood?

What Level II modifier is used when a service is performed without the presence of a teaching physician under the primary care exception?

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 confirming a diagnosis of testicular carcinoma. Select the appropriate CPT and ICD-10-CM codes.