Exam 27: Coding and Surgical Procedures

Preoperative Diagnosis: puncture wound to the L. ventricle as a result of a stabbing presented with cardiac tamponade. Postoperative Diagnosis: same Operative Procedure: removal of knife from the left ventricle followed by on-pump exploratory cardiotomy and cardiorrhaphy. Patient survived procedure and was sent to ICU in critical condition. Select the appropriate CPT and ICD-10-CM codes.

The patient underwent an abdominal pan-hysterectomy to remove a malignant hydatidiform mole. Select the appropriate ICD-10-CM and CPT code(s):

Mr. Jones, a new patient with a history of prostate cancer 6 years ago, presented today with pain in his lower back and weakness in his extremities. He brought films from x-rays taken earlier in the week and his previous records from his internal medicine physician. The physician takes a comprehensive PMFSH and ROS and performs a comprehensive examination. Based on review of the records and his findings, the physician's diagnosis is metastatic prostate cancer to the sacral vertebrae. The physician discussed treatment options with the patient including risks and benefits. Select the appropriate ICD-10-CM and CPT code(s):

Mary, age 53, underwent a laparoscopic assisted vaginal hysterectomy for menometrorrhagia. Select the appropriate CPT and ICD-10-CM codes for the anesthesiologist.

A patient is sent to the radiology department with an indication of abdominal pain. A KUB is ordered. The coder inputs data that is then transferred to line 21 of the CMS-1500 form, showing ICD-10-CM code R10.11, and line 24 field C showing CPT 74018. Which of the following has the coder demonstrated?

A patient was seen for administration of a gastroesophageal reflux test. The pH electrodes were inserted through the nose. The physician supervised the procedure, reviewed the results, and determined the test was positive for GERD. Select the appropriate CPT and ICD-10-CM codes.

A 38-year-old insulin-dependent established patient called his physician complaining of having some rectal bleeding after using the bathroom. The physician agreed to meet the patient in the outpatient department of the hospital. The physician performed an expanded problem-focused history with a detailed examination. The patient is to have blood work and a stool culture and is to be scheduled for a lower GI series. The physician's diagnosis was Hematochezia etiology unknown. Select the appropriate CPT and ICD-10-CM codes.

Georgette, a 57-year-old female, experiences polyneuropathy in the right arm due to a spur located at C4-C5. She presents today in the pain clinic for epidural injection by the anesthesiologist of an anesthetic agent for the purpose of pain control. Select the appropriate CPT and ICD-10-CM codes.

Preoperative Diagnosis: Kidney Mass Postoperative Diagnosis: Kidney Mass Operation: Kidney Biopsy Operation Description: A 20-year-old male was noted to have a kidney mass per the ultrasound results. Patient was advised to have a kidney biopsy of the mass. All risks understood and consent obtained. The patient was prepped in the outpatient surgical unit. A single needle biopsy was obtained of the kidney. The radiologist assisted the surgeon with the procedure. The kidney biopsy was sent to the pathology department. The patient entered the recovery room in stable condition. Select the appropriate CPT and ICD-10-CM codes for the service(s) of the surgeon only.

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):

Which Medicare program covers physician services?

Clinical history: Nevus, R pinna Postoperative diagnosis: Same Tissue/specimen: Skin of external ear nevus of R pinna Impression: Microscopic sections show the specimen shows a nevus identified as a melanoma. Select the appropriate CPT and ICD-10-CM codes.

A patient taking warfarin for atrial fibrillation reports to the lab for a venous draw for prothrombin time for her monthly INR evaluation. This is her third such visit in the past 90 days. She will see her physician in two days to review the results. Select the appropriate CPT and ICD-10-CM codes.

Patient undergoes a uterine evacuation and curettage for a hydatidiform mole and severe vaginal bleeding, which is complicated by a urinary tract infection caused by E. coli. Select the appropriate CPT and ICD-10-CM codes.

A patient was admitted with a hernia of the diaphragm. The medical term for this disease is

CPT codes that fall in the range titled "Introduction and Removal" in the Surgery/Musculoskeletal System include:

Steve presents today for an epidural injection of a steroid, caudal to relieve his low back pain, radiating leg pain, and coccygodynia. Steve is placed in a prone position with a cushion below his stomach to arch his back. Local anesthetic is applied to numb the skin and tissue down to the surface of the sacral hiatus. After the needle is placed in the area, 1.5cm of contrast solution helps the physician see painful areas under fluoroscope. The steroid is injected in the epidural space. The needle is removed, bandage applied, and the patient is sent home. Select the appropriate CPT and ICD-10-CM codes.

Esther Nelson, a 79-year-old female, came to see Dr. Talbot for a right total-knee arthroplasty due to osteoarthritis of right knee. Dr. Clearwater administered the general anesthesia for the procedure. Esther is in otherwise good health. Select the appropriate ICD-10-CM and CPT code(s) for Dr. Clearwater:

Preoperative diagnosis: Respiratory insufficiency Postoperative diagnosis: Respiratory insufficiency Operation: Tracheostomy with division of thyroid isthmus Estimated blood loss: Less than 10 mL Fluids: Crystalloid Complications: None Technique: The patient was brought to the operating room and placed in the supine position. He was given general anesthesia through his existing oral intubation tube. The anterior neck was prepped and draped in the usual sterile fashion. Lidocaine 1% with 1:100,000 epinephrine was infiltrated into the skin at the lower neck. A transverse incision was made at the cricoid ring level through skin and subcutaneous fat. The platysmal layer was traversed, and then the strap muscles were separated in the midline. The thyroid isthmus was ligated and divided with #2-0 silk ligatures. An inferiorly based tracheostomy flap was created using the second and third tracheal rings and sewn into place with a #3-0 chromic stitch to the inferior dermis margin. Hemostasis was achieved using suction cautery. At this point, the oral intubation tube was withdrawn, and a #8 Shiley low-pressure cuffed tube was passed into the newly created trach site. 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 was then allowed to awaken from general anesthesia and was taken back to the ICU in stable condition. Select the appropriate ICD-10-CM and CPT code(s):

Which of the following is not included in the CPT definition of lesion destruction?