Exam 27: Coding and Surgical Procedures

Procedure performed: Left-sided heart catheterization, selective coronary angiography, and left ventriculography Indication: Chest pain and abnormal Cardiolite stress test RESULTS Hemodynamics: The left ventricular pressure before the LV-gram was 117/1 with an LVEDP of 4; after the LV-gram it was111/4 with an LVEDP of 10. The aortic pressure on pullback was 111/17. Left ventriculography: The left ventriculography showed that the left ventricle was of normal size. There were no significant segmental wall motion abnormalities. The overall left ventricular systolic function was normal, with an ejection fraction of better than 60%. Selective coronary angiography: A. Right coronary artery: The right coronary artery is a medium- to large-size dominant artery that has about 80% to 90% proximal/mideccentric stenosis. The rest of the artery has only mild surface irregularities. B. Left main coronary artery: The left main has mild distal narrowing. C. Left circumflex artery: The left circumflex artery is a medium-size, nondominant artery. It gives rise to a very high first obtuse marginal/intermedius, which is a bifurcation medium-size artery that has only mild surface irregularities. The second obtuse marginal is also a medium-size artery that has about 20% to 25% proximal narrowing. After that second obtuse marginal, the circumflex artery is a small-size artery that has about 20% to 30% narrowing, a small aneurismal segment. D. Left anterior descending coronary artery: The left anterior descending artery is a medium-size artery that is mildly calcified. It gives rise to a very tiny first diagonal that has mild diffuse atherosclerotic disease. Right at the origin on the second diagonal, the LAD has about 30% narrowing. The rest of the artery is free of significant obstructive disease. The second diagonal is also a small-caliber artery that has no significant obstructive disease. Conclusion: Severe single-vessel atherosclerotic heart disease Select the appropriate ICD-10-CM and CPT code(s):

An established patient presents to the office with an acute, deep cough, along with wheezing. The patient has a history of allergies along with chronic rhinitis. After an expanded problem-focused exam, the physician learns that the patient's home has just been found to have mold in the walls. The physician has spent an additional 15 minutes providing resources and counseling with the patient regarding the effects of mold and treatment of his URI. The physician has also recommended lab tests and x-rays. Select the appropriate CPT and ICD-10-CM codes.

CARDIAC CATH LAB REPORT History: The patient is a 44-year-old with a family history of coronary artery disease. He is a heavy cigarette smoker with dependence. He had an electrocardiogram showing an old anterior septal myocardial infarction. MRI showed a fixed anterior defect. He is referred today for coronary angiography due to episodes of chest pain. Description of the Procedure: The patient arrived in the procedure room and was administered 100 mcg Fentanyl and 2 mg Versed. 1% lidocaine was infiltrated over the right femoral artery. A 6-French sheath was placed in the right femoral artery. Diagnostic coronary angiography was performed with a 6-French JL-4 and 6-French JR-4 diagnostic catheters. There was no aortic stenosis on left heart pullback. There was no significant obstructive coronary artery in the right coronary artery, the left circumflex artery or left anterior descending coronary artery. There is a 10% to 20% stenosis in the distal left main. Hemodynamic measurements were taken and repeated to evaluate hemodynamic response. Opening aortic pressure was 103/58. Following coronary angiography, the left ventricular pressure was 107/12. Following coronary angiography, a 6-French pigtail catheter was placed in the left ventricle where left ventriculography was performed with 36 cc of contrast injected at 12 cc per second for 2 minutes. The left ventricular systolic function is normal. There are no regional wall motion abnormalities and no mitral regurgitation. At the conclusion of the procedure, the catheter and sheath were removed and Angio-Seal plug was deployed. Impression: There is no significant obstructive coronary artery disease. There is plaque in the distal left main, but no significant obstruction. Left ventricular systolic function is normal. There is no evidence of previous anterior wall myocardial infarction. Plan: Patient is urged to discontinue smoking and was referred to a smoking cessation program. Continue daily low-dose aspirin therapy. Nitroglycerin as needed. Select the appropriate CPT and ICD-10-CM codes.

An emergency craniotomy was performed for evacuation of an intraparenchymal hemorrhage in the right frontal lobe that developed after resection of a pituitary tumor earlier in the day. Select the appropriate CPT and ICD-10-CM codes.

A 43-year-old male came into the doctor's office to have a hemorrhoidopexy by stapling for his second-degree hemorrhoids. He was very uneasy since he had never had this procedure before. Dr. Hanson administered an IV of Versed, for the anxiety. The procedure is not really painful, so there was no need for a full anesthetic or painkiller. Myrtle Pape, a certified registered nurse anesthetist (CRNA), sat with the patient throughout the procedure to ensure his safety and comfort level. The procedure was complete in one stage, taking 30 minutes.Select the appropriate ICD-10-CM and CPT code(s):

Preoperative Diagnosis: Cleft palate Postoperative Diagnosis: Cleft palate Operation: Repair of cleft palate Anesthesia: General Operation Description: A 3-year-old patient was diagnosed with cleft palate and was advised by the surgeon to complete the surgical procedure repairing the cleft palate. The risks were discussed and identified with the family. Consent was obtained and the operation performed. Select the appropriate CPT and ICD-10-CM codes for the anesthesia service for the procedure.

Bilateral Doppler Study: Carotid Arteries Indications: Status post-carotid endarterectomy imaging. The patient states that he was told that the right carotid artery is blocked. The right internal carotid artery is not identified, probably completely blocked. Velocity measurements on the right side: Common carotid artery: 58.9 cm/sec Right external carotid: 142 cm/sec Right vertebral: 44 cm/sec and showing antegrade flow Velocity measurements on the left side: Common carotid artery: 35 cm/sec Carotid bulb: 60 cm/sec Internal carotid: 52 cm/sec External carotid: 236 cm/sec Left vertebral: 55 cm/sec Status postendarterectomy changes are noted in the left internal carotid and the bulb. There is evidence of ectasia. On the right, the common carotid artery shows ectasia. Judging from the velocity measurements, the right internal carotid artery has a stenosis in the range of 50% to 79%. The left internal carotid artery has a stenosis in the range of 16% to 49%. The left external carotid artery is in the range of 50% to 79%. Impression: The right internal carotid artery is completely occluded. Status postendarterectomy changes in the left internal carotid and the bulb are noted. No significant occlusive disease is seen in the left internal carotid artery. Both vertebral arteries are showing antegrade flow. Select the appropriate ICD-10-CM and CPT code(s):

George presented with chronic intractable pain of unknown origin in his left leg. The neurologist used stereotaxis to create a lesion in the spinal cord in order to attempt to block the pain and provide sustainable relief. Select the appropriate ICD-10-CM and CPT code(s):

The time associated with coding sequelae (late effects) is:

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):

Procedure performed: Left-sided heart catheterization, selective coronary angiography, and left ventriculography Indication: Chest pain and abnormal Cardiolite stress test RESULTS Hemodynamics: The left ventricular pressure before the LV-gram was 117/1 with an LVEDP of 4; after the LV-gram it was111/4 with an LVEDP of 10. The aortic pressure on pullback was 111/17. Left ventriculography: The left ventriculography showed that the left ventricle was of normal size. There were no significant segmental wall motion abnormalities. The overall left ventricular systolic function was normal, with an ejection fraction of better than 60%. Selective coronary angiography: A. Right coronary artery: The right coronary artery is a medium- to large-size dominant artery that has about 80% to 90% proximal/mideccentric stenosis. The rest of the artery has only mild surface irregularities. B. Left main coronary artery: The left main has mild distal narrowing. C. Left circumflex artery: The left circumflex artery is a medium-size, nondominant artery. It gives rise to a very high first obtuse marginal/intermedius, which is a bifurcation medium-size artery that has only mild surface irregularities. The second obtuse marginal is also a medium-size artery that has about 20% to 25% proximal narrowing. After that second obtuse marginal, the circumflex artery is a small-size artery that has about 20% to 30% narrowing, a small aneurismal segment. D. Left anterior descending coronary artery: The left anterior descending artery is a medium-size artery that is mildly calcified. It gives rise to a very tiny first diagonal that has mild diffuse atherosclerotic disease. Right at the origin on the second diagonal, the LAD has about 30% narrowing. The rest of the artery is free of significant obstructive disease. The second diagonal is also a small-caliber artery that has no significant obstructive disease. Conclusion: Severe single-vessel atherosclerotic heart disease Select the appropriate ICD-10-CM and CPT code(s):

Diagnosis: Stomach (distal): Invasive adenocarcinoma Gross description: Received in formalin two specimens, 9.0- × 5.5- × 4.3- cm and 2.0- × 1.5- × 3.4-cm segments of the stomach, with a palpable firm 3.0- × 2.5-cm mass on the designated lesser curvature of the larger specimen. The external surfaces of the specimens are unremarkable and inked black. The curved surfaces demonstrate the mass and adjacent firm areas of nodularity. The remainder of the gastric mucosa is unremarkable. Microscopic description: Microscopic examination was performed. See synoptic report. Select the appropriate ICD-10-CM and CPT code(s):

A patient undergoes a percutaneous liver biopsy with US guidance. The pathology report reveals autoimmune hepatitis. Select the appropriate ICD-10-CM and CPT code(s):

Preoperative diagnosis: Melena Postoperative diagnosis: Internal hemorrhoids Procedure: Colonoscopy The 60-year-old patient was experiencing melena and it was recommended that he complete a colonoscopy as an outpatient procedure. The patient was prepped in the surgical suite and a scope inserted into the rectum and the large intestines examined which showed internal hemorrhoids. A biopsy was taken and sent to pathology. The scope was extracted and the patient was sent to the recovery room in good condition. Select the appropriate CPT and ICD-10-CM codes.

A patient with intractable pain from the left lower extremity due to varicose veins elected for ligation and stripping. The left greater saphenous vein was stripped to the level of the knee, and multiple left lower extremity varicose veins were also stripped. 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.

Examination of the interior of the tracheobronchial tree with an endoscope is a:

Preoperative diagnosis: Morbid obesity Postoperative diagnoisis: Morbid obesity Procedure performed: Abdominal panniculectomy Estimated blood loss: Throughout the procedure, approximately 20 Ml Anesthesia: General endotracheal anesthesia Indications for procedure: This is a 49-year-old female who previously underwent gastric bypass surgery and has lost 120 pounds, leaving a large lower pannus of the abdomen. This pannus needs to be resected. The nonoperative versus operative management options were discussed with the patient. The operative risks included bleeding, infection, hematoma, chance for further surgery as well as pain, and a resulting scar. The patient accepted the risks and consented to surgery. Procedure in detail: The patient was placed under general endotracheal anesthesia. The patient was draped in the proper manner, and the lower abdominal pannus was identified. It was preoperatively marked prior to going to the OR. The lower incision was made from the superior iliac crest with the middle being the pubic tubercle. That lower incision was then made. The pass was then elevated at the level of the anterior abdominal fascia and was elevated superiorly to the level of the inferior umbilicus. Then incisions were made on the umbilicus to the superior iliac crest, and the skin and subcutaneous pannus was passed off table as a specimen. The wound was then made hemostatic with the use of electrocautery. JP drains were placed. The abdominal skin flap was then brought to the inferior skin flap and sutured in place with 2-0 Vicryl sutures at the dermal level. The drains were then secured, and then the skin was closed with running 3-0 Monocryl suture. The wound was further dressed with Steri-strips, gauze, and abdominal binder. The patient tolerated the procedure well. All needle and instrument counts at the end of the procedure were correct, and the patient was taken to PACU in good condition. Select the appropriate ICD-10-CM and CPT code(s):

Dr. Jones accompanied a newborn girl with respiratory failure who had been born 23 hours earlier from the community hospital to the university children's hospital. The ride takes 95 minutes. Dr. Jones provided critical care services to the infant during the ambulance ride. The patient was admitted to the neonatal ICU at the new facility. Select the appropriate CPT and ICD-10-CM codes.

An 81-year-old patient, Marge, fractured the proximal end head of her femur on Thanksgiving while standing and cooking dinner. She has a history of osteoporosis and received radiation therapy 3 years ago in this area for a thigh muscle tumor. She is going to surgery today for an open treatment of femoral fracture with internal fixation. Select the appropriate CPT and ICD-10-CM codes.