Exam 27: Coding and Surgical Procedures

Preoperative Diagnosis: Tonsillitis Postoperative Diagnosis: Tonsillitis Operation: Tonsillectomy Anesthesia: General Operation Description: A 12-year-old patient is diagnosed with tonsillitis and was recommended to have a tonsillectomy. Family consented to the surgery and patient was admitted. Patient was positioned supine for the procedure. The right and the left tonsils were removed. The tonsillar area was irrigated. There was no bleeding before or after the suturing. The patient tolerated the procedure well. Select the appropriate CPT code for the anesthesia service, as well as the ICD-10-CM code.

Procedure: Debridement of 2nd degree burn, 200cm of right hand and wrist, excisional debridement of 3rd degree burns to 10% of the abdomen and 13% of the back. General anesthesia was achieved and the patient was placed in the right lateral decubitus position. The left hip and lower back as well as the abdomen and right upper extremity were prepped and draped with Betadine. The 2nd degree blisters were completely debrided off all of the fingers and the hand. The area was then scrubbed thoroughly with a scrub brush, bleeding was controlled with a saline epinephrine soak, and the hand was thoroughly dried. A large biobrane glove was stretched over the hand and held in place at the wrist with staples. The ellipsis was drawn around the skin transversely at both the lower back as well as the abdomen. These areas were then excised with a number 10 blade. The burns were scrubbed and dressed with biobrane. Select the appropriate CPT and ICD-10-CM codes.

An 18-year-old female weighing 485 lbs. is presenting today for a laparoscopic gastric bypass and roux-en-y gastroenterostomy for morbid obesity. Since the patient has a BMI of 73.7, the gastroenterologist feels it is necessary to remove at least 175cm. Select the appropriate CPT and ICD-10-CM codes.

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.

Dr. Helter, a gastroenterologist, is placing a feeding tube for a patient with gastroparesis in the outpatient surgery department of Community General Hospital. After the long gastrointestinal tube feeding tube was inserted, a KUB was done to verify the position in the duodenum. Select the appropriate CPT and ICD-10-CM codes.

A colposcopy is performed on patient, age 42, for cervical dysplasia. The pathology report later showed the specimen was negative for carcinoma. Select the appropriate CPT and ICD-10-CM codes.

Dr. Steele ordered the following lab tests to be performed: calcium ionized, carbon dioxide, chloride, creatinine, glucose, potassium, sodium, urea nitrogen (BUN) and an automated urinalysis with microscopy. Select the appropriate CPT code(s):

Pam presents at her podiatrist office for a right great toenail removal due to an ingrown nail. The podiatrist did a permanent removal of the distal half of the right great toenail. Select the appropriate CPT and ICD-10-CM codes.

Surgical removal of a lobe of the lung is a:

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.

An example of an opiate used to reduce physical pain and anxiety is

The rapid discharge of menstrual blood between periods is called:

After a work-related accident, a drug screen was performed to determine the presence of alcohol, marijuana, opiates, barbiturates, or amphetamines in the patient's system. A multiplexed screening kit was used and one procedure was performed. All tests were negative. Select the appropriate CPT and ICD-10-CM codes.

History: A 73-year-old 81-kg male with a history of non-Hodgkin's lymphoma and moderate in situ adenocarcinoma of the prostate presents for transurethral resection of the prostate (TURP). The preoperative evaluation reveals a history of smoking (60 pack-years), normal ejection fraction and heart valves, and normal chest x-ray and EKG. No other significant findings. Procedure: He was taken to the operating room and monitored as per routine for cystoscopy and TURP. After appropriate preoxygenation, general anesthesia was uneventfully induced with fentanyl, propofol, and rocuronium. The patient was intubated, ventilated, and placed in the lithotomy position. The operative procedure was started without difficulty. After 90 minutes, the patient's temperature had dropped from 35.9°C at the beginning of the case to 32.9°C. Blood was sent to the lab due to the length of the surgery. The patient's vital signs were stable. Shortly thereafter the following values were sent back from the laboratory to the operating room: NA 109 mEq/L, K 4.7 mEq/L, CL 83 mEq/L, Glucose 83 mg/dl, Hct 34. The anesthesiologist informed the surgeon about the findings, and the surgery was then stopped. The patient was transferred to the surgical intensive care unit (SICU). At arrival in the SICU: The patient was still intubated and sedated. The body temperature was 33.5°C. The laboratory measurements revealed NA 107 mEq/L, K 5.7 mEq/L, CL 79 mEq/L, CO2 109 mEq/L, ammonia level of 60 mmol/L, and serum osmolarity of 273. A radial arterial catheter and a central venous catheter were inserted, and rewarming with hot air (Bair Hugger) was initiated. Select the appropriate ICD-10-CM and CPT code(s):

A patient had atherosclerosis of the native first obtuse marginal artery and the native left anterior descending artery as well as aortic valve stenosis. While on cardiopulmonary bypass, he underwent an aortic valve replacement using a mechanical valve and two-vessel coronary artery bypass grafting procedure. The saphenous vein was used for the graft to the first obtuse marginal artery and the left radial artery was used for the graft to the left anterior descending artery. Select the appropriate CPT and ICD-10-CM codes.

George, a 73-year-old male, is hospitalized for epileptic seizure disorder. He experiences anoxic brain damage, and anesthesia was called to insert the endotracheal tube in order to put the patient on the ventilator. Select the appropriate CPT and ICD-10-CM codes for the anesthesiologist.

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.

What is the ICD-10-CM term for the character used to extend codes through the sixth character, allowing the seventh-character extender to remain in place? This character is represented by an "x" and is known as:

A patient undergoes single stage reconstruction of the right external auditory canal for congenital atresia. Select the appropriate CPT and ICD-10-CM codes.

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):