Exam 27: Coding and Surgical Procedures

The patient was diagnosed with Graves' disease and underwent a total thyroidectomy. Select the appropriate ICD-10-CM and CPT code(s):

The patient, who has complained of lower back pain and numbness of her legs, underwent an EMG of both legs with related spinal areas and 8 individual nerve conduction studies were performed. Interpretation and report revealed myelopathy. Select the appropriate CPT and ICD-10-CM codes.

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.

_____ is the ability of a tumor to invade surrounding tissue and spread to distant organs.

A proctosigmoidoscopy was performed to examine the sigmoid colon, rectum, and anal structure for pus in the stool and melena on a patient with a family history of carcinoma in the colon. During the procedure a biopsy of a lesion was also performed. The pathology report later came back with benign lesion. Select the appropriate CPT and ICD-10-CM codes.

Medicare patients should sign an ABN when

Bill was involved in a MVA. He was taken to the ED where the following was performed: A 3 cm simple repair of the left ear, an intermediate repair of the left thigh which was 7.8 cm, and an intermediate repair of the left calf muscle which was 2.0 cm. Select the appropriate CPT code(s) for the repairs only.

Procedure: Epididymectomy Preoperative diagnosis: Scrotal pain, right side Postoperative diagnosis: Scrotal pain, ride side Operation description: The patient was placed in the supine position and prepped and draped in the usual manner. A transverse scrotal incision was made and carried down to the tunica vaginalis, which was opened. The tunica vaginalis was opened and the testicle was brought out through this incision. The epididymis was separated off the surface of the testicle using a scalpel. With blunt and sharp dissection, the epididymis was dissected off the testicle. The vessels going to the testicle were preserved without any obvious injury, and a viable testicle was present after the epididymis was removed from this. The testicle was replaced in the scrotum. Skin was closed in two. A dry sterile dressing and compression were applied, and patient was sent to the recovery room in stable condition. 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 1-year-old has a nickel stuck in his esophagus found on x-ray. The doctor performs an esophagoscopy with use of balloon catheter to remove the nickel. Select the appropriate CPT and ICD-10-CM codes.

Jerry, an established patient, is seen today for evacuation of a subungual hematoma of his left index finger, sustained while hanging a picture. The physician performs a problem-focused history and problem-focused examination to evaluate the extent of the damage and determines that evacuation of the hematoma is needed. He then evacuates the subungual hematoma. Select the appropriate ICD-10-CM and CPT code(s):

Which of the following HCPCS modifiers is appropriate to report when a diagnostic mammogram is converted from a screening mammogram on the same day for the same patient?

The rapid discharge of menstrual blood between periods is called:

Dr. Willow is called in to administer general anesthesia to a 3-month-old female patient diagnosed with congenital tracheal stenosis. Dr. Gordon performs a surgical repair of her trachea. The patient is released to the recovery room staff in good condition. Select the appropriate ICD-10-CM and CPT code(s) for Dr. Willow:

A premature newborn is sent home with a recording apnea monitor. Select the appropriate CPT and ICD-10-CM codes for the monitor.

The patient, who has complained of lower back pain and numbness of her legs, underwent an EMG of both legs with related spinal areas and 8 individual nerve conduction studies were performed. Interpretation and report revealed myelopathy. Select the appropriate CPT and ICD-10-CM codes.

A patient underwent fine-needle aspiration of a thyroid cyst. Select the appropriate ICD-10-CM and CPT code(s):

A 3-year-old underwent plastic repair of her bilateral complete cleft lip. The CRNA was medically directed by the anesthesiologist. Select the appropriate CPT and ICD-10-CM codes.

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.

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.