Exam 27: Coding and Surgical Procedures

John, age 45, was seen in the office today for interim medical evaluation and management of his type II diabetes. The physician performed an expanded problem-focused history and examination. At the same visit, the physician also administered a flu shot, split virus 0.5ml, intramuscularly. Select the appropriate CPT and ICD-10-CM codes.

An 8-month-old male, in otherwise good health, was brought to the OR today for surgical repair of bilateral cryptorchidism. The anesthesiologist supervised the procedure. Select the appropriate CPT and ICD-10-CM codes.

Thoracic Aortogram with Cerebral Angiography History: The patient is an 82-year-old man with a thoracic aneurysm and carotid stenosis. Procedure: A 20-minute consultation was utilized explaining the risks, benefits, and alternatives of angiography. All the patient's questions were answered, and he had given informed consent prior to the procedure. The patient was premedicated with IM Demerol and Phenergan. Buffered lidocaine was used for local anesthesia. Sedation was not required. A 5-French pigtail catheter was advanced into the aorta via the right femoral artery with the standard Seldinger technique. With the tip of the catheter in the ascending aorta, an aortogram with digital subtraction technique was obtained in the left anterior projection. AP frontal view of the intracranial circulation was also obtained from an arch injection. The catheter was then exchanged over a guidewire for a 5-French Simmons II catheter. The carotid artery and left vertebral artery were selectively catheterized and injected with contrast for digital subtraction filming. In the right common carotid, it was initially difficult to get a stable catheter position, and various combinations of guidewires and a Simmons III catheter were used to obtain selective catheterization. After all images were reviewed, the catheter was removed, and direct pressure was applied to the puncture site until complete hemostasis was achieved. Total contrast load was 132 cc of Isovue. Fluoroscopy time was 41.5 minutes. Findings: The ascending aortic arch is dilated and has a more normal diameter just after the left subclavian catheter, and then the descending thoracic aorta enlarges again. There is no evidence of intimal dissection. The origins from the arch are patent. The right carotid bifurcation is slightly irregular; however, no hemodynamically significant stenosis is observed in the right internal carotid. The right external carotid is open. The left external carotid is completely occluded. The left internal carotid has 75% reduction of its cross-sectional area near its origin. On selective injections, it is interesting to note that the right anterior cerebral artery does not fill from the right carotid injection, but both anterior cerebral arteries fill from the left carotid injection. Vertebral arteries are patent. The left vertebral artery is larger. No obvious intracranial abnormality is observed. Impression: There is 75% stenosis of the left internal carotid. Complete occlusion of the left external carotid. Very mild irregularity of the right internal carotid. Widely patent right external carotid. Both vertebral arteries are patent. Select the appropriate ICD-10-CM codes.

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.

The patient undergoes excision of a lacrimal sac, left eye for a mucocele and acute dacryocystitis. Select the appropriate CPT and ICD-10-CM codes.

Dr. Mathis has been called to the ICU to provide care for a 37-year-old male patient who has received second-degree burns over 50% of his body. Dr. Mathis provides support from 1 p.m. to 3 p.m. After leaving the unit to do his rounds, Dr. Mathis is called back around 5 p.m., and he provides critical care support to the patient until 6 p.m. Select the appropriate CPT codes.

A patient with morbid obesity presents for laparoscopic revision of a previous gastro-restrictive procedure. Select the appropriate ICD-10-CM and CPT code(s):

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.

A recording of the electrical activity of the brain is a(n)

The ______ consists of specialized heart muscle cells that conduct electrical impulses from the AV node to the ventricles.

Preoperative Diagnosis: Gallstones Postoperative Diagnosis: Cholelithiasis Operation: Cholecystectomy Operation Description: A 52-year-old patient is diagnosed with gallstones. The patient was consulted by the surgeon and it was recommended that a cholecystectomy be scheduled. Patient reviewed the risks and the consent was signed. The procedure went well and the patient left to the recovery room in good condition. Select the appropriate CPT and ICD-10-CM codes.

Preoperative Diagnosis: ear infection Postoperative Diagnosis: otitis media Operation: Tympanostomy of the right ear Operation Description: A 9-month-old male was diagnosed with chronic ear infections, which keep occurring and resulted with otitis media. The risks of the operation, such as infection, hearing loss, and bleeding, were discussed. The parents understood all risks and wanted to proceed with the operation. Consent was obtained. The patient was prepped and draped in the usual sterile fashion in the operating room. General anesthesia was then administered to the patient. An incision to the tympanic membrane was completed to relieve pressure and fluid from the middle ear. A small tube was then inserted through the tympanic membrane to the middle ear to assist with pressure. The patient was in good stable condition and brought to the recovery room. Select the appropriate CPT and ICD-10-CM codes for the anesthesiologist.

Derek is here today for open tendon surgery in his right shoulder due to a ruptured rotator cuff. Under general anesthesia an incision of 5cm was made in the shoulder. All loose fragments of tendon, bursa, and other debris were removed. There was some subacromial smoothing to make room for the tendon. The tendon was properly placed and the incision was sewn with 5.0 vicryl. The patient tolerated the procedure well and was sent to the floor. Select the appropriate CPT and ICD-10-CM codes.

A 53-year-old male has been plagued by intermittent severe pain caused by his trigeminal neuralgia which interferes with his common daily activities. He has developed sleep deprivation, depression, and loss of appetite. Today he presents for destruction of the trigeminal nerve by neurolytic agent. Select the appropriate CPT and ICD-10-CM codes.

Clinical history: Shortness of breath - crackles and change in sound in base of lungs. Study performed: Chest X-ray, PA and lateral. Impression: Poor inspiratory effort which accentuates the basilar lung markings and cardiac silhouette, partially limiting evaluation. Small vertically oriented linear infiltrate subsegmental atelectasis is noted in the L retrocardiac region adjacent to the diaphragm. There is minimal hazy increased density and decreased definition in the L costophrenic angle suggesting pleural effusion. Segmental atelectasis and some pleural effusion. Select the appropriate CPT and ICD-10-CM codes.

A patient is in the office today for application of an external auto-activated ECG rhythm derived recorder for previously diagnosed syncope and palpitations not evidenced on a Holter Monitor. The patient is scheduled to wear this device for 30 days. This process will include a review and interpretation by the physician. Select the appropriate CPT and ICD-10-CM codes.

Which of the following is not a layer of membrane surrounding the brain and spinal cord?

Which of the following must the coder be able to do, in order to accurately translate provider documentation?

Which is NOT an appropriate step in determining an ICD-10-CM code?

Preoperative Diagnosis: thoracoabdominal aortic aneurysm Postoperative Diagnosis: same Operative Procedure: Patient placed on bypass pump after which the surgeon repaired the aneurysm using a graft. Select the appropriate CPT and ICD-10-CM codes.