Exam 27: Coding and Surgical Procedures

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.

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

A patient underwent tympanoplasty with a mastoidectomy and ossicular chain reconstruction for removal of a cholesteatoma of the right ear Select the appropriate ICD-10-CM and CPT code(s):

A 72-year-old female presents to her PCP with complaints of a sore, swollen left ankle. The patient has severe osteoporosis and Type II diabetes and states that she "tripped last night on her way to the bathroom" and thinks she sprained her ankle. Her PCP orders an x-ray of her left ankle, and the report showed a pathologic closed fracture of the left lateral malleolus. Closed treatment of the lateral malleolus is performed by an orthopedic surgeon. Select the appropriate CPT and ICD-10-CM codes for the surgeon.

A 22-year-old patient presents to the physician's office with a migraine headache, stiff neck, and fever. Dr. Blue performs a lumbar puncture in the office and confirms the condition of meningitis. The patient tolerated the procedure well. Select the appropriate CPT and ICD-10-CM codes.

The patient presented in the emergency room with a sudden outbreak of lesions on the face, bilaterally on arms and legs, and groin after taking her prescribed sulfa drugs. Several of the lesions had to be shaved: 2 on the leg, one 1.4cm on the groin, and 3 close to the ear. The physician concluded that this was dermatitis. Select the appropriate CPT and ICD-10-CM codes.

The doctor performs removal of a complete cerebrospinal fluid shunt system; without replacement due to infection. Select the appropriate CPT and ICD-10-CM codes.

The surgeon performed endovascular repair on a patient with an aneurysm in the descending thoracic aorta under fluoroscopic guidance, which was directed separately by the radiologist. An endoprosthesis was placed as well as an extension to the origin of the celiac artery. Select the appropriate CPT and ICD-10-CM codes.

A patient is referred to the Radiology Department for a repeat gastric emptying study. This 63-year-old female has been diagnosed with dumping syndrome and her symptoms have worsened over the past two weeks, so her gastroenterologist has requested another study be done. Select the appropriate CPT and ICD-10-CM codes.

Jane, a 75-year-old female, was brought to the OR today for operative ablation of her paroxysmal atrial fibrillation via a combined Wolff-Parkinson-White atrio-ventricular node tissue ablation and reconstruction of the atria using the MAZE procedure. Cardiopulmonary bypass was not required. The patient tolerated the procedure well and was sent to ICU for continued monitoring. Select the appropriate CPT and ICD-10-CM codes.

A 45-year-old male with pancreatic cancer presents with a distended abdomen. The ultrasound reveals fluid in the peritoneal cavity. The patient undergoes a therapeutic paracentesis with ultrasound imaging guidance to drain the fluid. Select the appropriate ICD-10-CM and CPT code(s):

Sam, a welder, was seen today by the ophthalmologist for removal of a welding flash from his left eye. The flash had caused a nonperforating tear in the cornea. The ophthalmologist removed the flash and repaired the cornea. Select the appropriate ICD-10-CM and CPT code(s):

A totally electric hospital bed without a mattress had a power pressure-reducing air mattress supplied. What would be the appropriate HCPCS code(s)?

A 5-week-old infant suffering from dehydration and projectile vomiting is having a pyloromyotomy for infantile hypertrophic pyloric stenosis. Select the appropriate CPT and ICD-10-CM codes.

Tina, age 31, gravida 2, Para 1, is pregnant with twins and has been seeing Dr. Smidley. At 41 weeks she experiences labor and is taken directly to the hospital by her husband. After 14 hours of extremely hard labor the first twin is born; it is a male weighing 6lbs 3ozs. Dr. Petrowski, the attending OB-GYN, orders a cesarean section because the second twin is large for dates, causing cephalopelvic disproportion. The second twin, a female weighing 9lbs 2ozs, was delivered via C-section. Select the appropriate CPT and ICD-10-CM codes.

Gross Description: Specimen labeled "sesamoid bone, first metatarsal, right" is received in formalin. Contains three irregular fragments of grey-brown, hard, bony tissue. Multiple fragments of brown-tan, rubbery, fibrocollagenous, soft tissue altogether measuring 2.8 x 1.7 x 0.8 cm. Specimen was decalcified and gross examination showed acute osteomyelitis, with foci of marrow fibrosis. Select the appropriate CPT and ICD-10-CM codes.

A patient was referred by her primary care physician to a physical therapist due to cervical pain. The PT performs physical therapy evaluation of low complexity and applies heat packs, followed by 15 minutes of manual traction and mobilization. The patient will return 3 times a week for 3 weeks, at which time a re-evaluation will be performed. Select the appropriate CPT and ICD-10-CM codes.

What is a term for inflammation of the intestines?

The doctor performs median tarsorrhapy severing for left eye for a patient with conjunctival edema and mucopurulent discharge with corneal infiltrate. Select the appropriate CPT and ICD-10-CM codes.

A patient's family receives 30 minutes of family training and counseling. This training and counseling was done for child development purposes. Select the appropriate HCPCS Level II code.