Exam 27: Coding and Surgical Procedures

A patient presents to his physician today complaining of pain in the left gluteal area. The physician gathers an expanded problem-focused history and performs an expanded problem-focused examination and decision making of straightforward complexity, determining that the cause of the pain is an infected sebaceous cyst in this area. An incision and drainage of the cyst is performed. Select the appropriate ICD-10-CM and CPT code(s):

Preoperative Diagnosis: Right knee degenerative arthritis Postoperative Diagnosis: Same Operation Performed: Arthroscopic irrigation and debridement of same with partial synovectomy Estimated Blood Loss: Minimal Complications: None Description of Operation: The patient was placed on the table in supine position. The right lower extremity was prepped and draped without a tourniquet. The knee was injected with 30 mL of normal saline and standard arthroscopy portals were created. The arthroscopy was inserted and a complete diagnostic was performed. The knee was copiously irrigated with 9 L of irrigant. A partial synovectomy was performed in all compartments. Minimal amount of polyethylene wear was noted. The knee was then drained and the arthroscopic instruments were removed. The portals were closed with 4-0 nylon and local anesthetic was injected. A sterile dressing was applied; the patient was awakened from anesthesia and transported to the recovery room in stable condition. Select the appropriate CPT and ICD-10-CM codes.

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.

S: A 46-year-old male who was in a car accident presents for a prosthetic spectacle. O: HEENT is unremarkable. Monofocal measurements are taken, and data for the creation of an appropriate prosthesis are recorded. A: Aphakia, left eye. P: Return in 10 days for a final fitting. Select the appropriate ICD-10-CM and CPT code(s):

A condition brought on due to an abnormal accumulation of acidic products of metabolism such as happens in uncontrolled diabetes mellitus is known as

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.

A 62-year-old female patient with metastatic lung cancer reports to the infusion center for chemotherapy. She receives a subarachnoid injection consisting of doxorubicin, cyclophosphamide, and etoposide via a subcutaneous reservoir. Select the appropriate CPT and ICD-10-CM codes.

The Health Insurance Portability and Accountability Act of 1996 (HIPAA) was designed to do which of the following?

An 85-year-old male presented to the ED with symptoms of an ischemic stroke including L hemiparesis and dysarthria but no apparent cognitive decline. This patient presented with

Sally was seen today for repair of four lacerations following a fall on some broken glass. The physician evaluated and performed simple repair on the following: a 6-cm laceration on the right forearm, a 2.5-cm laceration on the right forearm, a 0.5-cm laceration on the left hand, and a 20-cm laceration on the left upper arm. Select the appropriate ICD-10-CM and CPT code(s):

Hemodialysis is used to treat

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):

Preoperative diagnosis: Left perihilar mass Postoperative diagnosis: Left perihilar mass, mucosal abnormality in the posterior subsegment of the left upper lobe Procedure performed: Bronchoscopy, transbronchial lung biopsy and bronchial lung biopsy, brushing and washing Assistant: None Anesthesia: MAC Description of procedure: With the patient in the supine position, under monitored anesthesia care, the scope was introduced through the mouth, and the larynx and the laryngeal area were inspected. All of them were normal. The scope was then inserted through the trachea into the carina, which was sharp and clear. There was a moderate amount of thick-thin secretions that were suctioned through both right and left main bronchi. The scope was then directed into the right main bronchus, and then the right upper-lobe bronchus with its subsegments was inspected. All of them were normal. Right middle-lobe and right lower-lobe bronchi with their subsegments were also inspected and were normal. The scope was then directed into the left side, where the left main bronchus was normal. Left lower-lobe and middle-lobe bronchi with their subsegments were normal. The left upper-lobe bronchus, anterosuperior segment, showed an anterior subsegment to have a bulging in one of its subbronchi. Under fluoroscopy, biopsy forceps were inserted, and several pieces of lung tissue were obtained from the area of the left perihilar lesion. Then brushing was done in the same area. Washing was also done in the same area. Then, in a separate container, several pieces of bronchial tissue were taken from the area that was bulging, anterosuperior subsegment of the left upper-lobe bronchus. All specimens were submitted for cytology, pathology, and/or culture. The patient tolerated the procedure well, with no apparent complications. Chest x-ray is pending. 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 54-year-old patient presents to his primary physician office for a preoperative evaluation for a bilateral vasectomy. The patient's past history consists of controlled diabetes with no other known conditions. Identify which physical status modifier will be used for the surgery.

A patient presents to his physician today complaining of pain in the left gluteal area. The physician gathers an expanded problem-focused history and performs an expanded problem-focused examination and decision making of straightforward complexity, determining that the cause of the pain is an infected sebaceous cyst in this area. An incision and drainage of the cyst is performed. Select the appropriate ICD-10-CM and CPT code(s):

ESWL was performed on Mrs. Wilson's left kidney 1 week ago; now ESWL is being performed on her right kidney. She has 4 stones being removed today: 2 in the renal pelvis and 2 in the calyx. Under local anesthesia, the ESWL is performed and all 4 stones are successfully destroyed. Select the appropriate CPT and ICD-10-CM codes.

A 76-year-old female was admitted for intravenous antibiotic therapy to treat pneumonia due to pseudomonas bacteria, and a level 3 initial inpatient visit was provided. On the second and third days, the patient had not yet responded to treatment, which was noted after an expanded problem-focused examination and interval history. On day 4, the patient showed significant improvement and the doctor recorded a problem-focused history and examination. On day 5, the patient was discharged home and the doctor spent 30 minutes in discharge day management. Select the appropriate CPT and ICD-10-CM codes for the physician visits.

Which of the following terms is not associated with a closed fracture?

A patient underwent a 2D echocardiogram including M-mode recording without color Doppler echocardiography for hemorrhagic pericarditis. The report was sent out for interpretation. Select the appropriate CPT and ICD-10-CM codes for the interpreting physician.