Exam 27: Coding and Surgical Procedures

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 1-year-old patient has Down syndrome, complex heart disease consisting of atrioventricular septal defect and tetralogy of Fallot with pulmonary atresia, discontinuous pulmonary arteries and bilateral superior vena cava with a left cava draining to the coronary sinus and a right aortic arch. In this procedure, the septal defect was closed and both branches of the vena cava were anastomosed to the pulmonary artery. Select the appropriate CPT and ICD-10-CM codes.

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.

The patient underwent partial excision of the posterior C7 and L1 and L2 vertebrae to remove intrinsic bony lesions. Two surgeons worked simultaneously as primary surgeons to remove the lesions. Surgeon A removed the lesion at C7, and surgeon B removed the lesions at L1 and L2. Code the services of surgeon B with the appropriate ICD-10-CM and CPT code(s):

Patient underwent nasal endoscopy in the office of the ENT physician with removal of two pedunculated nasal polyps from the R nasal cavity. The patient tolerated the procedure well and was given an appointment to RTC in two weeks for follow up. Select the appropriate CPT and ICD-10-CM codes.

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.

Preoperative diagnosis: Carcinoma of the lung with right neck metastasis Postoperative diagnosis: Carcinoma of the lung with right neck metastasis Operative procedures: Cervical esophagoscopy, microlaryngoscopy, and biopsy Procedure and findings: With the patient under general anesthesia, the 10I 14 × 23 Roberts esophagoscope was passed. It was noticed that the left piriform sinus was of normal appearance. There was edema of the free tip of the epiglottis. The scope was advanced through the left piriform sinus into the cervical esophagus, and the cervical esophagus and postcricoid area were essentially normal. Also, the upper cervical esophagus was normal. The scope was slowly withdrawn through the right piriform sinus. It was noticed that there was a tumor involving the anterior wall of the right piriform sinus, extending approximately 1 cm below the pharyngeal epiglottic fold. This tumor then also involved the lateral hypopharyngeal wall to a minor degree. The scope was removed. The Dedo microlaryngoscope was passed. It was now noticed that the above findings were further defined. It was noticed that there was an exit through the tumor involving the vallecula on the right side going into the base of the tongue for a distance of approximately 0.5 cm. This tumor was quite exophytic, and it extended laterally above the pharyngeal epiglottic fold, extending, therefore, approximately 0.75 cm to the lateral hypopharyngeal wall. It also involved heavily the medial wall of the right piriform sinus without crossing over onto the laryngeal surface of the epiglottic fold. The vocal cords were of normal appearance. The right vocal cord was fixed in the midline. Inferiorly the tumor extended onto the medial wall of the piriform sinus just about 0.5 cm below the level of the right vocal cord. The scope was suspended. These findings were confirmed, and under 10 × magnification, several biopsies were obtained. The scope was removed. The neck was carefully palpated. The endoscopy had been preceded by a tracheostomy. The patient was initially prepared with Betadine solution and draped in the usual manner. A horizontal incision was made approximately 2 cm above the sternal notch and carried through the subcutaneous tissue down to the strap muscles. The strap muscles were divided in the midline. The cricoid cartilage was identified, the trach ties were tied securely into place, and the cuff was inflated to a comfortable pressure. The patient then received further ventilation through the newly placed trach tube. The patient tolerated all procedures well. Select the appropriate ICD-10-CM and CPT code(s):

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.

A 28-year-old patient was seen today for her annual physical exam by her OB/GYN. After discussion with the physician, the patient expressed her decision to have her IUD removed as she and her husband are ready to begin a family. This procedure was performed at this visit. Select the appropriate ICD-10-CM and CPT code(s):

A patient is placed on a ventilator as a result of a closed head injury with loss of consciousness due to a car accident. Select the appropriate CPT and ICD-10-CM codes for physician management on the initial and three subsequent days while the patient is in the hospital.

A patient was brought to the OR today for exploratory thoracotomy. Previous x-rays demonstrated a small foreign body in the pleural space. Exploration of the area revealed a small piece of shrapnel from a previous shooting accident. Under general anesthesia, the incision was made into the pleural space and the shrapnel was removed. Select the appropriate CPT and ICD-10-CM codes.

A 52-year-old patient was treated for endometriosis with ovarian and endometrial ablation. The surgeon inserted the endoscope through the vagina into the uterus to cauterize the endometrium. He then withdrew the endoscope, applied a new tip, and made three incisions on the lower abdomen. He inserted the endoscope to fulgurate the lesions on each ovary, withdrew the instrument, and closed with sutures. Patient tolerated the procedure well. Select the appropriate CPT and ICD-10-CM codes.

The maintenance of a stable internal physical state is

Preoperative diagnosis: Left hydrocele Postoperative diagnosis: Left hydrocele Procedure performed: Left hydrocelectomy Procedure description: The initial incision was made, and the left hydrocele was delivered out of the wound and incised. The hydrocele was emptied of about 500 mL and then incised completely. About 90% of the hydrocele sac was removed with the Bovie. The hydrocele sac was involuted and sewn to itself using running 3-0 Vicryl in the manner of Jaboulay. The testicle was replaced in the left scrotum, and the patient tolerated the procedure well. Select the appropriate ICD-10-CM and CPT code(s):

Smith works for "Doctors to You" and visits Jane, an established patient with this company, in her home. Jane is complaining of nausea, vomiting, and diarrhea for the past three days after eating tuna fish purchased from a local restaurant. After an expanded problem-focused interval history and expanded problem-focused examination, the diagnosis of food poisoning is made, and Jane is administered medication to treat the nausea and given instructions to prevent dehydration and reduce the diarrhea. Select the appropriate CPT and ICD-10-CM codes.

Which term is used in ICD-10-CM to describe a residual condition that occurs after the initial illness or injury?

10-year-old Susie Patterson had a fall and an injury occurred. She was taken to the emergency room, where the physician ordered an x-ray to be performed. The radiologist confirmed that she had a bimalleolar fracture. A temporary splint was applied, and she will follow up with the orthopedic specialist to obtain a permanent cast. Patient was discharged in stable condition. Identify the anatomic site of injury.

Dr. Green works for a house-call physician service. She was called to evaluate a new patient, an 88-year-old bedridden woman who has developed a painful rash on her posterior left side of the trunk, extending from C6 to C7 around the right side and ending midline on the anterior trunk just below the sternum. The physician performs a detailed history and a detailed examination and medical decision making is of low complexity. She diagnoses the patient with shingles. Select the appropriate codes.

June was admitted to the hospital with atrial fibrillation by her PCP, and cardiology was consulted at the time of admission. On the next day, the cardiologist made rounds and checked on Mary's progress. An expanded problem-focused interval history was obtained, and an expanded problem-focused exam was performed. Mary has been on IV therapy and is showing improvement. Select the code for the cardiologist encounter on the second day.

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.