Exam 27: Coding and Surgical Procedures

Jones is in the operating room today for repair of a nontraumatic tear of the rotator cuff of the right shoulder. The physician performs an arthroscopy subacromial decompression with an open repair of the rotator cuff. 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.

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.

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 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.

A 49-year-old patient has arthritis of the right and left knee with ongoing pain and swelling. The physician performed an arthrocentesis for the patient's condition. Patient was prepped and fluid withdrawn from the left knee joint. The patient tolerated the procedure well and was instructed to return for a follow up visit in one week to aspirate the right knee joint. Select the appropriate CPT and ICD-10-CM codes.

A 32-year-old female was diagnosed with premature menopause that is symptomatic of ovarian failure and is experiencing headaches, flushing, and night sweats. Select the correct ICD-10-CM code(s):

Steve presents today for an epidural injection of a steroid, caudal to relieve his low back pain, radiating leg pain, and coccygodynia. Steve is placed in a prone position with a cushion below his stomach to arch his back. Local anesthetic is applied to numb the skin and tissue down to the surface of the sacral hiatus. After the needle is placed in the area, 1.5cm of contrast solution helps the physician see painful areas under fluoroscope. The steroid is injected in the epidural space. The needle is removed, bandage applied, and the patient is sent home. Select the appropriate CPT and ICD-10-CM codes.

The patient was seen by a psychiatrist for post-traumatic stress disorder. This visit was a psychiatric diagnostic evaluation which included a history, mental status examination, and recommendations. The evaluation and treatment plan were communicated to the family as the patient has requested their involvement in his care. Select the appropriate CPT and ICD-10-CM codes.

A physician who is a member of a family practice group treats a patient for a sprained ankle. Two years later, a different physician from the same group practice sees the same patient for a knee injury. According to CPT definitions, this patient would be considered:

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.

A 36-year-old female who was the driver in a car accident presented with whiplash for chiropractic manipulative treatment of her cervical spine. The chiropractor provided a complete history and examination prior to the treatment plan of one visit a week for 2 months, at which point her status will be reevaluated. Today the first manipulation was performed. Select the appropriate ICD-10-CM and CPT code(s):

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):

Anesthesia was provided for a 75-year-old patient who was having a biopsy performed on the salivary gland to determine the nature of a mass. He also had chronic essential benign hypertension. Select the appropriate CPT codes for the anesthesia service, as well as the ICD-10-CM codes.

The small air-filled cavity that contains the ossicles is the

Jane Smith, a 54-year-old female, was diagnosed with gallstones. She was admitted for an outpatient procedure of a cholecystectomy to be performed. Due to safety reasons of the patient, the laparoscopic procedure became an open session in which the gallbladder was removed. The patient was admitted and left the hospital in three days in good recovery. Select the appropriate CPT and ICD-10-CM codes.

Procedure performed: Fiber-optic bronchoscopy, bronchial biopsy, bronchial washings, and bronchial brushings Preprocedure diagnosis: Abnormal chest x-ray Postprocedure diagnosis: Inflammation in all lobes, pneumonia; with pleural placquing? consistent with possible candidiasis The patient was already on a ventilator, so the bronchoscope tube was introduced through the ET tube. We saw 2.5 cm above the carina of the trachea, which was red and swollen as was the carina. The right lung: All entrances were patent, but they were all swollen and red, with increased secretions. The left lung was even more involved, with more swelling and more edema and had bloody secretions, especially at the left base. This area from the carina all the way down to the smaller airways on the left side had shown white placquing consistent with possible candidiasis. These areas were brushed, washed, and biopsied. A biopsy specimen was also sent for tissue culture, as well as two biopsy specimens sent for pathology. Sheath brushings were also performed. The patient tolerated the procedure well and was sent back to the ICU. Select the appropriate ICD-10-CM and CPT code(s):

Which term pertains to the heart muscle?

Preoperative Diagnosis: Rectum Pain Postoperative Diagnosis: Perirectum abscess Operation: Incision and drainage of abscess Operation Description: A patient was admitted for rectum pain. Patient consented to the surgery. Patient was prepped and draped in the usual manner. General anesthesia was administered. The anus was dilated with two fingers at which time the speculum was introduced. The submucosal abscess was identified, incised, drained, then irrigated. Area was packed with gauze and patient went to the recovery room in stable condition. Select the appropriate CPT and ICD-10-CM codes.

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.