Exam 27: Coding and Surgical Procedures

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.

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:

Preprocedure diagnosis: Lumbar radiculopathy Postprocedure diagnosis: Lumbar radiculopathy Procedure performed: Lumbar epidural steroid injection Anesthesia given: Local Indications for procedure: This 53-year-old female presents with symptoms consistent with a lumbar radiculopathy. Previous epidural steroid injections have resulted in significant improvement of her pain. This is the second in a series of three of those injections. Description of procedure: The patient was placed in the left lateral decubitus position. The L4-5 interspace was identified with deep palpation. Local infiltration was carried out with 3 cc of 1% lidocaine. The area was prepped and draped in the usual sterile fashion. An 18-gauge Tuohy needle was advanced to the epidural space with the loss-of-resistance technique. Then a mixture of Depo-Medrol 80 mg, normal saline 10 cc, and lidocaine 1% at 5 cc was injected. No complications were encountered, and the patient was returned to the outpatient surgery department in stable condition. Plan: To repeat this procedure in two weeks Select the appropriate ICD-10-CM and CPT code(s):

With the patient under general anesthesia, the ENT used a surgical microscope to perform a myringotomy to release pressure and a tympanoplasty to repair the perforated eardrum of a 6-year-old boy with chronic ear infections who stuck the end of his glasses in his ear. Select the appropriate CPT and ICD-10-CM codes.

Patient undergoes a uterine evacuation and curettage for a hydatidiform mole and severe vaginal bleeding, which is complicated by a urinary tract infection caused by E. coli. Select the appropriate CPT and ICD-10-CM codes.

Specimen site: Right medial cheek Specimen site: Left dorsal hand Gross description: Right medial cheek: The specimen is one gray-white fragment measuring 0.3 × 0.2 cm. Totally submitted in one cassette with a request for levels labeled "A." Left dorsal hand: The specimen is one gray-white fragment measuring 0.3 × 0.3 cm. Totally submitted in one cassette with a request for levels labeled "B." Microscopic description: The right medial cheek shows atypical keratinocytes within the entire thickness of the epidermis extending to the stratum corneum. The lesion appears to have been excised. The dermis shows elastosis. The dorsal hand shows hyperkeratosis. The epidermis is mildly acanthotic. There is extensive dermal elastosis. Final diagnoses: 1) Right medial cheek, biopsy: ? Squamous cell carcinoma in-situ. (See comment.) 2) Left dorsal hand, biopsy: ? Dermal elastosis. ? No malignant changes seen. Comment: The lesion from the cheek appears to reside within the confines of the histologic section. The skin lesion shows no invasive malignancy. Select the appropriate ICD-10-CM and CPT code(s):

A 38-year-old insulin-dependent established patient called his physician complaining of having some rectal bleeding after using the bathroom. The physician agreed to meet the patient in the outpatient department of the hospital. The physician performed an expanded problem-focused history with a detailed examination. The patient is to have blood work and a stool culture and is to be scheduled for a lower GI series. The physician's diagnosis was Hematochezia etiology unknown. 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.

Joey, a 5-year-old boy, was seen today for immunizations prior to beginning school. After counseling by the PA, he received diphtheria, tetanus toxoid, acellular pertussis, haemophilus influenza Type B, and polio virus as a single injection. Additionally, he received MMRV subcutaneously. Select the appropriate CPT and ICD-10-CM codes.

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.

Jeremy presented to the ED complaining of severe odynophagia after eating chicken wings. Upon initial x-rays, no perforation of the esophagus was noted. The gastrointestinal specialist was called, and the patient was taken to the endoscopy suite. There, with the patient under moderate sedation, the gastroenterologist performed an esophagoscopy and removed a small chicken bone lodged in the esophagus above the diaphragm. Select the appropriate ICD-10-CM and CPT code(s):

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):

Procedure: Debridement of 2nd degree burn, 200cm of right hand and wrist, excisional debridement of 3rd degree burns to 10% of the abdomen and 13% of the back. General anesthesia was achieved and the patient was placed in the right lateral decubitus position. The left hip and lower back as well as the abdomen and right upper extremity were prepped and draped with Betadine. The 2nd degree blisters were completely debrided off all of the fingers and the hand. The area was then scrubbed thoroughly with a scrub brush, bleeding was controlled with a saline epinephrine soak, and the hand was thoroughly dried. A large biobrane glove was stretched over the hand and held in place at the wrist with staples. The ellipsis was drawn around the skin transversely at both the lower back as well as the abdomen. These areas were then excised with a number 10 blade. The burns were scrubbed and dressed with biobrane. Select the appropriate CPT and ICD-10-CM codes.

The physician performed a screening colonoscopy and removed 2 polyps using a snare. Select the appropriate CPT and ICD-10-CM codes.

George, a 73-year-old male, is hospitalized for epileptic seizure disorder. He experiences anoxic brain damage, and anesthesia was called to insert the endotracheal tube in order to put the patient on the ventilator. Select the appropriate CPT and ICD-10-CM codes for the anesthesiologist.

A patient presented to the oncology clinic with a diagnosis of testicular tumor of uncertain behavior. The patient brought slides from his orchiectomy which was sent to the pathologist for review and report including a review of the medical records with written report confirming a diagnosis of testicular carcinoma. Select the appropriate CPT and ICD-10-CM codes.

Mr. 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 55-year-old established female patient was seen for management of uncontrolled diabetes due to taking oral corticosteroids for rheumatoid arthritis. She reported elevated glucose readings of 180, 210, 195, and 205 in recent weeks. The physician performed a brief history to update her record since the last visit, a detailed examination, and medical decision making of high complexity. He counseled the patient on diet and lifestyle factors and prevention of serious diabetic manifestations. He decided to start her on insulin to see how she responds. Select the appropriate CPT and ICD-10-CM codes.

Clinical diagnosis: Cholecystitis and Chronic Calculi Operation: Cholecystectomy Specimen: Gall bladder Pathology Report: Microscopic analysis of specimen measuring 9.0 X 3.0cm. Diagnosis: Chronic cholecystitis, cholelithiasis Select the appropriate CPT and ICD-10-CM codes.

Sally is a long-term alcoholic who has made the decision to receive treatment for her disease. However, before beginning her psychotherapy, Sally is required to undergo a behavioral health screening and alcohol assessment. Select the appropriate CPT and ICD-10-CM codes for these two procedures.