Exam 27: Coding and Surgical Procedures

Preoperative Diagnosis: Advanced primary open angle glaucoma, right eye, with related cortical cataract, right eye. Procedure: Trabeculectomy. Phacoemulsification and posterior chamber IOL insertion. Postoperative Diagnosis: Advanced primary open angle glaucoma, right eye, with related cortical cataract, right eye. Operation: The patient was brought in to the operating room on an eye stretcher and placed in the supine position. A peribulbar block using an equal concentration of 2% lidocaine and 0.5% Marcaine was administered and the right eye was draped and prepped in the usual sterile ophthalmic fashion and the microscope was brought in position. We placed a Lieberman lid speculum between the lid fissures on the right eye, then placed a superior rectus bridle suture to stabilize the eye. We created a superior peritomy using Vannas scissors and Bishop forceps. Next we used the cautery to outline a 3x4mm rectangular scleral flap. After applying mitomycin 0.2 mg/mL to the sclera and conjunctiva for two minutes per the clock, I thoroughly irrigated the area with saline. I then dissected the scleral flap using a #68 Beaver blade. I created a 2.70mm incision on the cornea under the scleral flap using a standard blade and created a primary posterior capsulorhexis using a cystotome and forceps. Hydrodissection of the lens nucleus was performed, then we did the phacoemulsification without difficulty and the area was irrigated with saline and the cortical remnants removed. We inserted an AcrySof® Aspheric IOL Model SN60WF +25 into the capsular sac and centered it without difficulty. We then created the internal sclerostomy under the scleral flap, measuring 1x2.5mm. We removed the limbal material with a Kelly punch. Next we created a peripheral iridectomy using Dewecker scissors and closed the scleral flap using 5 interrupted 10-0 nylon sutures, being attentive to carefully control the tension. When the tension allowed egress of aqueous, we tied off and buried the sutures. We reapproximated the conjunctival flap and suture it into position using 9-0 nylon mattress sutures and 8-0 Vicryl running sutures. We checked intraolcular pressure manually with a cannula and it was within normal limits. We applied Gentamicin 20 mg under the conjunctiva and erythromycin on the conjunctiva. We removed the lid speculum, closed the eyelids and placed a patch and shield over the eye. The patient tolerated the procedure well and was transferred to recovery in good condition. Select the appropriate CPT and ICD-10-CM codes.

A 76 year old female is admitted for IV antibiotic therapy to treat pneumonia due to pseudomonas bacteria and a level 3 initial inpatient visit was provided. On days 2 and 3, the patient had not yet responded to treatment as noted after an expanded problem-focused exam and history. On day 4, the patient showed significant improvement and the physician recorded a problem-focused history and exam. On day 5, the patient was discharged to home and the physician spent 30 minutes in discharge day management. Select the appropriate CPT codes for the physician visits from the admit to the discharge.

A 36-year-old patient is currently diagnosed with glaucoma and is having occurrences of blurry vision. The patient had a gonioscopy performed to determine the type of glaucoma. The physician has determined that the type is open angle. The patient tolerated the procedure well in the outpatient hospital setting and was sent home in good condition. Select the appropriate CPT and ICD-10-CM codes.

The patient undergoes simple mastectomy today for adenocarcinoma of the R breast. While the patient was still on the table, and immediately after the removal of the breast, the patient received a concentrated dose of radiation to the tumor site using IORT electron methodology. Select the appropriate CPT and ICD-10-CM codes.

A 54-year-old patient presented to the emergency room with a gunshot wound in the back exiting through the front. A CT scan shows some renal damage to the right kidney and a renal exploration is ordered. The surgeon has been called in and the patient is taken to surgery to examine the renal structure. Making an incision over the gunshot wound, the surgeon examines both the blood vessels and the kidney. The trauma has caused a hematoma to the kidney, which has not spread, so the surgeon closes and the patient is sent to the floor for observation. Select the appropriate CPT and ICD-10-CM codes.

What is the surgical term for removal of the lymph nodes or a group of lymph nodes?

Repair incomplete unilateral cleft lip with a cross lip pedicle flap. Select the appropriate CPT and ICD-10-CM codes.

A nonhealing burn should be coded as which type of burn?

The patient was seen for complaints of persistent cluster headaches and blurring vision. As part of the workup, a lumbar puncture was performed, the pressure of the spinal fluid was measured, and some fluid was removed for analysis. Select the appropriate ICD-10-CM and CPT code(s):

Clinical history: Shortness of breath - crackles and change in sound in base of lungs. Study performed: Chest X-ray, PA and lateral. Impression: Poor inspiratory effort which accentuates the basilar lung markings and cardiac silhouette, partially limiting evaluation. Small vertically oriented linear infiltrate subsegmental atelectasis is noted in the L retrocardiac region adjacent to the diaphragm. There is minimal hazy increased density and decreased definition in the L costophrenic angle suggesting pleural effusion. Segmental atelectasis and some pleural effusion. Select the appropriate CPT and ICD-10-CM codes.

Bilateral Doppler Study: Carotid Arteries Indications: Status post-carotid endarterectomy imaging. The patient states that he was told that the right carotid artery is blocked. The right internal carotid artery is not identified, probably completely blocked. Velocity measurements on the right side: Common carotid artery: 58.9 cm/sec Right external carotid: 142 cm/sec Right vertebral: 44 cm/sec and showing antegrade flow Velocity measurements on the left side: Common carotid artery: 35 cm/sec Carotid bulb: 60 cm/sec Internal carotid: 52 cm/sec External carotid: 236 cm/sec Left vertebral: 55 cm/sec Status postendarterectomy changes are noted in the left internal carotid and the bulb. There is evidence of ectasia. On the right, the common carotid artery shows ectasia. Judging from the velocity measurements, the right internal carotid artery has a stenosis in the range of 50% to 79%. The left internal carotid artery has a stenosis in the range of 16% to 49%. The left external carotid artery is in the range of 50% to 79%. Impression: The right internal carotid artery is completely occluded. Status postendarterectomy changes in the left internal carotid and the bulb are noted. No significant occlusive disease is seen in the left internal carotid artery. Both vertebral arteries are showing antegrade flow. Select the appropriate ICD-10-CM and CPT code(s):

A patient had atherosclerosis of the native first obtuse marginal artery and the native left anterior descending artery as well as aortic valve stenosis. While on cardiopulmonary bypass, he underwent an aortic valve replacement using a mechanical valve and two-vessel coronary artery bypass grafting procedure. The saphenous vein was used for the graft to the first obtuse marginal artery and the left radial artery was used for the graft to the left anterior descending artery. Select the appropriate CPT and ICD-10-CM codes.

A 45-year-old patient with BCBS is seen by a consultant at the request of her internal medicine physician for opinion and management recommendations regarding her subacute bronchitis. The consultant performs a comprehensive history and exam with decision making of moderate complexity. He returns the patient to her primary physician and sends a report discussing his findings and recommendations. Select the appropriate CPT and ICD-10-CM codes.

A premature newborn is sent home with a recording apnea monitor. Select the appropriate CPT and ICD-10-CM codes for the monitor.

Procedure: Epididymectomy Preoperative diagnosis: Scrotal pain, right side Postoperative diagnosis: Scrotal pain, ride side Operation description: The patient was placed in the supine position and prepped and draped in the usual manner. A transverse scrotal incision was made and carried down to the tunica vaginalis, which was opened. The tunica vaginalis was opened and the testicle was brought out through this incision. The epididymis was separated off the surface of the testicle using a scalpel. With blunt and sharp dissection, the epididymis was dissected off the testicle. The vessels going to the testicle were preserved without any obvious injury, and a viable testicle was present after the epididymis was removed from this. The testicle was replaced in the scrotum. Skin was closed in two. A dry sterile dressing and compression were applied, and patient was sent to the recovery room in stable condition. Select the appropriate CPT and ICD-10-CM codes.

Preoperative Diagnosis: Knee pain Postoperative Diagnosis: Juvenile Arthritis of the knee Operation: Arthroscopy of the right knee Operation Description: A 33-year-old patient was diagnosed with right knee pain. Patient is admitted to have an arthroscopy of the right knee. The risks were discussed with the patient and consent obtained. Select the appropriate CPT code for the anesthesia service, as well as the ICD-10-CM code.

Clinical history: Shortness of breath - crackles and change in sound in base of lungs. Study performed: Chest X-ray, PA and lateral. Impression: Poor inspiratory effort which accentuates the basilar lung markings and cardiac silhouette, partially limiting evaluation. Small vertically oriented linear infiltrate subsegmental atelectasis is noted in the L retrocardiac region adjacent to the diaphragm. There is minimal hazy increased density and decreased definition in the L costophrenic angle suggesting pleural effusion. Segmental atelectasis and some pleural effusion. Select the appropriate CPT and ICD-10-CM codes.

An established patient presents to the office with an acute, deep cough, along with wheezing. The patient has a history of allergies along with chronic rhinitis. After an expanded problem-focused exam, the physician learns that the patient's home has just been found to have mold in the walls. The physician has spent an additional 15 minutes providing resources and counseling with the patient regarding the effects of mold and treatment of his URI. The physician has also recommended lab tests and x-rays. Select the appropriate CPT and ICD-10-CM codes.

Preoperative Diagnosis: Thyroid goiter. Postoperative Diagnosis: Thyroid goiter. Procedure Performed: Total thyroidectomy. Indications: The patient is a 45-year-old female with Graves' disease. Suppression was attempted but unsuccessful. She presents today with her thyroid goiter. A thyroidectomy was indicated at this time secondary to the patient's chronic condition. A full informed consent was obtained. Procedure: The patient was brought back to surgical suite and given IV access and general endotracheal anesthesia. A 9 cc of 1% lidocaine with 1:100,000 of epinephrine was infiltrated into the area of pre-demarcated above the suprasternal notch. The patient was then prepped and draped in the normal sterile fashion. A #10 blade was then utilized to make an incision in the pre-demarcated and anesthetized area. Unipolar electrocautery was utilized for hemostasis. Finger dissection was carried out in the superior and inferior planes. Platysma was identified and dissected and a subplatysmal plane was created in the superior and inferior, medial and lateral directions. The strap muscles were identified. The midline raphe was not easily identifiable at this time. An incision was made through what appeared to be in the midline raphe and dissection was carried down to the thyroid. Sternohyoid and sternothyroid muscles were identified and separated on the patient's right side and then subsequently on the left side. It was noted at this time that the thyroid lobule on the right side is a bi-lobule. Kitner blunt dissection was utilized to bluntly dissect the overlying thyroid fascia as well as strap muscles off the thyroid, in the lateral direction. This was carried down to the inferior and superior areas. The superior pole of the right lobule was then identified. A hemostat was placed in the cricothyroid groove and the superior pole of the right thyroid was retracted inferiorly. Careful dissection was then carried out in the superior lobe and identified the appropriate vessels and cauterized with bipolar or ligated with the suture ligature. The superior pole was identified. Dissection was then carried down again bluntly separating the inferior and superior lobes. The bilobed right thyroid was then retracted medially. The recurrent laryngeal nerve was then identified and tracked to its insertion. A right dissection was performed to remove the fascial attachments superficial to the recurrent laryngeal nerve. This lobule was then removed from Berry's ligament. There was noted to be no isthmus at this time and the entire right lobule was then sent to pathology for evaluation. Attention was then directed to the patient's left side. In a similar fashion, the sternohyoid and sternothyroid muscles were separated. Blunt dissection was carried out laterally to superiorly once again. A careful dissection was utilized to identify the appropriate structures in the superior pole of the left thyroid and suture ligature as well as bipolar cautery was utilized for hemostasis. Once again, careful attention was made not to injure the nerve in this area. The superior pole was then freed appropriately and blunt dissection was carried down to lateral and inferior aspects. The inferior aspect was then identified. The inferior thyroid artery and vein were then identified and ligated. The left thyroid was then medialized and the recurrent laryngeal nerve was identified. Dissection was then carried out to remove the fascial attachments superficial to the recurrent laryngeal nerve on the side as close to the thyroid gland as possible. The thyroid was then removed from the Berry's ligament and it was then sent to pathology for evaluation. The patient tolerated the procedure well and was transferred to recovery in stable condition. Select the appropriate CPT and ICD-10-CM codes.

Electrical stimulation and ultrasound to aid bone healing are included in which of the following codes?