Exam 27: Coding and Surgical Procedures

An 11-year-old boy is brought to the ED with fever, malaise, and a stiff neck. The ED physician performs a spinal tap to R/O meningitis. The patient is admitted to University Hospital to further monitor his status. Later during the evening, the boy complains of a severe headache along with a "runny nose". The physician orders a nuclear medicine study to detect CSW fluid leakage and localization. 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.

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.

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.

A 48-year-old female comes to her physician for aspiration of her right ring finger where fluid has accumulated due to a past injury of that finger and she continues to have pain. The physician performs arthrocentesis and follows up with an injection of steroid in the same joint. Select the appropriate CPT code.

An 8-month-old male, in otherwise good health, was brought to the OR today for surgical repair of bilateral cryptorchidism. The anesthesiologist supervised the procedure. Select the appropriate CPT and ICD-10-CM codes.

Patient Susie Jones, a 32-year-old female, was admitted to the intensive care unit for acute respiratory distress syndrome. She was given critical care services by her provider Dr. Mark Smith for an hour and twenty minutes. Select the appropriate CPT and ICD-10-CM codes.

The patient underwent a hemorrhoidectomy for removal of two columns of prolapsed internal hemorrhoids, third-degree, and resolution of a chronic anal fissure-fissurectomy. Select the appropriate ICD-10-CM and CPT code(s):

Medicare patients should sign an ABN when

Pre-operative Diagnosis: Tumor on muscle of right arm Post-operative Diagnosis: same After localized anesthesia, a percutaneous bore needle was used to pierce into the muscle to obtain a biopsy of the muscle tissue. Tissue sample will be sent to pathology. No complications resulted to the patient, and he left the office in good condition. Select the appropriate CPT and ICD-10-CM codes.

Clinical indication: Salivary stones Procedure: CT scan of soft tissue of the neck with contrast Diagnosis: Salivary (parotid) duct stones Select the appropriate CPT and ICD-10-CM codes.

A 65-year-old male with severe droopy upper eyelids that also have severe spider veins along with skin plaques presents to the ambulatory surgery center for a non-cosmetic blepharoplasty of his upper eyelids. The diagnosis was pseudoptosis causing visual impairment along with a severe case of acne rosacea. Select the appropriate CPT and ICD-10-CM codes.

A 50-year-old male patient presents to the office today for his annual preventive visit. During the visit, Dr. Jones becomes concerned about the patient's hypertension and believes that this needs some evaluation and management beyond the preventive visit. Dr. Jones changes the patient's medications and orders lab work. Which modifier would be reported to the payer in order to be reimbursed for both the preventive visit and the office visit?

A 78-year-old male is hospitalized for removal of a foreign object from the left shoulder after a previously performed Neer hemiarthoplasty. Select the appropriate CPT code.

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 48-year-old female with a 20+ year smoking history is diagnosed with a pulmonary nodule growing in the left lower lobe of the lung. After discussion with her surgeon, the patient is brought to the OR for a laproscopic wedge resection of the nodule using VATS approach to obtain a frozen section. Following a pathology report of adenocarcinoma of the lung, a VATS lobectomy of the left lower lobe was performed. The patient tolerated the procedure and was sent to the surgical ICU in stable condition. Select the appropriate CPT and ICD-10-CM codes.

The patient presented in the emergency room with a sudden outbreak of lesions on the face, bilaterally on arms and legs, and groin after taking her prescribed sulfa drugs. Several of the lesions had to be shaved: 2 on the leg, one 1.4cm on the groin, and 3 close to the ear. The physician concluded that this was dermatitis. Select the appropriate CPT and ICD-10-CM codes.

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.

A 30-year-old male, who is a new patient, is brought into the physicians' office for the treatment of dermatitis. The physician's focus on the problem is a detailed history and examination. The MDM complexity is moderate. Select the appropriate CPT and ICD-10-CM codes.

Preoperative Diagnosis: Tonsillitis Postoperative Diagnosis: Tonsillitis Operation: Tonsillectomy Anesthesia: General Operation Description: A 12-year-old patient is diagnosed with tonsillitis and was recommended to have a tonsillectomy. Family consented to the surgery and patient admitted. Patient was positioned supine for the procedure. The right, then the left tonsil was removed. The tonsillar area was irrigated; no bleeding before or after the suturing. The patient tolerated the procedure well. Select the appropriate CPT and ICD-10-CM codes.