Exam 27: Coding and Surgical Procedures

Preoperative diagnosis: Left hip pain and bilateral chest and back pain Postoperative diagnosis: Left hip pain and bilateral chest and back pain Procedures: Bilateral lumbar paravertebral sympathetic nerve block under ultrasound guidance. Left hip greater trochanter bursa injection. Procedure in detail: All questions were answered. His back was palpated to try to elicit areas of discomfort. This was quite difficult to do, since he said he hurt all over. Of note is that we had looked at his legs, and on his right leg he had an area of excoriation or erythema that was unusual for him, and he stated that his pain seemed to correlate with his edema and erythema of his legs. With this in mind, we turned our attention first to his left hip pain and asked him to move his left hip to where we could elicit a point of maximum tenderness. Point of maximum tenderness was elicited over what appeared to be the greater trochanter of the left hip area itself. We then injected what appeared to be the bursa of the left hip with 10 cc of 0.25% Marcaine with 20 mg of Depo-Medrol. He was then placed in a prone position with a pillow supporting his upper abdomen. In light of his symptoms down his legs, we felt that a lumbar paravertebral sympathetic nerve block was indicated at this time. We identified the spinous process of L2. The midpoint of the spinous process of L2 was marked. A line perpendicular to the spinous process of L2 was then drawn on his skin, and a point that was 1¾ inches from the midline was then marked. The skin at this point was anesthetized with 1.5% lidocaine using a 25-gauge B-bevel needle. This was then followed with a 22-gauge 3½-inch needle that was advanced under a slightly cephalic medial direction, approximately 85 degrees off midline. Under fluoroscopic guidance, the needle was advanced. On the first attempt on the left, we encountered the transverse process of L2. The needle was repositioned left of cephalic, and we were able to bypass the transverse process. The needle was advanced until we encountered the vertebral body of L2 under ultrasound guidance. We then obtained a lateral view and found that indeed we were at the level of the midbody of L2. With this needle felt to be adequately placed, we then injected 6 cc of 0.25% Marcaine with 20 mg of Depo-Medrol. The needle was left in place, and the stylet was replaced. We then turned our attention to the right-hand side because of the excoriation on his legs and the edema that he said he experiences with increased levels of his pain. The skin was once again marked 1¾ inches from the midline at the midlevel of the spinous process of L2. The skin was anesthetized with 1.5% lidocaine. This was then followed with a 22-gauge 3½-inch spinal needle that was advanced under fluoroscopic guidance. Of note, we made three or four passes in the attempt to approximate the needle next to the vertebral body of L2. Interesting to note is that in order to obtain the maximum view of the spinous process of L2, we were approximately 5 degrees to the right in terms of off midline. Once the 22-gauge 3½-inch spinal needle was placed on the right after several attempts, he did not complain of any paresthesias at this time. We then took a lateral view and found that our needle was not as deep as it should be. We then withdrew the needle, and on ultrasound guidance, using a lateral view, the needle was advanced until it was felt that we were at the appropriate depth. An AP view was then retaken, and we were found to be not at the body of L2 in terms of next to it. The needle was then removed and repositioned in a slightly medial fashion, and it was felt that we encountered bone. We then turned to the lateral view once again and found that we were at this time at the midbody of L2. This was felt to be adequately placed after three attempts. Then 6 cc of 0.25% Marcaine with 20 mg of Depo-Medrol was injected. The needle stylet was then replaced, and we then waited approximately 4 minutes for the Marcaine to set. We then removed the needles of both the right and the left sides, respectively, and pressure was applied at the skin to prevent any bleeding. He was then placed in the supine position and was discharged home in satisfactory condition. He was instructed to call if he had any changes in edema of his legs. Select the appropriate ICD-10-CM and CPT code(s):

CT Scan of the Abdomen and Pelvis History: Malignant testicular neoplasm Technique: Axial CT images of the abdomen and pelvis were obtained with intravenous and oral contrast. Findings: Images of the lung bases are normal. Images of the abdomen show the liver, spleen, gallbladder, pancreas, and adrenal glands to be normal. No mass is seen. There is no evidence of cholelithiasis. A retroaortic left renal vein is seen. No obvious mass or enlarged lymph nodes are noted in the retroperitoneum. Mesenteric structures appear normal. A prominent inferior vena cava is seen. Gas is identified in the left inguinal structures, likely representing previous left orchidectomy and removal of the inguinal ring. No enlarged lymph node is identified in the pelvis. Impression: Left retroaortic renal vein is seen. No adenopathy is noted within the abdomen or pelvis. No enlarged lymph node is seen; no mass is identified. Select the appropriate ICD-10-CM and CPT code(s):

Sam, a welder, was seen today by the ophthalmologist for removal of a welding flash from his left eye. The flash had caused a nonperforating tear in the cornea. The ophthalmologist removed the flash and repaired the cornea. Select the appropriate ICD-10-CM and CPT code(s):

A 28-year-old was in a car accident and is now in the ED due to 3 fingers on his left hand being completely amputated above the metacarpophalangeal joint during the crash. The ED physician calls in an orthopedic surgeon and the patient is taken to surgery. Under surgical microscope his index finger and middle finger were reconnected; however, his 3rd finger was not able to be reconnected due to extensive crush injuries to that finger, so that finger was surgically amputated. Select the appropriate CPT and ICD-10-CM codes.

Joey, age 5, is taken to the OR today for removal of a small foreign body from his right nares. General anesthesia was required due to the significant level of anxiety displayed by the child, as well as the location of the small object. Select the appropriate CPT and ICD-10-CM codes.

A patient underwent incision and drainage of conjunctival cysts of left and right eyes. Select the appropriate CPT and ICD-10-CM codes.

A computerized lifelong healthcare record of an individual patient that incorporates data from all sources that provide treatment is called a(n)

A child is being seen for immunizations. The first immunization is a subcutaneous injection of live varicella virus, and the other is a subcutaneous administration of live poliovirus. Select the appropriate ICD-10-CM and CPT code(s):

Preoperative Diagnosis: Reduced inguinal hernia Postoperative Diagnosis: Reduced inguinal hernia Operation: Repair of the reduced hernia Operation Description: A 3-year-old boy was diagnosed with a reduced inguinal hernia within the past month. The surgeon explained the procedure of a reduced hernia repair and parents understood risks. The consent was obtained and signed. This is the first initial attempt to surgically repair the inguinal hernia. Patient was admitted for a reduced hernia repair. The hernia was manually reduced back into its correct cavity location. Upon completion of the procedure the patient went to the recovery room in stable condition. Select the appropriate CPT and ICD-10-CM codes.

A 45-year-old male with pancreatic cancer presents with a distended abdomen. The ultrasound reveals fluid in the peritoneal cavity. The patient undergoes a therapeutic paracentesis with ultrasound imaging guidance to drain the fluid. Select the appropriate ICD-10-CM and CPT code(s):

A patient returns to the physician's office with flulike symptoms during the postoperative period for an appendectomy performed 1 month ago. Which modifier would need to be appended to today's office visit?

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.

Jeffrey has developed cellulitis in his neck from his tracheostomy surgery for adenocarcinoma of the larynx. A tracheostoma revision, simple without flap rotation, was performed. Select the appropriate ICD-10-CM and CPT code(s):

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):

Timothy presents at Dr. Smith's office today with multiple painful lumps on his left upper arm. His skin is warm, red, and swollen. Dr. Smith determines that these are abscesses of a staphylococcus nature and will need to be incised and drained to remove the pus. Using a scalpel, all 8 lumps were incised, packed, and dressed. Timothy is given a prescription and told to return in 7 days for a wound check. Select the appropriate CPT and ICD-10-CM codes.

Examination: Gastric-emptying study Reason for the examination: This is a study of elimination for gastroparesis, abdominal cramping, and pain. Interpretation: One millicurie of technetium-99m sulfur colloid was given through a gastrostomy tube in saline. The normal half-time of clearance of liquid material from the stomach is 12 minutes. The patient's clearance is 50 minutes, which is a fourfold increase in time and is compatible with a marked delay in gastric emptying. Select the appropriate ICD-10-CM and CPT code(s):

A 24-year-old female patient completed her 40th week of pregnancy. Her physician had noted that her antepartum visits were all within normal ranges. She had a vaginal delivery with episiotomy. A single live newborn was delivered in the hospital. Patient had a successful delivery with no complications. Select the appropriate CPT and ICD-10-CM codes for the delivery only.

A 60-year-old patient was experiencing chest pain in the emergency department and went into cardiac arrest. CPR was performed on the patient by the ER physician, and the patient was resuscitated. The patient was then admitted to the telemetry unit for further monitoring by the cardiologist on-call. The cardiologist performed a comprehensive history, a detailed examination, and medical decision making of moderate complexity. Select the appropriate CPT and ICD-10-CM codes for cardiologist.

Joey, age 5, is taken to the OR today for removal of a small foreign body from his right nares. General anesthesia was required due to the significant level of anxiety displayed by the child, as well as the location of the small object. Select the appropriate CPT and ICD-10-CM codes.

The patient is an otherwise healthy 67-year-old male who sustained a fall three weeks ago. The patient is presenting with pain localized to his left knee. On exam the patient was unable to actively abduct and or externally rotate the knee secondary to pain and weakness. MRI demonstrated a displaced tibial tuberosity fracture. The surgeon performed an arthroscopic reduction and internal fixation of displaced greater tuberosity fracture with manipulation. Select the appropriate CPT and ICD-10-CM codes.