Exam 27: Coding and Surgical Procedures

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.

An 81-year-old patient, Marge, fractured the proximal end head of her femur on Thanksgiving while standing and cooking dinner. She has a history of osteoporosis and received radiation therapy 3 years ago in this area for a thigh muscle tumor. She is going to surgery today for an open treatment of femoral fracture with internal fixation. Select the appropriate CPT and ICD-10-CM codes.

Jane, a 75-year-old female, was brought to the OR today for operative ablation of her paroxysmal atrial fibrillation via a combined Wolff-Parkinson-White atrio-ventricular node tissue ablation and reconstruction of the atria using the MAZE procedure. Cardiopulmonary bypass was not required. The patient tolerated the procedure well and was sent to ICU for continued monitoring. Select the appropriate CPT and ICD-10-CM codes.

The patient is admitted for severe anemia due to chemotherapy treatments for metastatic bone cancer. The primary site is the prostate. What are the correct ICD-10-CM codes?

The surgeon performed endovascular repair on a patient with an aneurysm in the descending thoracic aorta under fluoroscopic guidance, which was directed separately by the radiologist. An endoprosthesis was placed as well as an extension to the origin of the celiac artery. Select the appropriate CPT and ICD-10-CM codes.

An 81-year-old female has primary open angle glaucoma, severe stage of the left eye. The patient was sent to the OR for a sequential cyclocryotherapy. After moderate sedation was administered by the physician, a wire lid speculum was used to separate the lids of the left eye. The cyroprobe with liquid nitrogen and nitrous oxide was applied. A freeze-thaw-freeze triple row of cryotheraphy was done. The entire procedure took 45 minutes, and the patient tolerated the procedure well and was sent home. Select the appropriate CPT and ICD-10-CM codes.

A patient was brought to the OR today for exploratory thoracotomy. Previous x-rays demonstrated a small foreign body in the pleural space. Exploration of the area revealed a small piece of shrapnel from a previous shooting accident. Under general anesthesia, the incision was made into the pleural space and the shrapnel was removed. Select the appropriate CPT and ICD-10-CM codes.

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.

Pre-op diagnosis: Left lung abscess Post-op diagnosis: Same Procedure performed: Left upper lobectomy with decortication and drainage Indications: The patient is a 56-year-old female with evidence of a left upper-lobe abscess seen on the MRI. She was admitted with tension pneumothorax, which was treated with double-lumen intubation and a chest tube. Procedure: The patient was brought to the operating room and placed in the supine position, with general intubation from the double-lumen tube. The patient was rolled onto the right lateral decubitus position, with left side up. A posterior lateral thoracotomy was performed. Adhesions were taken down sharply and bluntly and with cautery. Following this a standard artery first left upper lobectomy was carried out utilizing 0 silk and hemoclips. The left upper pulmonary vein was secured with a single application of the stapling machine. The posterior fissure was created with multiple applications of the automatic stapling machine and the bronchus secured with a single application of the bronchus stapling machine. Following this the wound was drained with three 24-French strium chest tubes and hemostasis obtained with spray Tisseel and surgical gauze. The bronchus was sealed with bio glue and the wound closed in layers. A sterile compression dressing was applied, and the patient was returned to the surgical intensive care unit after the double-lumen tube was changed to a single-lumen tube. The patient received 3 units of packed cells intraoperatively to maintain hemostasis. Sponge count and needle count correct × 2. Large abscess in the left upper lobe accounted for approximately 70% of the left upper-lobe parenchyma. Select the appropriate ICD-10-CM and CPT code(s):

A patient underwent fine needle aspiration of a cyst on the L breast and another on the R breast. Both aspirates were properly labeled and sent to cytopathology for interpretation and report. Pathology report demonstrated cells consistent with fibrocystic breast disease; no malignancy was noted. Select the appropriate CPT and ICD-10-CM codes.

History: A 62-year-old woman (height, 1.7 m; weight, 61 kg) was scheduled for resection of a sigmoid colon carcinoma. Her medical history revealed hypothyroidism, vitamin B12 deficiency, and stiff person syndrome. This syndrome started with low back pain, which rendered her unable to walk. She was experiencing stiffness, involuntary jerks, and painful cramps. Neurologic examination revealed extreme hypertonia of the body and proximal legs, with intercurrent, painful spasms. Reflexes were symmetrical without Babinski signs. Laboratory findings showed positive glutamic acid decarboxylase (GAD) and negative amphiphysin antibodies. The patient was successfully treated with baclofen and diazepam. Subsequently, prednisone as immunosuppressive therapy was started. The stiffness diminished, and the patient was able to walk unaided. The neurologic examination was unremarkable, except for a slight stiffness in the legs. Her medication at admission was prednisone 20 mg once a day, baclofen 12.5 mg twice a day (daily dose = 25 mg), diazepam 7.5 mg twice a day (daily dose = 15 mg), levothyroxine 25 ?g once a day, and vitamin B12 injections. Her medical history included urologic and gynecologic surgery under general anesthesia before she experienced SPS. Procedure: No premedication was given. Anesthesia was induced with propofol (2.5 mg/kg) and sufentanil (0.25 ?g/kg). After the administration of atracurium (0.6 mg/kg), the trachea was intubated, and anesthesia was continued with isoflurane (0.6-1.0 vol %) and oxygen/air for the duration of the procedure. Cefuroxime 1,500 mg, clindamycin 600 mg, and dexamethasone 10 mg were administered IV. In the following 2 hours, additional atracurium (35 mg), sufentanil (10 ?g), and morphine (8 mg) were administered. At the end of the procedure, which was uneventful, neuromuscular monitoring showed four strong twitches. Although the patient was responsive, she could not open her eyes, grasp with either hand, or generate tidal volumes beyond 200 mL. Neostigmine 2 mg (0.03 mg/kg) and glycopyrrolate 0.2 mg did not alter the clinical signs of muscle weakness. The patient was sedated with propofol and further mechanically ventilated in the recovery room. After 1 hour, the sedation was stopped and mechanical ventilation was terminated. At that time, baclofen 12.5 mg was administered into the gastric tube. Two hours later she was in a good clinical condition, and her trachea was extubated. Select the appropriate ICD-10-CM and CPT code(s):

Which term pertains to the heart muscle?

History: A 62-year-old woman (height, 1.7 m; weight, 61 kg) was scheduled for resection of a sigmoid colon carcinoma. Her medical history revealed hypothyroidism, vitamin B12 deficiency, and stiff person syndrome. This syndrome started with low back pain, which rendered her unable to walk. She was experiencing stiffness, involuntary jerks, and painful cramps. Neurologic examination revealed extreme hypertonia of the body and proximal legs, with intercurrent, painful spasms. Reflexes were symmetrical without Babinski signs. Laboratory findings showed positive glutamic acid decarboxylase (GAD) and negative amphiphysin antibodies. The patient was successfully treated with baclofen and diazepam. Subsequently, prednisone as immunosuppressive therapy was started. The stiffness diminished, and the patient was able to walk unaided. The neurologic examination was unremarkable, except for a slight stiffness in the legs. Her medication at admission was prednisone 20 mg once a day, baclofen 12.5 mg twice a day (daily dose = 25 mg), diazepam 7.5 mg twice a day (daily dose = 15 mg), levothyroxine 25 ?g once a day, and vitamin B12 injections. Her medical history included urologic and gynecologic surgery under general anesthesia before she experienced SPS. Procedure: No premedication was given. Anesthesia was induced with propofol (2.5 mg/kg) and sufentanil (0.25 ?g/kg). After the administration of atracurium (0.6 mg/kg), the trachea was intubated, and anesthesia was continued with isoflurane (0.6-1.0 vol %) and oxygen/air for the duration of the procedure. Cefuroxime 1,500 mg, clindamycin 600 mg, and dexamethasone 10 mg were administered IV. In the following 2 hours, additional atracurium (35 mg), sufentanil (10 ?g), and morphine (8 mg) were administered. At the end of the procedure, which was uneventful, neuromuscular monitoring showed four strong twitches. Although the patient was responsive, she could not open her eyes, grasp with either hand, or generate tidal volumes beyond 200 mL. Neostigmine 2 mg (0.03 mg/kg) and glycopyrrolate 0.2 mg did not alter the clinical signs of muscle weakness. The patient was sedated with propofol and further mechanically ventilated in the recovery room. After 1 hour, the sedation was stopped and mechanical ventilation was terminated. At that time, baclofen 12.5 mg was administered into the gastric tube. Two hours later she was in a good clinical condition, and her trachea was extubated. Select the appropriate ICD-10-CM and CPT code(s):

Procedures: Craniotomy for a patient with benign clinoidal meningioma. The surgeon carried out a stereotactic osteoplastic craniotomy along with resection of clinoidal/sphenoid wing mass. For the microdissection an intraoperative microscope was used. Prior to decompressing the superior orbital fissure, the tumor was extirpated through the opticocarotid, carotid oculomotor, as well as prechiasmatic spaces. Select the appropriate CPT and ICD-10-CM codes.

Mrs. Jones presented with pain in the right upper quadrant. Upon a CT of the abdomen and an ultrasound of the gallbladder, a diagnosis of cholelithiasis and acute cholecystitis was confirmed, and the patient was taken to the operating room. The patient underwent a laparoscopic cholecystectomy with a normal intraoperative cholangiogram to remove the gallstones. Select the appropriate ICD-10-CM and CPT code(s):

Procedures: Craniotomy for a patient with benign clinoidal meningioma. The surgeon carried out a stereotactic osteoplastic craniotomy along with resection of clinoidal/sphenoid wing mass. For the microdissection an intraoperative microscope was used. Prior to decompressing the superior orbital fissure, the tumor was extirpated through the opticocarotid, carotid oculomotor, as well as prechiasmatic spaces. Select the appropriate CPT and ICD-10-CM codes.

A 27-year-old patient is seen for ruptured synovium in the right shoulder and right elbow due to a baseball injury. An arthroscopic thermal capsulorrhaphy was performed for multidirectional instability and to prevent dislocation. 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 patient is referred to the Radiology Department for a repeat gastric emptying study. This 63-year-old female has been diagnosed with dumping syndrome and her symptoms have worsened over the past two weeks, so her gastroenterologist has requested another study be done. Select the appropriate CPT and ICD-10-CM codes.

John, a nine-year-old boy, is being seen today for persistent allergic sinusitis. Today he will undergo percutaneous sequential and incremental allergy testing with biological allergens with 15 various allergens being applied followed by interpretation and report. Select the appropriate CPT and ICD-10-CM codes.