Exam 27: Coding and Surgical Procedures

A patient was referred by her primary care physician to a physical therapist due to cervical pain. The PT performs physical therapy evaluation of low complexity and applies heat packs, followed by 15 minutes of manual traction and mobilization. The patient will return 3 times a week for 3 weeks, at which time a re-evaluation will be performed. Select the appropriate CPT and ICD-10-CM codes.

Preoperative diagnosis: Carcinoma of the lung with right neck metastasis Postoperative diagnosis: Carcinoma of the lung with right neck metastasis Operative procedures: Cervical esophagoscopy, microlaryngoscopy, and biopsy Procedure and findings: With the patient under general anesthesia, the 10I 14 × 23 Roberts esophagoscope was passed. It was noticed that the left piriform sinus was of normal appearance. There was edema of the free tip of the epiglottis. The scope was advanced through the left piriform sinus into the cervical esophagus, and the cervical esophagus and postcricoid area were essentially normal. Also, the upper cervical esophagus was normal. The scope was slowly withdrawn through the right piriform sinus. It was noticed that there was a tumor involving the anterior wall of the right piriform sinus, extending approximately 1 cm below the pharyngeal epiglottic fold. This tumor then also involved the lateral hypopharyngeal wall to a minor degree. The scope was removed. The Dedo microlaryngoscope was passed. It was now noticed that the above findings were further defined. It was noticed that there was an exit through the tumor involving the vallecula on the right side going into the base of the tongue for a distance of approximately 0.5 cm. This tumor was quite exophytic, and it extended laterally above the pharyngeal epiglottic fold, extending, therefore, approximately 0.75 cm to the lateral hypopharyngeal wall. It also involved heavily the medial wall of the right piriform sinus without crossing over onto the laryngeal surface of the epiglottic fold. The vocal cords were of normal appearance. The right vocal cord was fixed in the midline. Inferiorly the tumor extended onto the medial wall of the piriform sinus just about 0.5 cm below the level of the right vocal cord. The scope was suspended. These findings were confirmed, and under 10 × magnification, several biopsies were obtained. The scope was removed. The neck was carefully palpated. The endoscopy had been preceded by a tracheostomy. The patient was initially prepared with Betadine solution and draped in the usual manner. A horizontal incision was made approximately 2 cm above the sternal notch and carried through the subcutaneous tissue down to the strap muscles. The strap muscles were divided in the midline. The cricoid cartilage was identified, the trach ties were tied securely into place, and the cuff was inflated to a comfortable pressure. The patient then received further ventilation through the newly placed trach tube. The patient tolerated all procedures well. Select the appropriate ICD-10-CM and CPT code(s):

What is the other term for the subcutaneous layer of skin?

Section: Kidney (left): Adenocarcinoma MACROSCOPIC Specimen type: Radical nephrectomy Laterality: Left Tumor site: Upper pole Focality: Unifocal Tumor size: Greatest dimension is 7.2 cm. Macroscopic extent of tumor: Tumor extends into major veins. MICROSCOPIC Histologic type: Clear cell (conventional) renal carcinoma Histologic grade: Furhman Nuclear Grade 2 PATHOLOGIC STAGING (pTN) Primary tumor (pT): pT3 Regional lymph nodes (pN): Nx Number of lymph nodes examined: 0 Number of lymph nodes involved: 0 Margins: Renal vein margin positive Adrenal gland: Unevolved Venous (large vessel) invasion (V) (excluding renal vein and inferior vena cava): Negative Lymphatic (small vessel) invasion (L): Present Additional pathologic findings: Chronic glomerulonephritis present in noninvolved renal parenchyma Clinical history: A 76-year-old male with a left renal mass in the upper pole; hematuria Gross description section: Received in formalin, labeled "left kidney," is a 12.2- × 7.1- × 2.5-cm kidney with unremarkable perirenal fat present at the upper pole (suture oriented, per requisition). A 2.3 cm in length segment of ureter exits from the hilum. The renal vein appears occluded. The cut sections demonstrate a 7.2- × 1.5- × 1.5-cm brown-orange circumscribed tumor with sharp borders present in the upper pole. Gerota's fascia appears uninvolved. The tumor extends into the renal vein; the venous margin appears positive for tumor. Microscopic section: Microscopic examination was performed. Select the appropriate ICD-10-CM and CPT code(s):

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):

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 26-year-old male was seen in the emergency room for a laceration to his right ring finger when a glass window he was installing on his job as a construction worker broke. After exploring the wound, the surgeon found a 100% laceration to the ulnar digital neurovascular bundle, which was repaired. The flexor digitorum profundus nerve had a 25% transverse laceration, which was also repaired. The flexor digitorum superficialis nerve had a partial ulnar slip laceration, but no repair was needed because the majority of it was intact. 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 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.

Diagnosis: Stomach (distal): Invasive adenocarcinoma Gross description: Received in formalin two specimens, 9.0- × 5.5- × 4.3- cm and 2.0- × 1.5- × 3.4-cm segments of the stomach, with a palpable firm 3.0- × 2.5-cm mass on the designated lesser curvature of the larger specimen. The external surfaces of the specimens are unremarkable and inked black. The curved surfaces demonstrate the mass and adjacent firm areas of nodularity. The remainder of the gastric mucosa is unremarkable. Microscopic description: Microscopic examination was performed. See synoptic report. Select the appropriate ICD-10-CM and CPT code(s):

A patient is in the office today for application of an external auto-activated ECG rhythm derived recorder for previously diagnosed syncope and palpitations not evidenced on a Holter Monitor. The patient is scheduled to wear this device for 30 days. This process will include a review and interpretation by the physician. Select the appropriate CPT and ICD-10-CM codes.

Mrs. Mustin undergoes insertion of a left custom breast prosthesis 3 months after a mastectomy for breast cancer. The patient needed to undergo radiation to that area prior to the insertion of the prosthesis. 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.

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.

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):

Which of the following is not considered a covered entity?

After administering local anesthetic, the physician made a full-thickness elliptical incision through the skin. The arterio-venous malformations and the malignant melanoma including the margin were excised and reconstructive repair of the right lower eyelid was performed. Select the appropriate CPT and ICD-10-CM codes.

A 60-year-old male patient with cirrhosis received a CT scan of the liver without and with contrast in order to rule out hepatocellular carcinoma. The images showed an enlarged liver but no tumors were identified. Select the appropriate CPT and ICD-10-CM codes.

A totally electric hospital bed without a mattress had a power pressure-reducing air mattress supplied. What would be the appropriate HCPCS code(s)?

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: