Exam 27: Coding and Surgical Procedures

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.

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):

A 38-year-old insulin-dependent established patient called his physician complaining of having some rectal bleeding after using the bathroom. The physician agreed to meet the patient in the outpatient department of the hospital. The physician performed an expanded problem-focused history with a detailed examination. The patient is to have blood work and a stool culture and is to be scheduled for a lower GI series. The physician's diagnosis was Hematochezia etiology unknown. Select the appropriate CPT and ICD-10-CM codes.

Which of the following designates a waiver needed for any service that does not meet the coverage criteria established in an LCD?

Preoperative Diagnosis: atherosclerosis of right iliac artery Postoperative Diagnosis: same Operative Procedure: Transluminal peripheral atherectomy of right iliac artery via percutaneous approach Select the appropriate CPT and ICD-10-CM codes.

Hemodialysis is used to treat

Medicare provides coverage for:

Preoperative diagnosis: Left hydrocele Postoperative diagnosis: Left hydrocele Procedure performed: Left hydrocelectomy Procedure description: The initial incision was made, and the left hydrocele was delivered out of the wound and incised. The hydrocele was emptied of about 500 mL and then incised completely. About 90% of the hydrocele sac was removed with the Bovie. The hydrocele sac was involuted and sewn to itself using running 3-0 Vicryl in the manner of Jaboulay. The testicle was replaced in the left scrotum, and the patient tolerated the procedure well. Select the appropriate ICD-10-CM and CPT code(s):

A patient with a benign tumor on the parotid gland had a parotidectomy. Nerves were dissected off the gland and left intact. A suction drain was inserted, which will be removed in two days. Select the appropriate CPT and ICD-10-CM codes.

A patient with a recent total detached retina on the left eye underwent scleral buckling. A vitrectomy was also performed in order for the surgeon to adequately visualize the structures using the operating microscope. Select the appropriate CPT and ICD-10-CM codes.

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.

Preoperative Diagnosis: Pericardial Cyst Postoperative Diagnosis: Same Procedure: Thorascopy, surgical: with excision of pericardial cyst. Using VATS, the cyst was visualized and removed. The patient was sent to the ICU in good condition. Select the appropriate CPT and ICD-10-CM codes.

A 28-year-old patient was seen today for her annual physical exam by her OB/GYN. After discussion with the physician, the patient expressed her decision to have her IUD removed as she and her husband are ready to begin a family. This procedure was performed at this visit. Select the appropriate ICD-10-CM and CPT code(s):

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):

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.

Which of the following HCPCS modifiers would be appended in order to report to the payer that an Advanced Beneficiary Notice is on file at the physician's office?

Distention of the renal pelvis due to excessive urine collection in the kidney is

A 5-week-old infant suffering from dehydration and projectile vomiting is having a pyloromyotomy for infantile hypertrophic pyloric stenosis. Select the appropriate CPT and ICD-10-CM codes.

Clinical History: Herniated cervical disc C5-6 with myelopathy Source of Specimen: Cervical disc tissue C5-6 Pathology Report: The specimen consists of multiple irregular fragments of fibrocartilage, aggregating 2.5 X 1.5 X 1.2cm. It is blue stained. There is no gross evidence of malignancy. Diagnosis: Degenerating Fibrocartilage consistent with disc C5-6 Select the appropriate CPT and ICD-10-CM codes.

Which of the following HCPCS modifiers is appropriate to report when a diagnostic mammogram is converted from a screening mammogram on the same day for the same patient?