Exam 27: Coding and Surgical Procedures

Patient presents for cesarean section with no other deliveries or pregnancies noted in the chart. She was prepared and draped in the usual sterile manner for an abdominal procedure. An incision was made and carried down through the subcutaneous tissue, muscular fascia, and peritoneum. Once inside the abdominal cavity, a low cervical transverse incision was made in the lower uterine segment after creating a bladder flap by both blunt and sharp dissection. With creation of the bladder flap, a transverse incision was made and the infant was delivered as a vertex. The placenta was then removed as well. With removal of the placenta and baby, cord blood was obtained. The infant was handed off to the nurses in attendance. We then closed the uterine incision in the usual manner. A Foley catheter had been inserted. Clear urine was noted. The patient was then awakened and taken to the recovery room in good condition. Select the appropriate CPT and ICD-10-CM codes for the delivery only.

A proctosigmoidoscopy was performed to examine the sigmoid colon, rectum, and anal structure for pus in the stool and melena on a patient with a family history of carcinoma in the colon. During the procedure a biopsy of a lesion was also performed. The pathology report later came back with benign lesion. Select the appropriate CPT and ICD-10-CM codes.

A mother brings in her 3-year-old son for a well-child checkup. In addition to the physical examination for this established patient, the physician administers the DTP vaccine via IM injection and discusses the vaccines and possible side effects with the mother. Select the appropriate CPT and ICD-10-CM codes.

Procedure Description: Under anesthesia via endotracheal intubation, the ears were inspected with the operating microscope. Anterior inferior quadrant myringotomy incisions were performed bilaterally. Armstrong tubes were inserted. Diagnosis: Recurrent acute otitis media, bilateral middle ear effusions Select the appropriate CPT and ICD-10-CM codes.

A cervical PAP smear was reported using the Bethesda System and manually screened under physician supervision, then further interpreted by the pathologist. Select the appropriate CPT and ICD-10-CM codes.

Presbycusis is defined as:

Preoperative Diagnosis: Pulmonary nodule, left lower lobe Postoperative Diagnosis: Pathology report came back as squamous cell carcinoma of the left lower lobe Procedure: Left lower lobectomy Operation: General endotracheal anesthesia was administered satisfactorily. With the patient in the left lateral decubitus position, we made a left posterolateral thoracotomy with resection of the sixth rib. I could identify the lesion in the lateral segment of the left lower lobe. I carefully dissected the lobe out, being certain that the lesion was peripheral. I then dissected down and identified the vein to the left lower lobe, and tied it with 0 silk suture ligated. I then dissected down and identified two arteries to the lower lobe, and tied each of these. I carefully removed the fissure between the upper lobe and lower lobe using the stapler. I dissected out some nodes for staging purposes. I palpated the superior mediastinum and did not find any abnormalities. I placed a #32 chest tube in the wound, then closed it with 1 Vicryl and 0 Vicryl on the fascia, 3-0 Plain on the subcutaneous and skin staples on the skin. Estimated blood loss was 250 cc. We administered an epidural and removed the patient to the recovery room in stable condition. Select the appropriate CPT and ICD-10-CM codes.

Marc will be having a kidney transplant due to end stage renal disease caused by malignant hypertension. The donor is his cousin Sidney. Under general anesthesia, Sidney undergoes a radical nephrectomy; the surgeon then does his backbench work to dissect and remove any fat and prepares the ureters, veins, and arteries. Next the surgeon performs a renal nephrectomy and allo-transplantation on Will. Select the appropriate CPT and ICD-10-CM codes.

Preoperative Diagnoses: Oxygen dependency. Chronic obstructive pulmonary disease. Postoperative Diagnoses: Oxygen dependency. Chronic obstructive pulmonary disease. Procedure Performed: Tracheostomy with skin flaps. SCOOP Procedure FastTract. Indications: The patient is a 55-year-old male with a history of chronic obstructive pulmonary disease and O2 dependency of approximately 5 liters nasal cannula at home. The patient with extensive smoking history presents after risks, complications, and consequences of the SCOOP FastTract transtracheal oxygen procedure were explained. Procedure: The patient was brought to operating suite by Anesthesia and placed on the operating table in the supine position. After this, the patient was then placed in reverse Trendelenburg. The patient's sternal notch along with cricoid and thyroid cartilages were noted and palpated and a sternal marker was utilized to mark the cricoid cartilage in the sternal notch. The midline was also marked and 1% lidocaine with epinephrine 1:100,000 at approximately 4 cc total was then utilized to localize the neck. A skin incision was then made in the midline in a vertical fashion. After this, the skin was retracted laterally and a small anterior jugular branch was clamped and cross clamped and tied. Further bleeding was controlled with monopolar cauterization and attention was then drawn down on to the strap muscles. The patient's sternohyoid muscle was identified and grasped on either side and the midline raphe was identified. Cauterization was then utilized to take down the midline raphe and further dissection was utilized with the skin hook and stat clamps. The anterior aspect of the thyroid isthmus was identified and palpation on the cricoid cartilage was performed. The cricoid cauterization over the cricoid cartilage was obtained with the monopolar cauterization and blunt dissection then was carried along the posterior aspect of the thyroid isthmus. Stats were then placed on either side of the thyroid isthmus and the mid portion was bisected with the monopolar cauterization. Next, the patient's anterior trachea was identified and cleaned with pusher. The cricoid cartilage along the first and second tracheal rings was identified. The cricoid hook was placed and the trachea was brought more anteriorly and superiorly. A small 4 mm punch was created within the tracheal cartilage using the punch in the SCOOP FastTract kit. A tracheal stent was placed within the tracheal punched lumen and the tracheal stent secured to the neck with a Vicryl strap. Then the cricoid hook was removed and the patient then had FiO2 on the monitor noted with pulse oximetry of 100%. The patient was transferred to the recovery room in stable condition. Select the appropriate CPT and ICD-10-CM codes.

A 26-year-old female patient with uterine polyps is sent for a hysterosalpingography. Under contrast the full uterus and fallopian tubes are visualized. Select the appropriate CPT and ICD-10-CM codes.

A patient presents to his physician today complaining of pain in the left gluteal area. The physician gathers an expanded problem-focused history and performs an expanded problem-focused examination and decision making of straightforward complexity, determining that the cause of the pain is an infected sebaceous cyst in this area. An incision and drainage of the cyst is performed. Select the appropriate ICD-10-CM and CPT code(s):

An abnormal hump caused by increased convexity of the thoracic spine is called:

Patient Infant Male Crowley I was present, at the request of the delivering physician, at the vaginal delivery at 5:07 p.m. of a male infant 29 weeks' gestation with a spontaneous cry. At the 1-minute mark the Apgar was 5, the decreases were in tone, grimace, and color. An Apgar of 8 was reached at the 5-minute mark, with decreases continued in grimace and tone. The infant was taken to NICU for further management. Upon examination, decreased breath sounds and increased work to breathe were noted. The infant was intubated with difficulty. The patient did tolerate this well. An umbilical artery catheter was placed without difficulty, and labs were ordered. A chest x-ray and abdominal films were done. Both UAC and the endotracheal tube are in proper placement. The OG has been advanced; the lung fields do show significant granularity. Blood gas is 8.32, PCO2 of 50, PO2 of 102 on a setting of 22/4 rate of 60, and 80% FiO2. PE: Patient currently is intubated. His weight is 1,706 grams; OFC is 30.5; length is 39.6 cm. Heart rate is in the 120s to 130s. Respiratory rate is 60 on the ventilator; O2 saturation is in the mid-90s. Blood pressure in right arm is 67/34, with a mean of 46, and in right leg is 67/32, with a mean of 44. Plan: Observation for sepsis Maternal hypermagnesemia. Admission to the NICU, continued mechanical ventilation. Select the appropriate ICD-10-CM and CPT code(s):

Procedure: Permanent pacemaker implantation Indication for the procedure: Sick sinus syndrome with decreased mentation and confusion Description of the procedure: After a detailed description of the procedure, indications, and potential risks of permanent pacemaker implantation was given to the patient as well as the patient's daughter, informed consent was obtained. The patient was transferred to the cardiac catheterization lab. A left subclavian area was prepared and draped in the usual sterile manner, and the left subclavian vein was accessed by Seldinger technique. A guidewire was placed. The left subclavian vein was accessed, and a separate guidewire was also placed. Following this, a deep subcutaneous pacemaker pocket was created using the blunt dissection technique without any excessive bleeding. Following this, a French-7 introducer sheath was advanced over the guidewire, and the guidewire was removed. A Medtronic bipolar endocardial lead, model #5054 and serial #LEH025605V, was advanced under fluoroscopic guidance, and the tip of the pacemaker lead was positioned in the right ventricular apex. Following this, the French-9.5 introducer sheath was advanced over a separate guidewire under fluoroscopic guidance, and the guidewire was removed. Through this sheath, a bipolar atrial screw-in lead by Medtronic, model #4568, was selected. It was positioned in the right atrial appendage, and the lead was screwed in. Following this, the stimulation thresholds were obtained for the atrial lead. The amplitude was millivolts (mv) of resistance of 549 ohms, with pulse rate of 0.5 ms. Following the ventricular stimulation, threshold perimeters were obtained, including R-wave entry of 4.6 mv with resistance of 1,427 ohms, with a pulse wave of 0.5 ms. Minimum-stimulation threshold voltage was 0.4 volt for the ventricular lead, and minimal-stimulation voltage was 2 volts for the atrial lead. Select the appropriate ICD-10-CM and CPT code(s):

Pneumonia that is typically diffuse and bilateral is

Pam presents at her podiatrist office for a right great toenail removal due to an ingrown nail. The podiatrist did a permanent removal of the distal half of the right great toenail. Select the appropriate CPT and ICD-10-CM codes.

George presented with chronic intractable pain of unknown origin in his left leg. The neurologist used stereotaxis to create a lesion in the spinal cord in order to attempt to block the pain and provide sustainable relief. Select the appropriate ICD-10-CM and CPT code(s):

Jerry, an established patient, is seen today for evacuation of a subungual hematoma of his left index finger, sustained while hanging a picture. The physician performs a problem-focused history and problem-focused examination to evaluate the extent of the damage and determines that evacuation of the hematoma is needed. He then evacuates the subungual hematoma. Select the appropriate ICD-10-CM and CPT code(s):

Mrs. Jones, an established patient, is seen by the rheumatologist for repeated pain in her left knee due to osteoarthritis. Today she presents with pain and swelling. The rheumatologist performs an arthrocentesis of the left knee followed by injection of Dexa-Methasone sodium phosphate, 5 mg. No E/M service is performed. Select the appropriate ICD-10-CM and CPT code(s):

A 55-year-old female was having a problem with menopause. Because of the reported concerns about hormone replacement therapy, she decided to try acupuncture. After discussing her symptoms and discussing a treatment plan, Dr. Kind inserted several needles; the needles were removed 20 minutes later. Dr. Kind reviewed the follow-up plan and made an appointment for the patient's next visit. Dr. Kind spent 30 minutes in total face-to-face with Charlene. Select the appropriate ICD-10-CM and CPT code(s):