Exam 27: Coding and Surgical Procedures

Joan underwent excision of a benign lesion of the right leg, 4 cm × 4 cm, with a rotation flap to repair the incision site. The flap measures 12 cm × 5 cm. Select the appropriate ICD-10-CM and CPT code(s):

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.

Clinical history: Nevus, R pinna Postoperative diagnosis: same Tissue/specimen: skin of external ear nevus of R pinna Impression: microscopic sections show the specimen shows a nevus identified as a melanoma of right ear and auricular canal. Select the appropriate CPT and ICD-10-CM codes.

The patient undergoes simple mastectomy today for adenocarcinoma of the R breast. While the patient was still on the table, and immediately after the removal of the breast, the patient received a concentrated dose of radiation to the tumor site using IORT electron methodology. Select the appropriate CPT and ICD-10-CM codes.

What is the surgical term for removal of the lymph nodes or a group of lymph nodes?

RBRVS is the method of physician reimbursement for _______ services.

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 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.

History: A 73-year-old 81-kg male with a history of non-Hodgkin's lymphoma and moderate in situ adenocarcinoma of the prostate presents for transurethral resection of the prostate (TURP). The preoperative evaluation reveals a history of smoking (60 pack-years), normal ejection fraction and heart valves, and normal chest x-ray and EKG. No other significant findings. Procedure: He was taken to the operating room and monitored as per routine for cystoscopy and TURP. After appropriate preoxygenation, general anesthesia was uneventfully induced with fentanyl, propofol, and rocuronium. The patient was intubated, ventilated, and placed in the lithotomy position. The operative procedure was started without difficulty. After 90 minutes, the patient's temperature had dropped from 35.9°C at the beginning of the case to 32.9°C. Blood was sent to the lab due to the length of the surgery. The patient's vital signs were stable. Shortly thereafter the following values were sent back from the laboratory to the operating room: NA 109 mEq/L, K 4.7 mEq/L, CL 83 mEq/L, Glucose 83 mg/dl, Hct 34. The anesthesiologist informed the surgeon about the findings, and the surgery was then stopped. The patient was transferred to the surgical intensive care unit (SICU). At arrival in the SICU: The patient was still intubated and sedated. The body temperature was 33.5°C. The laboratory measurements revealed NA 107 mEq/L, K 5.7 mEq/L, CL 79 mEq/L, CO2 109 mEq/L, ammonia level of 60 mmol/L, and serum osmolarity of 273. A radial arterial catheter and a central venous catheter were inserted, and rewarming with hot air (Bair Hugger) was initiated. Select the appropriate ICD-10-CM and CPT code(s):

Jane Smith is a 44-year-old patient who returns back this month to her primary care physician office for a well woman exam. The exam reveals a normal pelvic exam; no masses in the vaginal and cervical area. Breast exam shows no masses or abnormalities. All other systems are normal. The patient is to return in one year. Select the appropriate CPT and ICD-10-CM codes.

Office outpatient: A Medicare patient, age 83, is seen for a therapeutic infusion of saline solution with prepackaged 5% dextrose IV 500 mL for dehydration, lasting 1 hour 20 minutes. Select the appropriate ICD-10-CM and CPT code(s):

A 14-year-old boy who is a new patient presents with acute contact dermatitis. During the expanded problem-focused history, the doctor learns that the boy just came back from a camping trip and was out in the woods when his skin began to itch. The examination was also expanded. The physician sends the patient home with a prescription and instructs him to return if the condition does not improve in a few days. While checking all of the patient's immunizations, the physician notes that the patient is in need of a tetanus vaccination, so that is also given. Select the appropriate CPT and ICD-10-CM codes.

Many conditions and diseases have "sequelae (late effects)," such as a CVA. How much time must elapse between the incident and the acute symptoms for a residual condition to be coded as a sequela (late effect)?

Holter Monitor Report History: This is a 36-year-old male referred for evaluation of syncope episodes and dizziness. He also has a history of depression and anxiety. A Holter monitor was placed on April 2 for 24 hours. Recording revealed sinus rhythm with three VPCs and three isolated APCs. There were no SVTs, no VTs, and no pauses. The patient had multiple complaints of dizziness, anxiety, panic, and feeling near syncopal. Rhythms at these times documented normal sinus rhythm at rates between 80 and 104 beats per minute. No significant arrhythmias. Impression: Normal Holter Select the appropriate ICD-10-CM and CPT code(s):

Clinical history: Carcinoma of the breast with skeletal metastasis. Study performed: Total Body Bone Scan. Impression: Abnormal total body bone scan with abnormalities noted in the ribs and spine and possibly within the skull. Select the appropriate CPT and ICD-10-CM codes.

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):

A colposcopy is performed on patient, age 42, for cervical dysplasia. The pathology report later showed the specimen was negative for carcinoma. Select the appropriate CPT and ICD-10-CM codes.

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.

Preoperative Diagnosis: Esophageal varices Postoperative Diagnosis: Esophageal varices Operation: Ligation of esophageal varices Operation Description: Patient diagnosed with esophageal varices. The patient had the procedure of a direct ligation of the esophageal varices performed for the condition identified. Upon completion of the procedure the patient went to the recovery room in stable condition. Select the appropriate CPT and ICD-10-CM codes

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):