Exam 27: Coding and Surgical Procedures

Clinical diagnosis: Cholecystitis and Chronic Calculi Operation: Cholecystectomy Specimen: Gall bladder Pathology Report: Microscopic analysis of specimen measuring 9.0 X 3.0cm. Diagnosis: Chronic cholecystitis, cholelithiasis Select the appropriate CPT and ICD-10-CM codes.

Sarah Jones has suffered with severe menorrhagia for many years. She also has severe rheumatoid arthritis. Dr. Jones performed a radical hysterectomy. General anesthesia was administered. The surgery was a success and the patient left the recovery room in good condition. Select the appropriate CPT code(s) for the anesthesia services, as well as the ICD-10-CM code.

Jones accompanied a newborn girl with respiratory failure who had been born 23 hours earlier from the community hospital to the university children's hospital. The ride takes 95 minutes. Dr. Jones provided critical care services to the infant during the ambulance ride. The patient was admitted to the neonatal ICU at the new facility. Select the appropriate CPT and ICD-10-CM codes.

CT Scan of the Abdomen and Pelvis History: Malignant testicular neoplasm Technique: Axial CT images of the abdomen and pelvis were obtained with intravenous and oral contrast. Findings: Images of the lung bases are normal. Images of the abdomen show the liver, spleen, gallbladder, pancreas, and adrenal glands to be normal. No mass is seen. There is no evidence of cholelithiasis. A retroaortic left renal vein is seen. No obvious mass or enlarged lymph nodes are noted in the retroperitoneum. Mesenteric structures appear normal. A prominent inferior vena cava is seen. Gas is identified in the left inguinal structures, likely representing previous left orchidectomy and removal of the inguinal ring. No enlarged lymph node is identified in the pelvis. Impression: Left retroaortic renal vein is seen. No adenopathy is noted within the abdomen or pelvis. No enlarged lymph node is seen; no mass is identified. Select the appropriate ICD-10-CM and CPT code(s):

Mr. Jones, a new patient with a history of prostate cancer 6 years ago, presented today with pain in his lower back and weakness in his extremities. He brought films from x-rays taken earlier in the week and his previous records from his internal medicine physician. The physician takes a comprehensive PMFSH and ROS and performs a comprehensive examination. Based on review of the records and his findings, the physician's diagnosis is metastatic prostate cancer to the sacral vertebrae. The physician discussed treatment options with the patient including risks and benefits. Select the appropriate ICD-10-CM and CPT code(s):

A 43-year-old male came into the doctor's office to have a hemorrhoidopexy by stapling for his second-degree hemorrhoids. He was very uneasy since he had never had this procedure before. Dr. Hanson administered an IV of Versed, for the anxiety. The procedure is not really painful, so there was no need for a full anesthetic or painkiller. Myrtle Pape, a certified registered nurse anesthetist (CRNA), sat with the patient throughout the procedure to ensure his safety and comfort level. The procedure was complete in one stage, taking 30 minutes.Select the appropriate ICD-10-CM and CPT code(s):

A patient is referred for a renal ultrasound following transplantation of his right kidney 6 months ago. The patient's creatinine clearance is elevated and the scan is directed to the renal vein only. Select the appropriate CPT code.

Preoperative Diagnosis: Upper gastrointestinal bleeding Postoperative Diagnosis: Gastritis Operation: EGD Operation Description: Patient admitted for upper gastrointestinal bleeding. Patient was informed that an EGD would be completed and understands the risks involved. Consent was obtained. Patient was prepped in the usual sterile fashion. The endoscope entered the oropharynx and the esophagus inspected and revealed no ulcerations or other abnormalities. Coffee ground material was present but no fresh blood noted. Area was biopsied and then scope removed. Patient went to the recovery room in stable condition. Select the appropriate CPT and ICD-10-CM codes

Albert Brown goes to get his RX filled for an outflare wedge to be placed in his left shoe. Select the appropriate HCPCS code.

Which of the following is not considered a covered entity?

An 11-year-old boy is brought to the ED with fever, malaise, and a stiff neck. The ED physician performs a spinal tap to R/O meningitis. The patient is admitted to University Hospital to further monitor his status. Later during the evening, the boy complains of a severe headache along with a "runny nose". The physician orders a nuclear medicine study to detect CSW fluid leakage and localization. Select the appropriate CPT and ICD-10-CM codes.

Patient Susie Jones, a 32-year-old female, was admitted to the intensive care unit for acute respiratory distress syndrome. She was given critical care services by her provider Dr. Mark Smith for an hour and twenty minutes. Select the appropriate CPT and ICD-10-CM codes.

A 59-year-old male patient is scheduled for a 2^nd stage TURP due to BPH with urinary obstruction and LUTS. 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.

The term meaning "many pregnancies" is:

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):

A wall dividing two cavities is the definition of:

History: 76-year-old female with colonic mass Diagnosis: Invasive adenocarcinoma, 3.4 × 3.0 cm, involving muscularis propria All margins negative. No lymphatic invasion. No metastatic tumor identified. Gross description: Received fresh is a right colon, 32 cm in length. Upon opening of the specimen, there is a 3.4- × 3.0-cm nodular mass. 36 lymph nodes were retrieved. Representative sections are submitted. Microscopic description: Microscopic examination performed Select the appropriate ICD-10-CM and CPT code(s):

A patient with pancreatic cancer was found to have a lung mass. A flexible bronchoscopy, transbronchial lung biopsy, brushing and washing were performed. The surgeon identified a left perihilar mass and mucosal abnormality in the posterior subsegment of the left upper lobe. The pathology finding was metastasis to the lung. Select the appropriate CPT and ICD-10-CM codes.

A patient with pulmonary artery stenosis was treated with balloon angioplasty of the pulmonary artery to crush the plaque into the walls of the artery. To accomplish this, a catheter was inserted through the skin into the femoral artery and threaded up to the pulmonary artery. Select the appropriate CPT and ICD-10-CM codes.