Exam 27: Coding and Surgical Procedures

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.

Patient is admitted as an inpatient to the hospital on 11-01 and discharged on 11-05 for pneumonia. Select the appropriate evaluation and management CPT code and ICD-10-CM code to report for the 11-05 discharge date.

Shelley presents to her endocrinologist for final determination on how the physician will proceed with her hyperthyroidism. He orders a thyroid uptake and scan for single determination to be done at the radiology department in his building. Choose the appropriate CPT and ICD-10-CM codes for the radiologist.

A patient with cerebral palsy was seen for evaluation for a non-speech-generating augmentative and alternative communication (AAC) device. The evaluation took one hour and forty minutes, including evaluation of motor, visual, cognitive, language and communication strengths and weaknesses, and discussion with family members. Select the appropriate CPT and ICD-10-CM codes.

An 81-year-old female has primary open angle glaucoma, severe stage of the left eye. The patient was sent to the OR for a sequential cyclocryotherapy. After moderate sedation was administered by the physician, a wire lid speculum was used to separate the lids of the left eye. The cyroprobe with liquid nitrogen and nitrous oxide was applied. A freeze-thaw-freeze triple row of cryotheraphy was done. The entire procedure took 45 minutes, and the patient tolerated the procedure well and was sent home. Select the appropriate CPT and ICD-10-CM codes.

Thoracic Aortogram with Cerebral Angiography History: The patient is an 82-year-old man with a thoracic aneurysm and carotid stenosis. Procedure: A 20-minute consultation was utilized explaining the risks, benefits, and alternatives of angiography. All the patient's questions were answered, and he had given informed consent prior to the procedure. The patient was premedicated with IM Demerol and Phenergan. Buffered lidocaine was used for local anesthesia. Sedation was not required. A 5-French pigtail catheter was advanced into the aorta via the right femoral artery with the standard Seldinger technique. With the tip of the catheter in the ascending aorta, an aortogram with digital subtraction technique was obtained in the left anterior projection. AP frontal view of the intracranial circulation was also obtained from an arch injection. The catheter was then exchanged over a guidewire for a 5-French Simmons II catheter. The carotid artery and left vertebral artery were selectively catheterized and injected with contrast for digital subtraction filming. In the right common carotid, it was initially difficult to get a stable catheter position, and various combinations of guidewires and a Simmons III catheter were used to obtain selective catheterization. After all images were reviewed, the catheter was removed, and direct pressure was applied to the puncture site until complete hemostasis was achieved. Total contrast load was 132 cc of Isovue. Fluoroscopy time was 41.5 minutes. Findings: The ascending aortic arch is dilated and has a more normal diameter just after the left subclavian catheter, and then the descending thoracic aorta enlarges again. There is no evidence of intimal dissection. The origins from the arch are patent. The right carotid bifurcation is slightly irregular; however, no hemodynamically significant stenosis is observed in the right internal carotid. The right external carotid is open. The left external carotid is completely occluded. The left internal carotid has 75% reduction of its cross-sectional area near its origin. On selective injections, it is interesting to note that the right anterior cerebral artery does not fill from the right carotid injection, but both anterior cerebral arteries fill from the left carotid injection. Vertebral arteries are patent. The left vertebral artery is larger. No obvious intracranial abnormality is observed. Impression: There is 75% stenosis of the left internal carotid. Complete occlusion of the left external carotid. Very mild irregularity of the right internal carotid. Widely patent right external carotid. Both vertebral arteries are patent. Select the appropriate ICD-10-CM codes.

Dell is a farrier, and he was kicked in the sacral-coccygeal area by a horse that he was shoeing. The injury was significant enough to require an open treatment to repair the coccygeal fracture. Select the appropriate ICD-10-CM and CPT code(s):

Preoperative diagnosis: Morbid obesity Postoperative diagnoisis: Morbid obesity Procedure performed: Abdominal panniculectomy Estimated blood loss: Throughout the procedure, approximately 20 Ml Anesthesia: General endotracheal anesthesia Indications for procedure: This is a 49-year-old female who previously underwent gastric bypass surgery and has lost 120 pounds, leaving a large lower pannus of the abdomen. This pannus needs to be resected. The nonoperative versus operative management options were discussed with the patient. The operative risks included bleeding, infection, hematoma, chance for further surgery as well as pain, and a resulting scar. The patient accepted the risks and consented to surgery. Procedure in detail: The patient was placed under general endotracheal anesthesia. The patient was draped in the proper manner, and the lower abdominal pannus was identified. It was preoperatively marked prior to going to the OR. The lower incision was made from the superior iliac crest with the middle being the pubic tubercle. That lower incision was then made. The pass was then elevated at the level of the anterior abdominal fascia and was elevated superiorly to the level of the inferior umbilicus. Then incisions were made on the umbilicus to the superior iliac crest, and the skin and subcutaneous pannus was passed off table as a specimen. The wound was then made hemostatic with the use of electrocautery. JP drains were placed. The abdominal skin flap was then brought to the inferior skin flap and sutured in place with 2-0 Vicryl sutures at the dermal level. The drains were then secured, and then the skin was closed with running 3-0 Monocryl suture. The wound was further dressed with Steri-strips, gauze, and abdominal binder. The patient tolerated the procedure well. All needle and instrument counts at the end of the procedure were correct, and the patient was taken to PACU in good condition. Select the appropriate ICD-10-CM and CPT code(s):

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 diagnosis: Morbid obesity Postoperative diagnoisis: Morbid obesity Procedure performed: Abdominal panniculectomy Estimated blood loss: Throughout the procedure, approximately 20 Ml Anesthesia: General endotracheal anesthesia Indications for procedure: This is a 49-year-old female who previously underwent gastric bypass surgery and has lost 120 pounds, leaving a large lower pannus of the abdomen. This pannus needs to be resected. The nonoperative versus operative management options were discussed with the patient. The operative risks included bleeding, infection, hematoma, chance for further surgery as well as pain, and a resulting scar. The patient accepted the risks and consented to surgery. Procedure in detail: The patient was placed under general endotracheal anesthesia. The patient was draped in the proper manner, and the lower abdominal pannus was identified. It was preoperatively marked prior to going to the OR. The lower incision was made from the superior iliac crest with the middle being the pubic tubercle. That lower incision was then made. The pass was then elevated at the level of the anterior abdominal fascia and was elevated superiorly to the level of the inferior umbilicus. Then incisions were made on the umbilicus to the superior iliac crest, and the skin and subcutaneous pannus was passed off table as a specimen. The wound was then made hemostatic with the use of electrocautery. JP drains were placed. The abdominal skin flap was then brought to the inferior skin flap and sutured in place with 2-0 Vicryl sutures at the dermal level. The drains were then secured, and then the skin was closed with running 3-0 Monocryl suture. The wound was further dressed with Steri-strips, gauze, and abdominal binder. The patient tolerated the procedure well. All needle and instrument counts at the end of the procedure were correct, and the patient was taken to PACU in good condition. Select the appropriate ICD-10-CM and CPT code(s):

A patient complained of pain in the lumbar region with pain down the right leg. The pain was felt in the posterior portion of the leg, and the pain radiated to the distal and lateral area of the leg. Based on this description, the pain

Thoracic Aortogram with Cerebral Angiography History: The patient is an 82-year-old man with a thoracic aneurysm and carotid stenosis. Procedure: A 20-minute consultation was utilized explaining the risks, benefits, and alternatives of angiography. All the patient's questions were answered, and he had given informed consent prior to the procedure. The patient was premedicated with IM Demerol and Phenergan. Buffered lidocaine was used for local anesthesia. Sedation was not required. A 5-French pigtail catheter was advanced into the aorta via the right femoral artery with the standard Seldinger technique. With the tip of the catheter in the ascending aorta, an aortogram with digital subtraction technique was obtained in the left anterior projection. AP frontal view of the intracranial circulation was also obtained from an arch injection. The catheter was then exchanged over a guidewire for a 5-French Simmons II catheter. The carotid artery and left vertebral artery were selectively catheterized and injected with contrast for digital subtraction filming. In the right common carotid, it was initially difficult to get a stable catheter position, and various combinations of guidewires and a Simmons III catheter were used to obtain selective catheterization. After all images were reviewed, the catheter was removed, and direct pressure was applied to the puncture site until complete hemostasis was achieved. Total contrast load was 132 cc of Isovue. Fluoroscopy time was 41.5 minutes. Findings: The ascending aortic arch is dilated and has a more normal diameter just after the left subclavian catheter, and then the descending thoracic aorta enlarges again. There is no evidence of intimal dissection. The origins from the arch are patent. The right carotid bifurcation is slightly irregular; however, no hemodynamically significant stenosis is observed in the right internal carotid. The right external carotid is open. The left external carotid is completely occluded. The left internal carotid has 75% reduction of its cross-sectional area near its origin. On selective injections, it is interesting to note that the right anterior cerebral artery does not fill from the right carotid injection, but both anterior cerebral arteries fill from the left carotid injection. Vertebral arteries are patent. The left vertebral artery is larger. No obvious intracranial abnormality is observed. Impression: There is 75% stenosis of the left internal carotid. Complete occlusion of the left external carotid. Very mild irregularity of the right internal carotid. Widely patent right external carotid. Both vertebral arteries are patent. Select the appropriate ICD-10-CM codes.

Jones is a patient with recurrent stage IV colon carcinoma of the sigmoid colon. He had previously undergone a laparoscopic low anterior resection (LAR). He was brought to the operating room today and under general anesthesia underwent a laparoscopic lysis of adhesions. The small bowel loops were found to be adherent to the anterior abdominal wall and also near the colostomy. These adhesions were lysed. There was one loop of small bowel that was adherent to the anterior abdominal wall of the RLQ, and this adhesion was not disturbed. Select the appropriate ICD-10-CM and CPT code(s):

Which Medicare program covers physician services?

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):

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.

Preoperative Diagnosis: Gallstones Postoperative Diagnosis: Cholelithiasis Operation: Cholecystectomy Operation Description: A 52-year-old patient is diagnosed with gallstones. The patient was consulted by the surgeon and it was recommended that a cholecystectomy be scheduled. Patient reviewed the risks and the consent was signed. The procedure went well and the patient left to the recovery room in good condition. Select the appropriate CPT and ICD-10-CM codes.

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?

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.

McKenna was born at 36 weeks and is now 1 month old. She presented with a reducible right inguinal hernia and hydrocele. She was taken to the OR for a repair. Select the appropriate ICD-10-CM and CPT code(s):