Exam 27: Coding and Surgical Procedures

A 3-year-old underwent plastic repair of her bilateral complete cleft lip. The CRNA was medically directed by the anesthesiologist. Select the appropriate CPT and ICD-10-CM codes.

Select the appropriate CPT and ICD-10-CM codes for marsupialization to treat a pancreatic pseudocyst with acute pancreatitis caused by alcoholism.

Patient underwent nasal endoscopy in the office of the ENT physician with removal of two pedunculated nasal polyps from the R nasal cavity. The patient tolerated the procedure well and was given an appointment to RTC in two weeks for follow up. Select the appropriate CPT and ICD-10-CM codes.

Which is NOT an appropriate step in determining an ICD-10-CM code?

Preoperative Diagnosis: Cleft palate Postoperative Diagnosis: Cleft palate Operation: Repair of cleft palate Anesthesia: General Operation Description: A 3-year-old patient was diagnosed with cleft palate was advised by the surgeon to complete the surgical procedure repairing the cleft palate. The risks were discussed and identified with the family. Consent was obtained. The procedure of the cleft palate repair was performed. No complications noted and the patient returned to the recovery room in good condition. Select the appropriate CPT and ICD-10-CM codes.

A computerized lifelong healthcare record of an individual patient that incorporates data from all sources that provide treatment is called a(n)

Mrs. Jones presented with pain in the right upper quadrant. Upon a CT of the abdomen and an ultrasound of the gallbladder, a diagnosis of cholelithiasis and acute cholecystitis was confirmed, and the patient was taken to the operating room. The patient underwent a laparoscopic cholecystectomy with a normal intraoperative cholangiogram to remove the gallstones. Select the appropriate ICD-10-CM and CPT code(s):

Sam, a 26-year-old male with Down syndrome, undergoes lithotripsy with a water bath for lodged ureteral stones. The procedure was supervised by the anesthesiologist under general anesthesia due to the patient's Down syndrome and associated anxiety. Select the appropriate CPT and ICD-10-CM codes.

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):

A 55-year-old male presents at his surgeon's office with Gynecomastia. The surgeon decides he will perform a mastectomy of the patient's left breast. Select the appropriate CPT and ICD-10-CM codes.

The physician used cryotherapy to correct an ingrown eyelash on the left upper lid. Select the appropriate CPT and ICD-10-CM codes.

A 22-year-old patient presents to the physician's office with a migraine headache, stiff neck, and fever. Dr. Blue performs a lumbar puncture in the office and confirms the condition of meningitis. The patient tolerated the procedure well. Select the appropriate CPT and ICD-10-CM codes.

Jeremy is seen at the clinic today by his regular physician for a rash on his arm that developed while camping in the woods this past weekend. After the problem-focused history and examination the physician determines that the problem was caused by poison oak, and Jeremy is diagnosed with allergic contact dermatitis and prescribed corticosteroid skin cream to reduce the inflammation. Select the appropriate ICD-10-CM and CPT code(s):

An infant was born with a hole in the septum dividing the ventricles of the heart. A right heart catheterization was performed using a percutaneous catheter to repair the defect and implant an occlusive device. The outcome was successful. Select the appropriate CPT and ICD-10-CM codes.

Doug, a 45-year-old patient with ESRD, receives a unilateral cadaver kidney transplant. The surgeon performs the backbench work in addition to the transplant. Select the appropriate ICD-10-CM and CPT code(s):

Clarkston visited the nursing home today to see how the stage 3 pressure ulcer he debrided was doing. He also changed the dressing on the pressure ulcer. The original damage was through the full thickness of the dermis and into the subcutaneous tissue on the right buttock. Select the appropriate CPT and ICD-10-CM codes.

An emergency craniotomy was performed for evacuation of an intraparenchymal hemorrhage in the right frontal lobe that developed after resection of a pituitary tumor earlier in the day. Select the appropriate CPT and ICD-10-CM codes.

Preoperative diagnosis: Respiratory insufficiency Postoperative diagnosis: Respiratory insufficiency Operation: Tracheostomy with division of thyroid isthmus Estimated blood loss: Less than 10 mL Fluids: Crystalloid Complications: None Technique: The patient was brought to the operating room and placed in the supine position. He was given general anesthesia through his existing oral intubation tube. The anterior neck was prepped and draped in the usual sterile fashion. Lidocaine 1% with 1:100,000 epinephrine was infiltrated into the skin at the lower neck. A transverse incision was made at the cricoid ring level through skin and subcutaneous fat. The platysmal layer was traversed, and then the strap muscles were separated in the midline. The thyroid isthmus was ligated and divided with #2-0 silk ligatures. An inferiorly based tracheostomy flap was created using the second and third tracheal rings and sewn into place with a #3-0 chromic stitch to the inferior dermis margin. Hemostasis was achieved using suction cautery. At this point, the oral intubation tube was withdrawn, and a #8 Shiley low-pressure cuffed tube was passed into the newly created trach site. The trach ties were tied securely into place, and the cuff was inflated to a comfortable pressure. The patient then received further ventilation through the newly placed trach tube. The patient was then allowed to awaken from general anesthesia and was taken back to the ICU in stable condition. Select the appropriate ICD-10-CM and CPT code(s):

Steve presents today for an epidural injection of a steroid, caudal to relieve his low back pain, radiating leg pain, and coccygodynia. Steve is placed in a prone position with a cushion below his stomach to arch his back. Local anesthetic is applied to numb the skin and tissue down to the surface of the sacral hiatus. After the needle is placed in the area, 1.5cm of contrast solution helps the physician see painful areas under fluoroscope. The steroid is injected in the epidural space. The needle is removed, bandage applied, and the patient is sent home. Select the appropriate CPT and ICD-10-CM codes.

A patient with chronic recurrent acute sinusitis and nasal polyps presented to the outpatient surgical center for endoscopic frontal sinus exploration with osteomeatal complex resection, anterior ethmoidectomy, and removal of nasal polyps. Select the appropriate CPT and ICD-10-CM codes.