Exam 27: Coding and Surgical Procedures

A 27-year-old female comes to her OB/GYN office for removal of her Norplant capsule because it is at the end of its efficacy. She is undecided on whether to have this capsule replaced. After discussion with her physician, she decides to continue the Norplant as a contraceptive. Select the appropriate CPT and ICD-10-CM codes.

Specimen site: Right medial cheek Specimen site: Left dorsal hand Gross description: Right medial cheek: The specimen is one gray-white fragment measuring 0.3 × 0.2 cm. Totally submitted in one cassette with a request for levels labeled "A." Left dorsal hand: The specimen is one gray-white fragment measuring 0.3 × 0.3 cm. Totally submitted in one cassette with a request for levels labeled "B." Microscopic description: The right medial cheek shows atypical keratinocytes within the entire thickness of the epidermis extending to the stratum corneum. The lesion appears to have been excised. The dermis shows elastosis. The dorsal hand shows hyperkeratosis. The epidermis is mildly acanthotic. There is extensive dermal elastosis. Final diagnoses: 1) Right medial cheek, biopsy: ? Squamous cell carcinoma in-situ. (See comment.) 2) Left dorsal hand, biopsy: ? Dermal elastosis. ? No malignant changes seen. Comment: The lesion from the cheek appears to reside within the confines of the histologic section. The skin lesion shows no invasive malignancy. Select the appropriate ICD-10-CM and CPT code(s):

A 2-year-old with osteogenesis imperfecta was brought to the OR for application of a halo with placement of seven pins. Select the appropriate ICD-10-CM and CPT code(s):

Which of the following combining forms is for the liver?

A 36-year-old female who was the driver in a car accident presented with whiplash for chiropractic manipulative treatment of her cervical spine. The chiropractor provided a complete history and examination prior to the treatment plan of one visit a week for 2 months, at which point her status will be reevaluated. Today the first manipulation was performed. Select the appropriate ICD-10-CM and CPT code(s):

History: The patient is a 79-year-old male with dyspepsia and weight loss. A recent supraclavicular lymph node biopsy revealed signet-ring cell adenocarcinoma. Specimen site: Stomach Gross description: Received in formalin is a 10.0- × 6.5- × 3.2-cm segment of stomach, with a palpable firm 4.0- × 2.2-cm mass on the designated lesser curvature. The external surface of the specimen is unremarkable and inked black. The cut surfaces demonstrate the mass and adjacent firm areas of nodularity. The remainder of the gastric mucosa is unremarkable. Six lymph node candidates and representative sections of the stomach are submitted. Microscopic description: Microscopic examination was performed. See synoptic report. The uninvolved stomach shows chronic inactive gastritis with intestinal metaplasia. Diagnosis: Stomach (proximal): Invasive adenocarcinoma Comment: Signet-ring cell carcinomas are not typically graded but are high-grade and would correspond to grade 3. Select the appropriate ICD-10-CM and CPT code(s):

Description: CT scan of the abdomen and pelvis without and with intravenous contrast. Exam: CT scan of the abdomen and pelvis without and with intravenous contrast. Clinical Indication: Left lower quadrant abdominal pain. Comparison: None. Findings: CT scan of the abdomen and pelvis was performed without and with intravenous contrast. Total of 100 mL of Isovue was administered intravenously. Oral contrast was also administered. The lung bases are clear. The liver is enlarged and decreased in attenuation. There are no focal liver masses. The adrenal glands, pancreas, spleen, and right kidney are normal. A 9-mm simple cyst is present in the inferior pole of the left kidney. There is no hydronephrosis or hydroureter. The appendix is nonremarkable. There are multiple diverticula in the rectosigmoid. There is evidence of focal wall thickening in the sigmoid colon with adjacent fat stranding in association with a diverticulum. These findings are consistent with diverticulitis. No pneumoperitoneum is identified. There is no ascites or focal fluid collection. The aorta is normal in contour and caliber. Impression: Findings consistent with diverticulitis. Select the appropriate CPT and ICD-10-CM codes.

Diagnosis: Stomach (distal): Invasive adenocarcinoma Gross description: Received in formalin two specimens, 9.0- × 5.5- × 4.3- cm and 2.0- × 1.5- × 3.4-cm segments of the stomach, with a palpable firm 3.0- × 2.5-cm mass on the designated lesser curvature of the larger specimen. The external surfaces of the specimens are unremarkable and inked black. The curved surfaces demonstrate the mass and adjacent firm areas of nodularity. The remainder of the gastric mucosa is unremarkable. Microscopic description: Microscopic examination was performed. See synoptic report. Select the appropriate ICD-10-CM and CPT code(s):

A 27-year-old patient is seen for ruptured synovium in the right shoulder and right elbow due to a baseball injury. An arthroscopic thermal capsulorrhaphy was performed for multidirectional instability and to prevent dislocation. Select the appropriate CPT and ICD-10-CM codes.

Gregory underwent a prostatomy for drainage of a complicated prostatic abscess. Select the appropriate ICD-10-CM and CPT code(s):

A 75-year-old female recently underwent a stroke assessment of her aphasia. The following assessments were performed using Boston diagnostic aphasia examination: expressive and receptive speech, language function, language comprehensive, speed production ability, reading, spelling, and writing skills. Total time 60 minutes. Select the appropriate ICD-10-CM and CPT code(s):

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):

A patient underwent fine-needle aspiration without imaging guidance of a thyroid cyst. 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.

A wall dividing two cavities is the definition of:

Dr. 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.

Preoperative diagnosis: Right subdural hematoma Postoperative diagnosis: Right subdural hematoma Procedure performed: Right temporoparietal craniotomy for evacuation of subdural hematoma Anesthesia: General endotracheal Complications: None Conditions: Stable Indications for procedure: Mr. Green is a 45-year-old male with a known history of alcoholism. He reported falling today, with loss of consciousness for about 20 minutes. Upon arrival at the ED, he was minimally responsive, with some spontaneous movement on the right side. He was intubated and taken to CT, which demonstrated a large right temporal subdural hematoma with 2.5-cm midline shift and effacement of the right lateral ventricle. Description of procedure: The patient was brought to the OR already intubated. General anesthesia was induced. He was given Ancef for preoperative prophylactic IV antibiotics. Lacri-Lube was placed in both eyes, which were then taped shut. A Foley was placed. The patient was positioned supine on the operating room table with the right side elevated with a gel roll. The head was secured in the three-point Mayfield head-holder with the right side up. All pressure points were inspected and padded adequately. The patient's scalp was clipped, prepped, and draped in standard sterile surgical fashion. Local anesthetic was infiltrated along the line of the planned skin incision. A right temporoparietal inverted-question-mark incision was performed with a #10 blade down to the level of the periosteum. The scalp flap, along with the muscle and periosteum, was elevated and reflected anteriorly and held in place with fishhooks. Raney clips were applied to the skin edges. Using the high-speed Midas Rex drill with the perforator bit, burr holes were placed in the temporoparietal region, and they were connected with the B1 and footplate. The bone flap was elevated from the dura and set aside. The underlying brain appeared to be tense. The dura was opened with a 15-blade, and a large amount of subdural hematoma was immediately released. The subdural space was copiously irrigated, and hemostasis was achieved. Select the appropriate ICD-10-CM and CPT code(s):

Dr. Medevial sees Daphnee age 45, for her annual preventative exam. Since Daphnee is an established patient, Dr. Medevial wants a CBC. The CBC is drawn by the nurse, but due to equipment failure, the tube will be sent to MetCare Labs for processing. MetCare labs will be paid directly by Dr. Medevial for the processing. Select the appropriate CPT and ICD-10-CM codes.

The patient is an otherwise healthy 67-year-old male who sustained a fall three weeks ago. The patient is presenting with pain localized to his left knee. On exam the patient was unable to actively abduct and or externally rotate the knee secondary to pain and weakness. MRI demonstrated a displaced tibial tuberosity fracture. The surgeon performed an arthroscopic reduction and internal fixation of displaced greater tuberosity fracture with manipulation. Select the appropriate CPT and ICD-10-CM codes.

Esther Nelson, a 79-year-old female, came to see Dr. Talbot for a right total-knee arthroplasty due to osteoarthritis of right knee. Dr. Clearwater administered the general anesthesia for the procedure. Esther is in otherwise good health. Select the appropriate ICD-10-CM and CPT code(s) for Dr. Clearwater: