Exam 27: Coding and Surgical Procedures

A patient with severe muscle cramps, pain, and discomfort in his extremities, and an elevated creatinine kinase level, is presenting today for a percutaneous needle muscle biopsy. Select the appropriate CPT and ICD-10-CM codes.

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.

A 53-year-old male has been plagued by intermittent severe pain caused by his trigeminal neuralgia which interferes with his common daily activities. He has developed sleep deprivation, depression, and loss of appetite. Today he presents for destruction of the trigeminal nerve by neurolytic agent. Select the appropriate CPT and ICD-10-CM codes.

The patient was seen for complaints of persistent cluster headaches and blurring vision. As part of the workup, a lumbar puncture was performed, the pressure of the spinal fluid was measured, and some fluid was removed for analysis. Select the appropriate ICD-10-CM and CPT code(s):

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):

An established patient presents to the office with an acute, deep cough, along with wheezing. The patient has a history of allergies along with chronic rhinitis. After an expanded problem-focused exam, the physician learns that the patient's home has just been found to have mold in the walls. The physician has spent an additional 15 minutes providing resources and counseling with the patient regarding the effects of mold and treatment of his URI. The physician has also recommended lab tests and x-rays. Select the appropriate CPT and ICD-10-CM codes.

The patient is in the intensive care unit with fluid overload with acute renal failure. He has type 2 DM and sepsis. The patient is sedated and on a ventilator because of respiratory failure. Code the diagnoses only:

A surgeon performs a ritualistic surgical circumcision on a 30 day old male. Select the appropriate ICD-10-CM and CPT code(s):

_____ is defined as making false statements or representations of material facts to obtain some benefit or payment for which no entitlement would otherwise exist.

A 58-year-old male is undergoing a therapeutic endoscopic retrograde cholangiopancreatography. The gastroenterologist injects the contrast agent, and using fluoroscopy views the hepatobiliary system, collects specimens for testing, and places a biliary stent to relieve the patient's jaundice. Select the appropriate CPT and ICD-10-CM codes.

CPT codes are considered HCPCS _______________codes:

Jim Jones is a 32-year-old from Maryland who was in town last week with ESRD. He was seen for four dialysis treatments this month. Select the appropriate ICD-10-CM and CPT code(s):

The purpose of the medical record includes:

Procedure: This 10-year-old female is referred for a 16-channel electroencephalogram due to unexplained seizures. During wakefulness, the posterior background is comprised predominately of 9 Hertz alpha activity, which is well modulated, symmetric, and responsive to eye opening. The anterior background contains 15-20 Hertz low voltage beta activity. With drowsiness there is attenuation of the posterior alpha rhythms, and 5-7 Hertz bi-temporal and sensual beta rhythms are noted. With early stage 2 sleep, there is 3-4 Hertz slowing of the record with occasional midline vertex waves and synchronous sleep spindle formation. No lateralizing asymmetries or epileptiform discharges are noted. Total duration was 4 hours. Impression: This is an unremarkable awake, drowsy, and stage 2 sleep electroencephalogram. No evidence of ictal discharges or lateralizing asymmetries. Select the appropriate CPT and ICD-10-CM codes.

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.

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):

John, a nine-year-old boy, is being seen today for persistent allergic sinusitis. Today he will undergo percutaneous sequential and incremental allergy testing with biological allergens with 15 various allergens being applied followed by interpretation and report. Select the appropriate CPT and ICD-10-CM codes.

Sally was seen today in her first trimester for her prenatal blood work. The blood work ordered is complete blood count with automated differential, Hepatitis B surface antigen, rubella antibody, syphilis test, RBC antibody screen, blood typing, Rh typing and automated urinalysis with microscopy. Select the appropriate CPT and ICD-10-CM codes.

Which of the following are true statements concerning acute and chronic conditions and their coding guidelines?

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