Exam 27: Coding and Surgical Procedures

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.

Specimen site: Cervical biopsy Pre-operative Diagnosis: Severe squamous dysplasia, consistent with CIN III (high-grade dysplasia) Gross description: Cervical biopsy: One fragment of gray-white tissue, measuring 0.5 centimeters in diameter. Totally submitted with a request for levels. Submitted request for stains. Microscopic description: Sections of the cervical biopsy show high-grade dysplasia, consistent with CIN III. No evidence of invasive malignancy is present. 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.

Preoperative Diagnosis: worsening effort angina with severe left ventricular failure. Postoperative Diagnosis: same Operative Procedure: endoscopic coronary artery bypass graft including harvesting of the saphenous vein X 3. Select the appropriate CPT and ICD-10-CM codes.

Preoperative Diagnoses: Oxygen dependency. Chronic obstructive pulmonary disease. Postoperative Diagnoses: Oxygen dependency. Chronic obstructive pulmonary disease. Procedure Performed: Tracheostomy with skin flaps. SCOOP Procedure FastTract. Indications: The patient is a 55-year-old male with a history of chronic obstructive pulmonary disease and O2 dependency of approximately 5 liters nasal cannula at home. The patient with extensive smoking history presents after risks, complications, and consequences of the SCOOP FastTract transtracheal oxygen procedure were explained. Procedure: The patient was brought to operating suite by Anesthesia and placed on the operating table in the supine position. After this, the patient was then placed in reverse Trendelenburg. The patient's sternal notch along with cricoid and thyroid cartilages were noted and palpated and a sternal marker was utilized to mark the cricoid cartilage in the sternal notch. The midline was also marked and 1% lidocaine with epinephrine 1:100,000 at approximately 4 cc total was then utilized to localize the neck. A skin incision was then made in the midline in a vertical fashion. After this, the skin was retracted laterally and a small anterior jugular branch was clamped and cross clamped and tied. Further bleeding was controlled with monopolar cauterization and attention was then drawn down on to the strap muscles. The patient's sternohyoid muscle was identified and grasped on either side and the midline raphe was identified. Cauterization was then utilized to take down the midline raphe and further dissection was utilized with the skin hook and stat clamps. The anterior aspect of the thyroid isthmus was identified and palpation on the cricoid cartilage was performed. The cricoid cauterization over the cricoid cartilage was obtained with the monopolar cauterization and blunt dissection then was carried along the posterior aspect of the thyroid isthmus. Stats were then placed on either side of the thyroid isthmus and the mid portion was bisected with the monopolar cauterization. Next, the patient's anterior trachea was identified and cleaned with pusher. The cricoid cartilage along the first and second tracheal rings was identified. The cricoid hook was placed and the trachea was brought more anteriorly and superiorly. A small 4 mm punch was created within the tracheal cartilage using the punch in the SCOOP FastTract kit. A tracheal stent was placed within the tracheal punched lumen and the tracheal stent secured to the neck with a Vicryl strap. Then the cricoid hook was removed and the patient then had FiO2 on the monitor noted with pulse oximetry of 100%. The patient was transferred to the recovery room in stable condition. Select the appropriate CPT and ICD-10-CM codes.

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.

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.

The patient undergoes repair of the renal pelvis to treat an ureteropelvic junction obstruction the patient has had since birth. An incision is made and an excision is performed on the (right) congenital kidney abnormality; a secondary pyeloplasty, solitary kidney or calycoplasty is performed on the left kidney. Select the appropriate CPT and ICD-10-CM codes.

Joe Arrow came in to have a small lesion on his right cheek removed. After examination, his dermatologist decided to remove the 0.5 lesion by shaving. Select the appropriate CPT code(s).

Mrs. Jones, an established patient, is seen by the rheumatologist for repeated pain in her left knee due to osteoarthritis. Today she presents with pain and swelling. The rheumatologist performs an arthrocentesis of the left knee followed by injection of Dexa-Methasone sodium phosphate, 5 mg. No E/M service is performed. Select the appropriate ICD-10-CM and CPT code(s):

Julia was playing baseball in her hardball league and was hit in the face with a line drive. Upon waking she was taken directly to the hospital. She has a fractured mandible, and the orthopedic surgeon is performing a closed treatment with interdental fixation. Select the appropriate CPT and ICD-10-CM codes.

A 49-year-old patient has arthritis of the right and left knee with ongoing pain and swelling. The physician performed an arthrocentesis for the patient's condition. Patient was prepped and fluid withdrawn from the left knee joint. The patient tolerated the procedure well and was instructed to return for a follow up visit in one week to aspirate the right knee joint. Select the appropriate CPT and ICD-10-CM codes.

A 14-year-old boy who is a new patient presents with acute contact dermatitis. During the expanded problem-focused history, the doctor learns that the boy just came back from a camping trip and was out in the woods when his skin began to itch. The examination was also expanded. The physician sends the patient home with a prescription and instructs him to return if the condition does not improve in a few days. While checking all of the patient's immunizations, the physician notes that the patient is in need of a tetanus vaccination, so that is also given. Select the appropriate CPT and ICD-10-CM codes.

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.

Preoperative Diagnosis: Uterine Mass Postoperative Diagnosis: Uterine Mass Operation: Hysteroscopy Operation Description: A 43-year-old patient was diagnosed with a uterine mass as noted on an ultrasound. Patient was administered general anesthesia upon arrival to the operating room. The patient was prepped. The hysteroscope was introduced and biopsy was obtained. Specimen was sent to pathology. Patient tolerated the procedure well. Select the appropriate CPT code for the anesthesia service, as well as the ICD-10-CM code.

Procedure Description: Under anesthesia via endotracheal intubation, the ears were inspected with the operating microscope. Anterior inferior quadrant myringotomy incisions were performed bilaterally. Armstrong tubes were inserted. Diagnosis: Recurrent acute otitis media, bilateral middle ear effusions Select the appropriate CPT and ICD-10-CM codes.

Sam, a welder, was seen today by the ophthalmologist for removal of a welding flash from his left eye. The flash had caused a nonperforating tear in the cornea. The ophthalmologist removed the flash and repaired the cornea. Select the appropriate ICD-10-CM and CPT code(s):

Smith is performing a vaginal hysterectomy, with removal of tubes and ovaries, for a 59 year old patient. Her diagnoses include menorrhagia and ovarian endometriosis. Select the appropriate CPT and ICD-10-CM codes.

A 4-year-old male underwent a frenoplasty using the Z technique to correct his speech difficulty due to ankyloglossia. Select the appropriate ICD-10-CM and CPT code(s):

Julia was playing baseball in her hardball league and was hit in the face with a line drive. Upon waking she was taken directly to the hospital. She has a fractured mandible, and the orthopedic surgeon is performing a closed treatment with interdental fixation. Select the appropriate CPT and ICD-10-CM codes.