Exam 27: Coding and Surgical Procedures

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.

Patient was admitted with chest pain, R/O MI. The physician ordered the following laboratory tests: Comprehensive metabolic panel, CBC w/differential, Sedimentation rate, PT, troponin level, automated urinalysis w/microscopy. Select the appropriate CPT and ICD-10-CM codes for the laboratory tests.

Section: Kidney (left): Adenocarcinoma MACROSCOPIC Specimen type: Radical nephrectomy Laterality: Left Tumor site: Upper pole Focality: Unifocal Tumor size: Greatest dimension is 7.2 cm. Macroscopic extent of tumor: Tumor extends into major veins. MICROSCOPIC Histologic type: Clear cell (conventional) renal carcinoma Histologic grade: Furhman Nuclear Grade 2 PATHOLOGIC STAGING (pTN) Primary tumor (pT): pT3 Regional lymph nodes (pN): Nx Number of lymph nodes examined: 0 Number of lymph nodes involved: 0 Margins: Renal vein margin positive Adrenal gland: Unevolved Venous (large vessel) invasion (V) (excluding renal vein and inferior vena cava): Negative Lymphatic (small vessel) invasion (L): Present Additional pathologic findings: Chronic glomerulonephritis present in noninvolved renal parenchyma Clinical history: A 76-year-old male with a left renal mass in the upper pole; hematuria Gross description section: Received in formalin, labeled "left kidney," is a 12.2- × 7.1- × 2.5-cm kidney with unremarkable perirenal fat present at the upper pole (suture oriented, per requisition). A 2.3 cm in length segment of ureter exits from the hilum. The renal vein appears occluded. The cut sections demonstrate a 7.2- × 1.5- × 1.5-cm brown-orange circumscribed tumor with sharp borders present in the upper pole. Gerota's fascia appears uninvolved. The tumor extends into the renal vein; the venous margin appears positive for tumor. Microscopic section: Microscopic examination was performed. Select the appropriate ICD-10-CM and CPT code(s):

Sally was seen today for repair of four lacerations following a fall on some broken glass. The physician evaluated and performed simple repair on the following: a 6-cm laceration on the right forearm, a 2.5-cm laceration on the right forearm, a 0.5-cm laceration on the left hand, and a 20-cm laceration on the left upper arm. Select the appropriate ICD-10-CM and CPT code(s):

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.

The surgeon performed a correction of hallux valgus with sesamoidectomy using the Joplin procedure on the left foot to correct a bunion. Select the appropriate ICD-10-CM and CPT code(s):

Preoperative Diagnosis: Urethritis Postoperative Diagnosis: Urethritis Operation: Urethral biopsy Operation Description: A 22-year-old male was diagnosed with urethritis. The PCP referred the patient to an urologist, who ordered a urethral biopsy. The patient understood the risks and consent was obtained. The patient was prepped and the biopsy obtained then sent to pathology. Patient left the procedure room in stable condition. Select the appropriate CPT and ICD-10-CM codes.

ESWL was performed on Mrs. Wilson's left kidney 1 week ago; now ESWL is being performed on her right kidney. She has 4 stones being removed today: 2 in the renal pelvis and 2 in the calyx. Under local anesthesia, the ESWL is performed and all 4 stones are successfully destroyed. Select the appropriate CPT and ICD-10-CM codes.

Mustin undergoes insertion of a left custom breast prosthesis 3 months after a mastectomy for breast cancer. The patient needed to undergo radiation to that area prior to the insertion of the prosthesis. Select the appropriate ICD-10-CM and CPT code(s):

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:

Diagnostic esophagogastroduodenoscopy was performed for a patient with suspected ulcers. The endoscope was inserted in the pharynx and was passed all the way through to the jejunum, which revealed ulcers of the stomach, pylorus, and duodenum. The patient tolerated the procedure well and was sent home with prescriptions and a referral to a nutritionist. 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.

Jane Smith is a 44-year-old patient who returns back this month to her primary care physician office for a well woman exam. The exam reveals a normal pelvic exam; no masses in the vaginal and cervical area. Breast exam shows no masses or abnormalities. All other systems are normal. The patient is to return in one year. Select the appropriate CPT and ICD-10-CM codes.

A 26-year-old female was given an epidural during labor for pain management. As a result of cephalopelvic distortion, the decision was made to perform a cesarean section. Select the appropriate CPT and ICD-10-CM codes for anesthesia.

Description: Diagnostic Mammogram and ultrasound of the breast. Exam: Bilateral diagnostic mammogram and right breast ultrasound. History of palpable abnormality at 11 o'clock in the right breast. Family history of mother with breast cancer at age 45. Technique: CC and MLO views of both breasts were obtained. Spot compression views of the palpable area were also obtained. Right breast ultrasound was performed. Comparison is made with 10/31/11. Findings: The breast parenchymal pattern is stable with heterogeneous scattered areas of fibroglandular tissue. No new mass or architectural distortion is evident. Asymmetric density in the upper outer posterior left breast and a nodule in the upper outer right breast are unchanged. There is no suspicious cluster of microcalcifications. Directed ultrasonography of the upper outer quadrant of the right breast revealed no cystic or solid mass. Impression: 1) Stable mammographic appearance from 10/31/11. 2) No sonographic evidence of a mass at 11 o'clock in the right breast to correspond to the palpable abnormality. The need for further assessment of a palpable abnormality should be determined clinically. Select the appropriate CPT codes for this encounter.

Upon orders from Dr. Clyos, a portable x-ray machine was transported to the city nursing home for chest x-rays of a patient with possible tuberculosis. The diagnosis was nodular lesions and patchy infiltrates in the upper lobes. Select the appropriate ICD-10-CM and CPT code(s):

Anesthesia is administered to a normal, healthy patient for a cesarean hysterectomy following neuraxial labor anesthesia. Select the appropriate CPT code(s):

A 26-year-old male was seen in the emergency room for a laceration to his right ring finger when a glass window he was installing on his job as a construction worker broke. After exploring the wound, the surgeon found a 100% laceration to the ulnar digital neurovascular bundle, which was repaired. The flexor digitorum profundus nerve had a 25% transverse laceration, which was also repaired. The flexor digitorum superficialis nerve had a partial ulnar slip laceration, but no repair was needed because the majority of it was intact. Select the appropriate CPT and ICD-10-CM codes.

Presbycusis is defined as:

Clinical History: Symptoms of SOB, chest pain on inspiration, as well an oxygen saturation of 84. Study performed: Ventilation and perfusion studies of the lungs. Interpretation: Particularly positive ventilation and perfusion lung scan. There are no segmental defects to suggest a pulmonary embolus. Select the appropriate CPT and ICD-10-CM codes.