Exam 27: Coding and Surgical Procedures

The patient is seen in the OB/GYN office for follow-up postpartum. She had been seen by her previous physician throughout her pregnancy, but has relocated since the normal vaginal delivery of her daughter 6 weeks ago. Select the appropriate ICD-10-CM and CPT code(s):

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):

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.

Preoperative Diagnosis: Ovarian Cyst Postoperative Diagnosis: Ovarian Cyst Operation: I&D of ovarian cyst Operation Description: A 20-year-old female patient was diagnosed with a left ovarian cyst. After being admitted, the patient was prepped in the surgical suite for the drainage of the ovarian cyst, using an abdominal approach. The left ovarian cyst was drained. Patient tolerated the procedure well. Select the appropriate CPT and ICD-10-CM codes.

George presented with chronic intractable pain of unknown origin in his left leg. The neurologist used stereotaxis to create a lesion in the spinal cord in order to attempt to block the pain and provide sustainable relief. Select the appropriate ICD-10-CM and CPT code(s):

A patient presented to the oncology clinic with a diagnosis of testicular tumor of uncertain behavior. The patient brought slides from his orchiectomy which was sent to the pathologist for review and report including a review of the medical records with written report confirming a diagnosis of testicular carcinoma. Select the appropriate CPT and ICD-10-CM codes.

A 59-year-old male patient is scheduled for a 2^nd stage TURP due to BPH with urinary obstruction and LUTS. Select the appropriate CPT and ICD-10-CM codes.

Jim went to the doctor for removal of his skin tags. The physician noted 32 skin tags on his back. Using a scalpel the physician removed all of the skin tags and gave Mr. Evans an antibiotic cream prescription to use for the next 7-10 days. Select the appropriate CPT and ICD-10-CM codes.

CPT codes that fall in the range titled "Introduction and Removal" in the Surgery/Musculoskeletal System include:

An abnormal hump caused by increased convexity of the thoracic spine is called:

A patient is sent to the radiology department with an indication of abdominal pain. A KUB is ordered. The coder inputs data that is then transferred to line 21 of the CMS-1500 form, showing ICD-10-CM code R10.11, and line 24 field C showing CPT 74018. Which of the following has the coder demonstrated?

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.

Clinical history: Nevus, R pinna Postoperative diagnosis: Same Tissue/specimen: Skin of external ear nevus of R pinna Impression: Microscopic sections show the specimen shows a nevus identified as a melanoma. 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):

Jerry is a 55-year-old diabetic with ESRD. At the beginning of September, Jerry began home-based dialysis services. However, on September 18, he was admitted to the hospital where he remained until September 25 when he was discharged home. Dialysis continued on alternate days while he was in the hospital, and physician visits with expanded problem-focused history and examinations were done on those days in between. Select the appropriate CPT and ICD-10-CM codes.

The medical term for air in the pleural cavity is:

Clinical history: Nevus, R pinna Postoperative diagnosis: same Tissue/specimen: skin of external ear nevus of R pinna Impression: microscopic sections show the specimen shows a nevus identified as a melanoma of right ear and auricular canal. Select the appropriate CPT and ICD-10-CM codes.

Bilateral Doppler Study: Carotid Arteries Indications: Status post-carotid endarterectomy imaging. The patient states that he was told that the right carotid artery is blocked. The right internal carotid artery is not identified, probably completely blocked. Velocity measurements on the right side: Common carotid artery: 58.9 cm/sec Right external carotid: 142 cm/sec Right vertebral: 44 cm/sec and showing antegrade flow Velocity measurements on the left side: Common carotid artery: 35 cm/sec Carotid bulb: 60 cm/sec Internal carotid: 52 cm/sec External carotid: 236 cm/sec Left vertebral: 55 cm/sec Status postendarterectomy changes are noted in the left internal carotid and the bulb. There is evidence of ectasia. On the right, the common carotid artery shows ectasia. Judging from the velocity measurements, the right internal carotid artery has a stenosis in the range of 50% to 79%. The left internal carotid artery has a stenosis in the range of 16% to 49%. The left external carotid artery is in the range of 50% to 79%. Impression: The right internal carotid artery is completely occluded. Status postendarterectomy changes in the left internal carotid and the bulb are noted. No significant occlusive disease is seen in the left internal carotid artery. Both vertebral arteries are showing antegrade flow. Select the appropriate ICD-10-CM and CPT code(s):

The patient was taken to the OR for draining of the pus from the middle ear. The surgeon accomplished this with an incision in the tympanic membrane. This procedure is called a: