Exam 27: Coding and Surgical Procedures

Wanda is visiting her dermatologist to have a biopsy done on some lesions on her back. Dr. Trummel examined the lesions on her back and decided to do a punch biopsy of 4 of them. The pathology report later came back as benign. Select the appropriate CPT and ICD-10-CM codes.

Clinical History: Patient with neuropathy and pain in arm. Diagnosed with possible cervical disc. Study performed: Cervical Myelogram -injection procedure and radiological supervision and interpretation. Impression: Moderate ventral extradural defect C5-6 with bilateral C-6 root encroachments. Select the appropriate CPT and ICD-10-CM codes.

Where in the CPT manual will a coder locate all the instructions necessary to properly code a procedure?

Specimen site: Gastric biopsy Gross description: Gastric biopsy: Received in formalin, the specimen consists of two fragments of gray-brown mucosa, each measuring approximately 0.3 centimeter in diameter. Totally submitted for routine and special stains and additional levels. Microscopic description: Sections show benign-appearing gastric mucosa with acute and chronic inflammatory cells within the lamina propria. The surface and pit-lining epithelium are also infiltrated with neutrophils. There is no dysplasia or malignancy. Special stains for H. pylori are positive. Final diagnosis: Gastric biopsy: ? Chronic active gastritis. ? Warthin-Starry stain positive for H. pylori. ? Negative for intestinal metaplasia, dysplasia, or malignancy. Select the appropriate ICD-10-CM and CPT code(s):

A patient with tachybrady syndrome received a DDDR permanent pacemaker with a steroid-eluting screw in right atrial lead, a steroid-eluting screw in right ventricular apical lead, and a pulse generator. Select the appropriate CPT and ICD-10-CM codes.

A 24-year-old female patient completed her 40th week of pregnancy. Her physician had noted that her antepartum visits were all within normal ranges. She had a vaginal delivery with episiotomy. A single live newborn was delivered in the hospital. Patient had a successful delivery with no complications. Select the appropriate CPT and ICD-10-CM codes for the delivery only.

Office outpatient: A Medicare patient, age 83, is seen for a therapeutic infusion of saline solution with prepackaged 5% dextrose IV 500 mL for dehydration, lasting 1 hour 20 minutes. Select the appropriate ICD-10-CM and CPT code(s):

The Anesthesia reimbursement services follow a formula approved by the American Society of Anesthesiologists (ASA). Identify the correct order for the formula used to calculate the charges and payment.

A 55-year-old established female patient was seen for management of uncontrolled diabetes due to taking oral corticosteroids for rheumatoid arthritis. She reported elevated glucose readings of 180, 210, 195, and 205 in recent weeks. The physician performed a brief history to update her record since the last visit, a detailed examination, and medical decision making of high complexity. He counseled the patient on diet and lifestyle factors and prevention of serious diabetic manifestations. He decided to start her on insulin to see how she responds. Select the appropriate CPT and ICD-10-CM codes.

Preoperative Diagnosis: atherosclerosis of right iliac artery Postoperative Diagnosis: same Operative Procedure: Transluminal peripheral atherectomy of right iliac artery via percutaneous approach Select the appropriate CPT and ICD-10-CM codes.

Georgette, a 57-year-old female, experiences polyneuropathy in the right arm due to a spur located at C4-C5. She presents today in the pain clinic for epidural injection by the anesthesiologist of an anesthetic agent for the purpose of pain control. 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):

Preoperative Diagnosis: Rectum Pain Postoperative Diagnosis: Perirectum abscess Operation: Incision and drainage of abscess Operation Description: A patient was admitted for rectum pain. Patient consented to the surgery. Patient was prepped and draped in the usual manner. General anesthesia was administered. The anus was dilated with two fingers at which time the speculum was introduced. The submucosal abscess was identified, incised, drained, then irrigated. Area was packed with gauze and patient went to the recovery room in stable condition. 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 64-year-old female was brought to the ED with a severe nosebleed. The medical term for nosebleed is

Mr. Jones is a patient with recurrent stage IV colon carcinoma of the sigmoid colon. He had previously undergone a laparoscopic low anterior resection (LAR). He was brought to the operating room today and under general anesthesia underwent a laparoscopic lysis of adhesions. The small bowel loops were found to be adherent to the anterior abdominal wall and also near the colostomy. These adhesions were lysed. There was one loop of small bowel that was adherent to the anterior abdominal wall of the RLQ, and this adhesion was not disturbed. Select the appropriate ICD-10-CM and CPT code(s):

Sally, a 3-year-old girl, has been fitted with a cochlear implant due to profound deafness. She is seen today for aural rehabilitation. Sally worked with the audiologist today for 1.25 hours making good progress. Select the appropriate CPT and ICD-10-CM codes.

The coiled tubules on top of the testicles that hold the testicles in place are called:

Sally was seen today for a percutaneous aspiration of a cyst of the left kidney with a translumbar renal cyst study. Select the appropriate ICD-10-CM and CPT code(s):

Practice management programs are used to: