Exam 27: Coding and Surgical Procedures

A patient undergoes a percutaneous liver biopsy with US guidance. The pathology report reveals autoimmune hepatitis. Select the appropriate ICD-10-CM and CPT code(s):

Preoperative Diagnosis: Tonsillitis Postoperative Diagnosis: Tonsillitis Operation: Tonsillectomy Anesthesia: General Operation Description: A 12-year-old patient is diagnosed with tonsillitis and was recommended to have a tonsillectomy. Family consented to the surgery and patient was admitted. Patient was positioned supine for the procedure. The right and the left tonsils were removed. The tonsillar area was irrigated. There was no bleeding before or after the suturing. The patient tolerated the procedure well. Select the appropriate CPT code for the anesthesia service, as well as the ICD-10-CM code.

Specimen site: Right medial cheek Specimen site: Left dorsal hand Gross description: Right medial cheek: The specimen is one gray-white fragment measuring 0.3 × 0.2 cm. Totally submitted in one cassette with a request for levels labeled "A." Left dorsal hand: The specimen is one gray-white fragment measuring 0.3 × 0.3 cm. Totally submitted in one cassette with a request for levels labeled "B." Microscopic description: The right medial cheek shows atypical keratinocytes within the entire thickness of the epidermis extending to the stratum corneum. The lesion appears to have been excised. The dermis shows elastosis. The dorsal hand shows hyperkeratosis. The epidermis is mildly acanthotic. There is extensive dermal elastosis. Final diagnoses: 1) Right medial cheek, biopsy: ? Squamous cell carcinoma in-situ. (See comment.) 2) Left dorsal hand, biopsy: ? Dermal elastosis. ? No malignant changes seen. Comment: The lesion from the cheek appears to reside within the confines of the histologic section. The skin lesion shows no invasive malignancy. Select the appropriate ICD-10-CM and CPT code(s):

Government health insurance programs include all of the following except:

A 6-hour-old critically ill infant undergoes on-pump anesthesia for emergency repair of transposition of the great vessels. Select the appropriate CPT and ICD-10-CM codes.

Clinical indication: Salivary stones Procedure: CT scan of soft tissue of the neck with contrast Diagnosis: Salivary (parotid) duct stones Select the appropriate CPT and ICD-10-CM codes.

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.

Dr. 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.

A disease caused by overproduction of the growth hormone after puberty is:

Procedure performed: Fiber-optic bronchoscopy, bronchial biopsy, bronchial washings, and bronchial brushings Preprocedure diagnosis: Abnormal chest x-ray Postprocedure diagnosis: Inflammation in all lobes, pneumonia; with pleural placquing? consistent with possible candidiasis The patient was already on a ventilator, so the bronchoscope tube was introduced through the ET tube. We saw 2.5 cm above the carina of the trachea, which was red and swollen as was the carina. The right lung: All entrances were patent, but they were all swollen and red, with increased secretions. The left lung was even more involved, with more swelling and more edema and had bloody secretions, especially at the left base. This area from the carina all the way down to the smaller airways on the left side had shown white placquing consistent with possible candidiasis. These areas were brushed, washed, and biopsied. A biopsy specimen was also sent for tissue culture, as well as two biopsy specimens sent for pathology. Sheath brushings were also performed. The patient tolerated the procedure well and was sent back to the ICU. Select the appropriate ICD-10-CM and CPT code(s):

S: A 46-year-old male who was in a car accident presents for a prosthetic spectacle. O: HEENT is unremarkable. Monofocal measurements are taken, and data for the creation of an appropriate prosthesis are recorded. A: Aphakia, left eye. P: Return in 10 days for a final fitting. Select the appropriate ICD-10-CM and CPT code(s):

Preoperative diagnosis: Melena Postoperative diagnosis: Internal hemorrhoids Procedure: Colonoscopy The 60-year-old patient was experiencing melena and it was recommended that he complete a colonoscopy as an outpatient procedure. The patient was prepped in the surgical suite and a scope inserted into the rectum and the large intestines examined which showed internal hemorrhoids. A biopsy was taken and sent to pathology. The scope was extracted and the patient was sent to the recovery room in good condition. 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.

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):

Procedure performed: Left-sided heart catheterization, selective coronary angiography, and left ventriculography Indication: Chest pain and abnormal Cardiolite stress test RESULTS Hemodynamics: The left ventricular pressure before the LV-gram was 117/1 with an LVEDP of 4; after the LV-gram it was111/4 with an LVEDP of 10. The aortic pressure on pullback was 111/17. Left ventriculography: The left ventriculography showed that the left ventricle was of normal size. There were no significant segmental wall motion abnormalities. The overall left ventricular systolic function was normal, with an ejection fraction of better than 60%. Selective coronary angiography: A. Right coronary artery: The right coronary artery is a medium- to large-size dominant artery that has about 80% to 90% proximal/mideccentric stenosis. The rest of the artery has only mild surface irregularities. B. Left main coronary artery: The left main has mild distal narrowing. C. Left circumflex artery: The left circumflex artery is a medium-size, nondominant artery. It gives rise to a very high first obtuse marginal/intermedius, which is a bifurcation medium-size artery that has only mild surface irregularities. The second obtuse marginal is also a medium-size artery that has about 20% to 25% proximal narrowing. After that second obtuse marginal, the circumflex artery is a small-size artery that has about 20% to 30% narrowing, a small aneurismal segment. D. Left anterior descending coronary artery: The left anterior descending artery is a medium-size artery that is mildly calcified. It gives rise to a very tiny first diagonal that has mild diffuse atherosclerotic disease. Right at the origin on the second diagonal, the LAD has about 30% narrowing. The rest of the artery is free of significant obstructive disease. The second diagonal is also a small-caliber artery that has no significant obstructive disease. Conclusion: Severe single-vessel atherosclerotic heart disease Select the appropriate ICD-10-CM and CPT code(s):

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).

Patient had a lesion removed from the third digit on the left hand. What would be the appropriate HCPCS modifier?

What is the ICD-10-CM term for the character used to extend codes through the sixth character, allowing the seventh-character extender to remain in place? This character is represented by an "x" and is known as:

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):

Pre-op diagnosis: Left lung abscess Post-op diagnosis: Same Procedure performed: Left upper lobectomy with decortication and drainage Indications: The patient is a 56-year-old female with evidence of a left upper-lobe abscess seen on the MRI. She was admitted with tension pneumothorax, which was treated with double-lumen intubation and a chest tube. Procedure: The patient was brought to the operating room and placed in the supine position, with general intubation from the double-lumen tube. The patient was rolled onto the right lateral decubitus position, with left side up. A posterior lateral thoracotomy was performed. Adhesions were taken down sharply and bluntly and with cautery. Following this a standard artery first left upper lobectomy was carried out utilizing 0 silk and hemoclips. The left upper pulmonary vein was secured with a single application of the stapling machine. The posterior fissure was created with multiple applications of the automatic stapling machine and the bronchus secured with a single application of the bronchus stapling machine. Following this the wound was drained with three 24-French strium chest tubes and hemostasis obtained with spray Tisseel and surgical gauze. The bronchus was sealed with bio glue and the wound closed in layers. A sterile compression dressing was applied, and the patient was returned to the surgical intensive care unit after the double-lumen tube was changed to a single-lumen tube. The patient received 3 units of packed cells intraoperatively to maintain hemostasis. Sponge count and needle count correct × 2. Large abscess in the left upper lobe accounted for approximately 70% of the left upper-lobe parenchyma. Select the appropriate ICD-10-CM and CPT code(s):