Exam 27: Coding and Surgical Procedures

Joseph, age 6, was admitted and an IV started for dehydration due to severe gastroenterocolitis for the previous three days. The physician ordered this IV to be administered over 5 hours. Select the appropriate CPT and ICD-10-CM codes.

Mrs. Carmichael sees her foot and ankle surgeon with open ulcerated areas on the left lower leg and a separate lesion on the right lower leg. The surgeon documents staphylococcal carbuncles which need debridement. He proceeds to excise the skin, subcutaneous tissue, and muscle of a 4.0 cm × 3.0 cm, or 12 sq. cm, lesion in the right lower leg, and an excision of skin and subcutaneous tissue in the left lower leg of 3.0 cm × 8.0 cm, or 24 sq. cm. Select the appropriate CPT and ICD-10-CM codes.

Jeremy presented to the ED complaining of severe odynophagia after eating chicken wings. Upon initial x-rays, no perforation of the esophagus was noted. The gastrointestinal specialist was called, and the patient was taken to the endoscopy suite. There, with the patient under moderate sedation, the gastroenterologist performed an esophagoscopy and removed a small chicken bone lodged in the esophagus above the diaphragm. Select the appropriate ICD-10-CM and CPT code(s):

Preoperative Diagnosis: Cleft palate Postoperative Diagnosis: Cleft palate Operation: Repair of cleft palate Anesthesia: General Operation Description: A 3-year-old patient was diagnosed with cleft palate was advised by the surgeon to complete the surgical procedure repairing the cleft palate. The risks were discussed and identified with the family. Consent was obtained. The procedure of the cleft palate repair was performed. No complications noted and the patient returned to the recovery room in good condition. Select the appropriate CPT and ICD-10-CM codes.

An 85-year-old male presented to the ED with symptoms of an ischemic stroke including L hemiparesis and dysarthria but no apparent cognitive decline. This patient presented with

What is a term for inflammation of the intestines?

This is a new 35-year-old male who is experiencing a piercing ringing sound in his left ear that began 6 months ago. The ringing interferes with his daily life, and he has problems sleeping. The patient is taken to a testing suite for a bilateral tinnitus assessment; pitch frequency matching loudness and masking procedures are included. The findings of the testing indicate a positive determination of tinnitus, acute tinnitus. Follow-up masking therapy scheduled. Select the appropriate ICD-10-CM and CPT code(s):

Jerry, an established patient, is seen today for evacuation of a subungual hematoma of his left index finger, sustained while hanging a picture. The physician performs a problem-focused history and problem-focused examination to evaluate the extent of the damage and determines that evacuation of the hematoma is needed. He then evacuates the subungual hematoma. Select the appropriate ICD-10-CM and CPT code(s):

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.

Roger was in an altercation with his neighbor and he has 3 wounds. The first is a 15.5cm wound on the face that required a single layer closure, the second is a 25.5cm laceration of the left forearm that required a layered closure of the subcutaneous tissue, and the third laceration is a 10cm wound on the right external ear that required a layered closure. Select the appropriate CPT and ICD-10-CM codes.

Mrs. Jones is in the operating room today for repair of a nontraumatic tear of the rotator cuff of the right shoulder. The physician performs an arthroscopy subacromial decompression with an open repair of the rotator cuff. Select the appropriate ICD-10-CM and CPT code(s):

A procedure in which a surgeon reattaches a severed arm, hand, finger, toe, or foot is a(n)

Patient presents for cesarean section with no other deliveries or pregnancies noted in the chart. She was prepared and draped in the usual sterile manner for an abdominal procedure. An incision was made and carried down through the subcutaneous tissue, muscular fascia, and peritoneum. Once inside the abdominal cavity, a low cervical transverse incision was made in the lower uterine segment after creating a bladder flap by both blunt and sharp dissection. With creation of the bladder flap, a transverse incision was made and the infant was delivered as a vertex. The placenta was then removed as well. With removal of the placenta and baby, cord blood was obtained. The infant was handed off to the nurses in attendance. We then closed the uterine incision in the usual manner. A Foley catheter had been inserted. Clear urine was noted. The patient was then awakened and taken to the recovery room in good condition. Select the appropriate CPT and ICD-10-CM codes for the delivery only.

Which statement is NOT true concerning the guideline for reporting the Zika virus code A92.5?

A 10-year-old male is seen in the emergency department for epistaxis. The hemorrhaging was controlled with nasal packing. The physician performs a detailed history and examination. The MDM complexity is moderate. Selectthe appropriate CPT and ICD-10-CM codes.

A 36-year-old female who was the driver in a car accident presented with whiplash for chiropractic manipulative treatment of her cervical spine. The chiropractor provided a complete history and examination prior to the treatment plan of one visit a week for 2 months, at which point her status will be reevaluated. Today the first manipulation was performed. Select the appropriate ICD-10-CM and CPT code(s):

Preoperative Diagnosis: Thyroid goiter. Postoperative Diagnosis: Thyroid goiter. Procedure Performed: Total thyroidectomy. Indications: The patient is a 45-year-old female with Graves' disease. Suppression was attempted but unsuccessful. She presents today with her thyroid goiter. A thyroidectomy was indicated at this time secondary to the patient's chronic condition. A full informed consent was obtained. Procedure: The patient was brought back to surgical suite and given IV access and general endotracheal anesthesia. A 9 cc of 1% lidocaine with 1:100,000 of epinephrine was infiltrated into the area of pre-demarcated above the suprasternal notch. The patient was then prepped and draped in the normal sterile fashion. A #10 blade was then utilized to make an incision in the pre-demarcated and anesthetized area. Unipolar electrocautery was utilized for hemostasis. Finger dissection was carried out in the superior and inferior planes. Platysma was identified and dissected and a subplatysmal plane was created in the superior and inferior, medial and lateral directions. The strap muscles were identified. The midline raphe was not easily identifiable at this time. An incision was made through what appeared to be in the midline raphe and dissection was carried down to the thyroid. Sternohyoid and sternothyroid muscles were identified and separated on the patient's right side and then subsequently on the left side. It was noted at this time that the thyroid lobule on the right side is a bi-lobule. Kitner blunt dissection was utilized to bluntly dissect the overlying thyroid fascia as well as strap muscles off the thyroid, in the lateral direction. This was carried down to the inferior and superior areas. The superior pole of the right lobule was then identified. A hemostat was placed in the cricothyroid groove and the superior pole of the right thyroid was retracted inferiorly. Careful dissection was then carried out in the superior lobe and identified the appropriate vessels and cauterized with bipolar or ligated with the suture ligature. The superior pole was identified. Dissection was then carried down again bluntly separating the inferior and superior lobes. The bilobed right thyroid was then retracted medially. The recurrent laryngeal nerve was then identified and tracked to its insertion. A right dissection was performed to remove the fascial attachments superficial to the recurrent laryngeal nerve. This lobule was then removed from Berry's ligament. There was noted to be no isthmus at this time and the entire right lobule was then sent to pathology for evaluation. Attention was then directed to the patient's left side. In a similar fashion, the sternohyoid and sternothyroid muscles were separated. Blunt dissection was carried out laterally to superiorly once again. A careful dissection was utilized to identify the appropriate structures in the superior pole of the left thyroid and suture ligature as well as bipolar cautery was utilized for hemostasis. Once again, careful attention was made not to injure the nerve in this area. The superior pole was then freed appropriately and blunt dissection was carried down to lateral and inferior aspects. The inferior aspect was then identified. The inferior thyroid artery and vein were then identified and ligated. The left thyroid was then medialized and the recurrent laryngeal nerve was identified. Dissection was then carried out to remove the fascial attachments superficial to the recurrent laryngeal nerve on the side as close to the thyroid gland as possible. The thyroid was then removed from the Berry's ligament and it was then sent to pathology for evaluation. The patient tolerated the procedure well and was transferred to recovery in stable condition. Select the appropriate CPT and ICD-10-CM codes.

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):

Which CPT Level I modifier is the appropriate one to use when a radiologist reads an x-ray but is not employed by the facility where the x-ray was taken?

With the patient under general anesthesia, the ENT used a surgical microscope to perform a myringotomy to release pressure and a tympanoplasty to repair the perforated eardrum of a 6-year-old boy with chronic ear infections who stuck the end of his glasses in his ear. Select the appropriate CPT and ICD-10-CM codes.