Exam 27: Coding and Surgical Procedures

Preoperative Diagnosis: Herniated nucleus pulposus of L5-S1 on the left. Postoperative Diagnosis: Herniated nucleus pulposus of L5-S1 on the left. Procedure Performed: Microscopic assisted lumbar laminotomy with discectomy at L5-S1 on the left. Surgical Indications: The patient is a 51-year-old female who has had unrelenting low back pain that radiates down her left leg for the past several months. The symptoms were not helped by conservative treatments and were interfering with all aspects of daily living and her job. Procedure: The patient was taken to the operating room and after anesthesia was administered, she was placed on the Jackson spinal table with the Wilson attachment in the prone position. Palpation revealed the iliac crest and suspected L5-S1 interspace. The lumbar spine was prepped and draped in the usual sterile fashion. A midline incision was made over the spinal process of L5 to S1. Skin and subcutaneous tissue were divided sharply. Electrocautery provided hemostasis. Electrocautery was then utilized to dissect through the subcutaneous tissues to the lumbar fascia. On the left side, superior aspect dissection was carried out with the Cobb elevator and electrocautery. This revealed the interspace of level of L5-S1 on the left. A Kocher clamp was placed between the spinous processes of L5-S1. X-ray confirmed the L5-S1 interval. An angled curet was used to detach the ligamentum flavum from its bony attachments at the inferior edge of the L5 lamina and the superior edge of S1 lamina. Dissection was undertaken and the ligamentum flavum was removed. Laminotomy was created with Kerrison rongeur, both proximally and distally. The microscope was positioned and a blunt Penfield elevator was utilized to dissect and identify the L5-S1 nerve root on the left. It was noted to be tented over a disc extrusion. The nerve root was retracted with a nerve root retractor. This revealed a subligamentous disc herniation at the L5-S1 disc space and neuroforaminal area. A #15 Bard-Parker blade was utilized to create an annulotomy. Medially, disc material was extruding through this annulotomy. Two tier rongeur was then utilized to grasp the disc material and the disc was removed from the interspace. Additional disc material was then removed, both to the right and left of the annulotomy. The Penfield elevator was placed in the disc space of L5-S1 and a crosstable x-ray confirmed this level. Nerve root was inspected exhibiting the foramina. A foraminotomy was created with a Kerrison rongeur. Then the nerve root was again inspected and determined to be free of tension. A free fat graft was then harvested from the subcutaneous tissues and placed over the exposed dura. Lumbar fascia was then approximated with #1 Vicryl interrupted sutures, subcutaneous tissue with #2-0 Vicryl interrupted sutures, and #4-0 undyed Vicryl was utilized to approximate the skin. Compression dressing was applied. Estimated blood loss was less than 50 cc. She tolerated the procedure well and was taken to the recovery room in satisfactory condition. Select the appropriate CPT and ICD-10-CM codes.

Which of the following tumors are considered to be benign?

Carpal tunnel release was performed for a patient with carpal tunnel syndrome. She had been experiencing chronic and worsening pain in the right hand and had previously tried a series of injections that did not relieve the problem. An EMG showed compression of the median nerve, so she opted for surgery which was performed today. Select the appropriate CPT and ICD-10-CM codes.

The doctor performs strabismus surgery for 2 vertical muscles and the superior oblique muscle using adjustable sutures for palsy of conjugate gaze due to unilateral frontal lobe surgery 6 months ago. Select the appropriate CPT and ICD-10-CM codes.

A 75-year-old female recently underwent a stroke assessment of her aphasia. The following assessments were performed using Boston diagnostic aphasia examination: expressive and receptive speech, language function, language comprehensive, speed production ability, reading, spelling, and writing skills. Total time 60 minutes. Select the appropriate ICD-10-CM and CPT code(s):

The patient was seen by a psychiatrist for post-traumatic stress disorder. This visit was a psychiatric diagnostic evaluation which included a history, mental status examination, and recommendations. The evaluation and treatment plan were communicated to the family as the patient has requested their involvement in his care. Select the appropriate CPT and ICD-10-CM codes.

Preoperative Diagnosis: puncture wound to the L. ventricle as a result of a stabbing presented with cardiac tamponade. Postoperative Diagnosis: same Operative Procedure: removal of knife from the left ventricle followed by on-pump exploratory cardiotomy and cardiorrhaphy. Patient survived procedure and was sent to ICU in critical condition. Select the appropriate CPT and ICD-10-CM codes.

A 58-year-old male is undergoing a therapeutic endoscopic retrograde cholangiopancreatography. The gastroenterologist injects the contrast agent, and using fluoroscopy views the hepatobiliary system, collects specimens for testing, and places a biliary stent to relieve the patient's jaundice. Select the appropriate CPT and ICD-10-CM codes.

An 11-year-old boy is brought to the ED with fever, malaise, and a stiff neck. The ED physician performs a spinal tap to R/O meningitis. The patient is admitted to University Hospital to further monitor his status. Later during the evening, the boy complains of a severe headache along with a "runny nose". The physician orders a nuclear medicine study to detect CSW fluid leakage and localization. Select the appropriate CPT and ICD-10-CM codes.

A 55-year-old female was having a problem with menopause. Because of the reported concerns about hormone replacement therapy, she decided to try acupuncture. After discussing her symptoms and discussing a treatment plan, Dr. Kind inserted several needles; the needles were removed 20 minutes later. Dr. Kind reviewed the follow-up plan and made an appointment for the patient's next visit. Dr. Kind spent 30 minutes in total face-to-face with Charlene. Select the appropriate ICD-10-CM and CPT code(s):

After administering local anesthetic, the physician made a full-thickness elliptical incision through the skin. The arterio-venous malformations and the malignant melanoma including the margin were excised and reconstructive repair of the right eyelid was performed. Select the appropriate CPT and ICD-10-CM codes.

Preoperative Diagnosis: puncture wound to the L. ventricle as a result of a stabbing presented with cardiac tamponade. Postoperative Diagnosis: same Operative Procedure: removal of knife from the left ventricle followed by on-pump exploratory cardiotomy and cardiorrhaphy. Patient survived procedure and was sent to ICU in critical condition. Select the appropriate CPT and ICD-10-CM codes.

A diabetic patient underwent a partial amputation of his foot due to gangrene. Today, the patient is fitted for a partial foot with a molded socket, ankle height, and toe filler. Select the appropriate CPT and ICD-10-CM codes.

A 36-year-old patient is currently diagnosed with glaucoma and is having occurrences of blurry vision. The patient had a gonioscopy performed to determine the type of glaucoma. The physician has determined that the type is open angle. The patient tolerated the procedure well in the outpatient hospital setting and was sent home in good condition. Select the appropriate CPT and ICD-10-CM codes.

A surgeon performs a ritualistic surgical circumcision on a 30 day old male. Select the appropriate ICD-10-CM and CPT code(s):

A patient was seen by the physician today for follow-up testing for exophthalmos. The meaning of this term is

Julia was playing baseball in her hardball league and was hit in the face with a line drive. Upon waking she was taken directly to the hospital. She has a fractured mandible, and the orthopedic surgeon is performing a closed treatment with interdental fixation. Select the appropriate CPT and ICD-10-CM codes.

Mrs. Jones is seen today for puncture aspiration of three cysts on the left breast and one on the right. The pathology report revealed cystic breast disease. Select the appropriate ICD-10-CM and CPT code(s):

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.

A patient with type II diabetes under control was at laboratory today for HbA1C to determine control of sugar over time. Results reported at 8.9%. Select the appropriate CPT and ICD-10-CM codes.