Exam 27: Coding and Surgical Procedures

Holter Monitor Report History: This is a 36-year-old male referred for evaluation of syncope episodes and dizziness. He also has a history of depression and anxiety. A Holter monitor was placed on April 2 for 24 hours. Recording revealed sinus rhythm with three VPCs and three isolated APCs. There were no SVTs, no VTs, and no pauses. The patient had multiple complaints of dizziness, anxiety, panic, and feeling near syncopal. Rhythms at these times documented normal sinus rhythm at rates between 80 and 104 beats per minute. No significant arrhythmias. Impression: Normal Holter Select the appropriate ICD-10-CM and CPT code(s):

A 54-year-old patient presented to the emergency room with a gunshot wound in the back exiting through the front. A CT scan shows some renal damage to the right kidney and a renal exploration is ordered. The surgeon has been called in and the patient is taken to surgery to examine the renal structure. Making an incision over the gunshot wound, the surgeon examines both the blood vessels and the kidney. The trauma has caused a hematoma to the kidney, which has not spread, so the surgeon closes and the patient is sent to the floor for observation. Select the appropriate CPT and ICD-10-CM codes.

A patient was seen for a 2.0 cm scalp wound which required a simple repair, and a 7.5 cm scalp wound which required an intermediate repair. In addition, a 4.0 cm laceration on the face required a simple repair. 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 43-year-old male came into the doctor's office to have a hemorrhoidopexy by stapling for his second-degree hemorrhoids. He was very uneasy since he had never had this procedure before. Dr. Hanson administered an IV of Versed, for the anxiety. The procedure is not really painful, so there was no need for a full anesthetic or painkiller. Myrtle Pape, a certified registered nurse anesthetist (CRNA), sat with the patient throughout the procedure to ensure his safety and comfort level. The procedure was complete in one stage, taking 30 minutes.Select the appropriate ICD-10-CM and CPT code(s):

Clinical history of enlarged prostate determined by DRE. Patient presents today for transrectal ultrasound. Findings indicate benign prostatic hyperplasia. Select the appropriate CPT and ICD-10-CM codes.

Which term is used in ICD-10-CM to describe a residual condition that occurs after the initial illness or injury?

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 patient is in the office today for application of an external auto-activated ECG rhythm derived recorder for previously diagnosed syncope and palpitations not evidenced on a Holter Monitor. The patient is scheduled to wear this device for 30 days. This process will include a review and interpretation by the physician. Select the appropriate CPT and ICD-10-CM codes.

A 28-year-old patient was seen today for her annual physical exam by her OB/GYN. After discussion with the physician, the patient expressed her decision to have her IUD removed as she and her husband are ready to begin a family. This procedure was performed at this visit. Select the appropriate ICD-10-CM and CPT code(s):

Jane, a 75-year-old female, was brought to the OR today for operative ablation of her paroxysmal atrial fibrillation via a combined Wolff-Parkinson-White atrio-ventricular node tissue ablation and reconstruction of the atria using the MAZE procedure. Cardiopulmonary bypass was not required. The patient tolerated the procedure well and was sent to ICU for continued monitoring. Select the appropriate CPT and ICD-10-CM codes.

John Smith is seen by his PCP Dr. Ron Blue at home for his monthly visit in regards to monitoring his diabetes. John's diabetes is still stable as noted the previous month. No changes were made to his medications. The history is problem focused and exam is expanded problem focused. Medical decision making is noted as moderate. Select the appropriate CPT and ICD-10-CM codes.

John Smith is seen by his PCP Dr. Ron Blue at home for his monthly visit in regards to monitoring his diabetes. John's diabetes is still stable as noted the previous month. No changes were made to his medications. The history is problem focused and exam is expanded problem focused. Medical decision making is noted as moderate. Select the appropriate CPT and ICD-10-CM codes.

A 50-year-old male patient presents to the office today for his annual preventive visit. During the visit, Dr. Jones becomes concerned about the patient's hypertension and believes that this needs some evaluation and management beyond the preventive visit. Dr. Jones changes the patient's medications and orders lab work. Which modifier would be reported to the payer in order to be reimbursed for both the preventive visit and the office visit?

The patient presented with jaundiced skin. This means that the skin appeared:

A 48-year-old female with a 20+ year smoking history is diagnosed with a pulmonary nodule growing in the left lower lobe of the lung. After discussion with her surgeon, the patient is brought to the OR for a laproscopic wedge resection of the nodule using VATS approach to obtain a frozen section. Following a pathology report of adenocarcinoma of the lung, a VATS lobectomy of the left lower lobe was performed. The patient tolerated the procedure and was sent to the surgical ICU in stable condition. Select the appropriate CPT and ICD-10-CM codes.

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?

The patient presented in the emergency room with a sudden outbreak of lesions on the face, bilaterally on arms and legs, and groin after taking her prescribed sulfa drugs. Several of the lesions had to be shaved: 2 on the leg, one 1.4cm on the groin, and 3 close to the ear. The physician concluded that this was dermatitis. Select the appropriate CPT and ICD-10-CM codes.

The final section of the small intestine is the

Preoperative Diagnosis: Urethritis Postoperative Diagnosis: Urethritis Operation: Urethral biopsy Operation Description: A 22-year-old male was diagnosed with urethritis. The PCP referred the patient to an urologist, who ordered a urethral biopsy. The patient understood the risks and consent was obtained. The patient was prepped and the biopsy obtained then sent to pathology. Patient left the procedure room in stable condition. Select the appropriate CPT and ICD-10-CM codes.