Exam 27: Coding and Surgical Procedures

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.

Procedure: Permanent pacemaker implantation Indication for the procedure: Sick sinus syndrome with decreased mentation and confusion Description of the procedure: After a detailed description of the procedure, indications, and potential risks of permanent pacemaker implantation was given to the patient as well as the patient's daughter, informed consent was obtained. The patient was transferred to the cardiac catheterization lab. A left subclavian area was prepared and draped in the usual sterile manner, and the left subclavian vein was accessed by Seldinger technique. A guidewire was placed. The left subclavian vein was accessed, and a separate guidewire was also placed. Following this, a deep subcutaneous pacemaker pocket was created using the blunt dissection technique without any excessive bleeding. Following this, a French-7 introducer sheath was advanced over the guidewire, and the guidewire was removed. A Medtronic bipolar endocardial lead, model #5054 and serial #LEH025605V, was advanced under fluoroscopic guidance, and the tip of the pacemaker lead was positioned in the right ventricular apex. Following this, the French-9.5 introducer sheath was advanced over a separate guidewire under fluoroscopic guidance, and the guidewire was removed. Through this sheath, a bipolar atrial screw-in lead by Medtronic, model #4568, was selected. It was positioned in the right atrial appendage, and the lead was screwed in. Following this, the stimulation thresholds were obtained for the atrial lead. The amplitude was millivolts (mv) of resistance of 549 ohms, with pulse rate of 0.5 ms. Following the ventricular stimulation, threshold perimeters were obtained, including R-wave entry of 4.6 mv with resistance of 1,427 ohms, with a pulse wave of 0.5 ms. Minimum-stimulation threshold voltage was 0.4 volt for the ventricular lead, and minimal-stimulation voltage was 2 volts for the atrial lead. Select the appropriate ICD-10-CM and CPT code(s):

Jones accompanied a newborn girl with respiratory failure who had been born 23 hours earlier from the community hospital to the university children's hospital. The ride takes 95 minutes. Dr. Jones provided critical care services to the infant during the ambulance ride. The patient was admitted to the neonatal ICU at the new facility. Select the appropriate CPT and ICD-10-CM codes.

Arteriogram: Left Renal Artery Stenosis Procedure in detail: The procedure, indications, possible complications of an abdominal aortogram, and possible renal arteriogram were discussed with the patient. The patient agreed to have the procedure done and signed the consent. Under sterile technique with fluoroscopy control, a vascular sheath was introduced in the right common femoral artery using the Seldinger technique. Through this sheath, a 5-French pigtail catheter was introduced and placed at the proximal abdominal aorta. Flush aortogram followed, and a digital subtraction study of the abdominal aorta, by placing the catheter close to the renal artery origin, was performed. Evidence of mild atheromatous plaque disease involving the infrarenal abdominal aorta, causing focal dilation, is seen. No significant stenosis is noted at the aortic bifurcation. The celiac axis, including the splenic artery, gastroduodenal artery, and hepatic artery, is normal. On the right side, the renal artery is normal in caliber, without any significant stenosis. Segmental arteries are normal. Contrast nephrogram is also uniform. On the left side, there is segmental narrowing at the origin of the left renal artery. The narrowed segment is approximately 2 cm in length, with the narrowing more than 50% to 60% seen. No significant distal stenotic dilation of the renal artery is seen. Segmental arteries of the left renal artery are normal. Nephrogram of the left kidney is also normal. Since the digital subtraction study was done with stenosis analysis, left renal artery stenosis is in the range of 50% to 65%. Hence, a selective renal arteriogram was not performed. Impression: A 2-cm stenotic segment involving the origin of the left renal artery with stenosis in the range of 50% to 65% is noted. Segmental arteries of the left kidney are normal. Nephrogram of the left kidney is also normal. Select the appropriate ICD-10-CM and CPT code(s):

Willow is called in to administer general anesthesia to a 3-month-old female patient diagnosed with congenital tracheal stenosis. Dr. Gordon performs a surgical repair of her trachea. The patient is released to the recovery room staff in good condition. Select the appropriate ICD-10-CM and CPT code(s) for Dr. Willow:

The patient was seen for complaints of persistent cluster headaches and blurring vision. As part of the workup, a lumbar puncture was performed, the pressure of the spinal fluid was measured, and some fluid was removed for analysis. Select the appropriate ICD-10-CM and CPT code(s):

A 27-year-old patient is seen for ruptured synovium in the right shoulder and right elbow due to a baseball injury. An arthroscopic thermal capsulorrhaphy was performed for multidirectional instability and to prevent dislocation. 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):

Which word is a term meaning muscular disease?

A 45-year-old male with pancreatic cancer presents with a distended abdomen. The ultrasound reveals fluid in the peritoneal cavity. The patient undergoes a therapeutic paracentesis with ultrasound imaging guidance to drain the fluid. 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.

Clinical Indication: Carcinoma of the right breast, mastectomy and chemotherapy completed with no recurrence; now presents with skeletal metastases. Procedure: Multiple tomograms of L. lung show no dominant nodules within the lung. Multiple osteolytic metastases are present in several of the ribs in posteriolateral aspect involving third, fourth, fifth, six, and seventh ribs. Small amount of pleural reaction is noted in the L costophrenic angle. Hilar shadows are unremarkable. Shadow for L breast is absent. Impression: No definite metastatic nodules in L lung. Multiple mixed osteolytic and osteoblastic changes in several ribs in the L chest probably due to metastatic neoplasm. Select the appropriate CPT and ICD-10-CM codes.

Gross Description: Specimen labeled "sesamoid bone, first metatarsal, right" is received in formalin. Contains three irregular fragments of grey-brown, hard, bony tissue. Multiple fragments of brown-tan, rubbery, fibrocollagenous, soft tissue altogether measuring 2.8 x 1.7 x 0.8 cm. Specimen was decalcified and gross examination showed acute osteomyelitis, with foci of marrow fibrosis. Select the appropriate CPT and ICD-10-CM codes.

Marc will be having a kidney transplant due to end stage renal disease caused by malignant hypertension. The donor is his cousin Sidney. Under general anesthesia, Sidney undergoes a radical nephrectomy; the surgeon then does his backbench work to dissect and remove any fat and prepares the ureters, veins, and arteries. Next the surgeon performs a renal nephrectomy and allo-transplantation on Will. Select the appropriate CPT and ICD-10-CM codes.

Fred, a 75-year-old male, undergoes surgical placement of a permanent transvenous pacemaker for treatment of symptomatic bradycardia as a result of a bundle branch block. Select the appropriate CPT and ICD-10-CM codes.

Esther Nelson, a 79-year-old female, came to see Dr. Talbot for a right total-knee arthroplasty due to osteoarthritis of right knee. Dr. Clearwater administered the general anesthesia for the procedure. Esther is in otherwise good health. Select the appropriate ICD-10-CM and CPT code(s) for Dr. Clearwater:

Patient is admitted as an inpatient to the hospital on 11-01 and discharged on 11-05 for pneumonia. Select the appropriate evaluation and management CPT code and ICD-10-CM code to report for the 11-05 discharge date.

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):

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 and 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 and the operation performed. Select the appropriate CPT and ICD-10-CM codes for the anesthesia service for the procedure.

Sally is a long-term alcoholic who has made the decision to receive treatment for her disease. However, before beginning her psychotherapy, Sally is required to undergo a behavioral health screening and alcohol assessment. Select the appropriate CPT and ICD-10-CM codes for these two procedures.