Exam 27: Coding and Surgical Procedures

History: The patient is a 79-year-old male with dyspepsia and weight loss. A recent supraclavicular lymph node biopsy revealed signet-ring cell adenocarcinoma. Specimen site: Stomach Gross description: Received in formalin is a 10.0- × 6.5- × 3.2-cm segment of stomach, with a palpable firm 4.0- × 2.2-cm mass on the designated lesser curvature. The external surface of the specimen is unremarkable and inked black. The cut surfaces demonstrate the mass and adjacent firm areas of nodularity. The remainder of the gastric mucosa is unremarkable. Six lymph node candidates and representative sections of the stomach are submitted. Microscopic description: Microscopic examination was performed. See synoptic report. The uninvolved stomach shows chronic inactive gastritis with intestinal metaplasia. Diagnosis: Stomach (proximal): Invasive adenocarcinoma Comment: Signet-ring cell carcinomas are not typically graded but are high-grade and would correspond to grade 3. Select the appropriate ICD-10-CM and CPT code(s):

Mrs. Jones, an established patient, is seen by the rheumatologist for repeated pain in her left knee due to osteoarthritis. Today she presents with pain and swelling. The rheumatologist performs an arthrocentesis of the left knee followed by injection of Dexa-Methasone sodium phosphate, 5 mg. No E/M service is performed. Select the appropriate ICD-10-CM and CPT code(s):

Preoperative Diagnosis: Reduced inguinal hernia Postoperative Diagnosis: Reduced inguinal hernia Operation: Repair of the reduced hernia Operation Description: A 3-year-old boy was diagnosed with a reduced inguinal hernia within the past month. The surgeon explained the procedure of a reduced hernia repair and parents understood risks. The consent was obtained and signed. This is the first initial attempt to surgically repair the inguinal hernia. Patient was admitted for a reduced hernia repair. The hernia was manually reduced back into its correct cavity location. Upon completion of the procedure the patient went to the recovery room in stable condition. Select the appropriate CPT and ICD-10-CM codes.

A 14-year-old boy who is a new patient presents with acute contact dermatitis. During the expanded problem-focused history, the doctor learns that the boy just came back from a camping trip and was out in the woods when his skin began to itch. The examination was also expanded. The physician sends the patient home with a prescription and instructs him to return if the condition does not improve in a few days. While checking all of the patient's immunizations, the physician notes that the patient is in need of a tetanus vaccination, so that is also given. Select the appropriate CPT and ICD-10-CM codes.

Which of the following must the coder be able to do, in order to accurately translate provider documentation?

Dr. Black, a cardiologist, today is seeing Mrs. Smythe, a 72-year-old Medicare patient, at the request of her internist regarding her chronic atrial fibrillation. After a comprehensive history, comprehensive cardiology-specific examination, and decision making of moderate complexity, Dr. Black prescribes some adjustments to her medications and sends a letter to her internist with his findings and suggested follow-up. 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):

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):

Identify the true statement concerning signs and symptoms:

What is a two-digit modifier used for in CPT coding?

Preoperative diagnosis: Morbid obesity Postoperative diagnoisis: Morbid obesity Procedure performed: Abdominal panniculectomy Estimated blood loss: Throughout the procedure, approximately 20 Ml Anesthesia: General endotracheal anesthesia Indications for procedure: This is a 49-year-old female who previously underwent gastric bypass surgery and has lost 120 pounds, leaving a large lower pannus of the abdomen. This pannus needs to be resected. The nonoperative versus operative management options were discussed with the patient. The operative risks included bleeding, infection, hematoma, chance for further surgery as well as pain, and a resulting scar. The patient accepted the risks and consented to surgery. Procedure in detail: The patient was placed under general endotracheal anesthesia. The patient was draped in the proper manner, and the lower abdominal pannus was identified. It was preoperatively marked prior to going to the OR. The lower incision was made from the superior iliac crest with the middle being the pubic tubercle. That lower incision was then made. The pass was then elevated at the level of the anterior abdominal fascia and was elevated superiorly to the level of the inferior umbilicus. Then incisions were made on the umbilicus to the superior iliac crest, and the skin and subcutaneous pannus was passed off table as a specimen. The wound was then made hemostatic with the use of electrocautery. JP drains were placed. The abdominal skin flap was then brought to the inferior skin flap and sutured in place with 2-0 Vicryl sutures at the dermal level. The drains were then secured, and then the skin was closed with running 3-0 Monocryl suture. The wound was further dressed with Steri-strips, gauze, and abdominal binder. The patient tolerated the procedure well. All needle and instrument counts at the end of the procedure were correct, and the patient was taken to PACU in good condition. Select the appropriate ICD-10-CM and CPT code(s):

CT Scan of the Chest and Adrenals History: Left pulmonary nodule on chest x-ray Technique: Helical transaxial images, 7 mm, of the chest were obtained after the administration of oral and intravenous contrast. Findings: The patient's chest x-rays from February 24 and 25 were reviewed. There is an ill-defined opacity suggested in the left midlung zones on those studies, including oblique views. Within the left lower lobe laterally, there is an approximately 2-cm area of parenchymal density that has the appearance of interstitial changes without findings of a significant nodule or mass. This finding can relate to scarring. There is no other nodule, mass, or effusion. Within the mediastinum, there is no evidence of adenopathy seen. The heart and great vessels are normal in appearance. There is a suggestion of minimal pericardial thickening anteriorly that is not specific. Osseous structures show degenerative changes with osteophyte formation at multiple levels in the thoracic spine. Visualized upper abdominal structures, including liver, spleen, kidneys, pancreas, aorta, and para-aortic retroperitoneum, show no specific finding. The adrenal glands are not enlarged. Impression: There is a small focal area of increased parenchymal density that has an interstitial pattern. There is no significant nodule or mass. This is suggestive of scarring. There is no nodule, mass, effusion, or adenopathy seen. Consider chest x-ray follow-up of this lesion to assess stability. Select the appropriate ICD-10-CM and CPT code(s):

The lab performs the following tests for a patient who presents to the emergency department with signs of Luetscher's syndrome: comprehensive metabolic panel, complete CBC automated, automated differential WBC count, TSH. Select the appropriate CPT and ICD-10-CM codes.

Which word is a term meaning muscular disease?

The Health Insurance Portability and Accountability Act of 1996 (HIPAA) was designed to do which of the following?

An endoscopy of the urinary bladder is called a(n)

The patient underwent an examination of the esophagus, stomach, and duodenum. This procedure is a(n):

A patient with schizophreniform disorder, who participated in a partial hospitalization program, was seen for 30 minutes of individual psychotherapy and 10 minutes of medication evaluation and management, which required a problem-focused history and straightforward medical decision making. The physician spent 30 minutes face-to-face with the patient. Select the appropriate CPT and ICD-10-CM codes.

A 2-month-old infant with congenital hydrocephalus presented for replacement of a previously placed VP shunt system. Select the appropriate CPT and ICD-10-CM codes.

A patient underwent tympanoplasty with a mastoidectomy and ossicular chain reconstruction for removal of a cholesteatoma of the right ear Select the appropriate ICD-10-CM and CPT code(s):