Exam 27: Coding and Surgical Procedures

An 81-year-old patient, Marge, fractured the proximal end head of her femur on Thanksgiving while standing and cooking dinner. She has a history of osteoporosis and received radiation therapy 3 years ago in this area for a thigh muscle tumor. She is going to surgery today for an open treatment of femoral fracture with internal fixation. Select the appropriate CPT and ICD-10-CM codes.

The patient is an otherwise healthy 67-year-old male who sustained a fall three weeks ago. The patient is presenting with pain localized to his left knee. On exam the patient was unable to actively abduct and or externally rotate the knee secondary to pain and weakness. MRI demonstrated a displaced tibial tuberosity fracture. The surgeon performed an arthroscopic reduction and internal fixation of displaced greater tuberosity fracture with manipulation. Select the appropriate CPT and ICD-10-CM codes.

A 38-year-old male was seen today for complete and standing x-rays of L knee following injury sustained playing hockey. Impression: torn medial meniscus with degenerative joint disease, L. knee. Select the appropriate CPT and ICD-10-CM codes.

Sally, a 3-year-old girl, has been fitted with a cochlear implant due to profound deafness. She is seen today for aural rehabilitation. Sally worked with the audiologist today for 1.25 hours making good progress. Select the appropriate CPT and ICD-10-CM codes.

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.

A patient underwent a 2D echocardiogram including M-mode recording without color Doppler echocardiography for hemorrhagic pericarditis. The report was sent out for interpretation. Select the appropriate CPT and ICD-10-CM codes for the interpreting physician.

History: A 62-year-old woman (height, 1.7 m; weight, 61 kg) was scheduled for resection of a sigmoid colon carcinoma. Her medical history revealed hypothyroidism, vitamin B12 deficiency, and stiff person syndrome. This syndrome started with low back pain, which rendered her unable to walk. She was experiencing stiffness, involuntary jerks, and painful cramps. Neurologic examination revealed extreme hypertonia of the body and proximal legs, with intercurrent, painful spasms. Reflexes were symmetrical without Babinski signs. Laboratory findings showed positive glutamic acid decarboxylase (GAD) and negative amphiphysin antibodies. The patient was successfully treated with baclofen and diazepam. Subsequently, prednisone as immunosuppressive therapy was started. The stiffness diminished, and the patient was able to walk unaided. The neurologic examination was unremarkable, except for a slight stiffness in the legs. Her medication at admission was prednisone 20 mg once a day, baclofen 12.5 mg twice a day (daily dose = 25 mg), diazepam 7.5 mg twice a day (daily dose = 15 mg), levothyroxine 25 ?g once a day, and vitamin B12 injections. Her medical history included urologic and gynecologic surgery under general anesthesia before she experienced SPS. Procedure: No premedication was given. Anesthesia was induced with propofol (2.5 mg/kg) and sufentanil (0.25 ?g/kg). After the administration of atracurium (0.6 mg/kg), the trachea was intubated, and anesthesia was continued with isoflurane (0.6-1.0 vol %) and oxygen/air for the duration of the procedure. Cefuroxime 1,500 mg, clindamycin 600 mg, and dexamethasone 10 mg were administered IV. In the following 2 hours, additional atracurium (35 mg), sufentanil (10 ?g), and morphine (8 mg) were administered. At the end of the procedure, which was uneventful, neuromuscular monitoring showed four strong twitches. Although the patient was responsive, she could not open her eyes, grasp with either hand, or generate tidal volumes beyond 200 mL. Neostigmine 2 mg (0.03 mg/kg) and glycopyrrolate 0.2 mg did not alter the clinical signs of muscle weakness. The patient was sedated with propofol and further mechanically ventilated in the recovery room. After 1 hour, the sedation was stopped and mechanical ventilation was terminated. At that time, baclofen 12.5 mg was administered into the gastric tube. Two hours later she was in a good clinical condition, and her trachea was extubated. Select the appropriate ICD-10-CM and CPT code(s):

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.

Preoperative Diagnosis: End Stage Renal Disease Postoperative Diagnosis: End Stage Renal Disease Operative Procedure: Creation of right cephalic vein arteriovenous fistula for dialysis. Select the appropriate CPT and ICD-10-CM codes.

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.

CARDIAC CATH LAB REPORT History: The patient is a 44-year-old with a family history of coronary artery disease. He is a heavy cigarette smoker with dependence. He had an electrocardiogram showing an old anterior septal myocardial infarction. MRI showed a fixed anterior defect. He is referred today for coronary angiography due to episodes of chest pain. Description of the Procedure: The patient arrived in the procedure room and was administered 100 mcg Fentanyl and 2 mg Versed. 1% lidocaine was infiltrated over the right femoral artery. A 6-French sheath was placed in the right femoral artery. Diagnostic coronary angiography was performed with a 6-French JL-4 and 6-French JR-4 diagnostic catheters. There was no aortic stenosis on left heart pullback. There was no significant obstructive coronary artery in the right coronary artery, the left circumflex artery or left anterior descending coronary artery. There is a 10% to 20% stenosis in the distal left main. Hemodynamic measurements were taken and repeated to evaluate hemodynamic response. Opening aortic pressure was 103/58. Following coronary angiography, the left ventricular pressure was 107/12. Following coronary angiography, a 6-French pigtail catheter was placed in the left ventricle where left ventriculography was performed with 36 cc of contrast injected at 12 cc per second for 2 minutes. The left ventricular systolic function is normal. There are no regional wall motion abnormalities and no mitral regurgitation. At the conclusion of the procedure, the catheter and sheath were removed and Angio-Seal plug was deployed. Impression: There is no significant obstructive coronary artery disease. There is plaque in the distal left main, but no significant obstruction. Left ventricular systolic function is normal. There is no evidence of previous anterior wall myocardial infarction. Plan: Patient is urged to discontinue smoking and was referred to a smoking cessation program. Continue daily low-dose aspirin therapy. Nitroglycerin as needed. Select the appropriate CPT and ICD-10-CM codes.

Pyogenic arthritis in the right elbow due to methicillin susceptible staphylococcus aureus has caused continual extreme pain to the patient. Elbow replacement, arthroplasty, is recommended. The physician began the replacement procedure by removing the damaged joint components. They were then replaced with plastic implants. One implant was attached to the humerus, the other to the ulna, and the two were connected to form a hinge. The patient tolerated the procedure well and was released to the recovery room. Select the appropriate CPT and ICD-10-CM codes.

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):

The medical term for air in the pleural cavity is:

June was admitted to the hospital with atrial fibrillation by her PCP, and cardiology was consulted at the time of admission. On the next day, the cardiologist made rounds and checked on Mary's progress. An expanded problem-focused interval history was obtained, and an expanded problem-focused exam was performed. Mary has been on IV therapy and is showing improvement. Select the code for the cardiologist encounter on the second day.

Specimen site: Cervical biopsy Pre-operative Diagnosis: Severe squamous dysplasia, consistent with CIN III (high-grade dysplasia) Gross description: Cervical biopsy: One fragment of gray-white tissue, measuring 0.5 centimeters in diameter. Totally submitted with a request for levels. Submitted request for stains. Microscopic description: Sections of the cervical biopsy show high-grade dysplasia, consistent with CIN III. No evidence of invasive malignancy is present. Select the appropriate ICD-10-CM and CPT code(s):

Preoperative Diagnosis: thoracoabdominal aortic aneurysm Postoperative Diagnosis: same Operative Procedure: Patient placed on bypass pump after which the surgeon repaired the aneurysm using a graft. 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):

Specimen site: Gastric biopsy Gross description: Gastric biopsy: Received in formalin, the specimen consists of two fragments of gray-brown mucosa, each measuring approximately 0.3 centimeter in diameter. Totally submitted for routine and special stains and additional levels. Microscopic description: Sections show benign-appearing gastric mucosa with acute and chronic inflammatory cells within the lamina propria. The surface and pit-lining epithelium are also infiltrated with neutrophils. There is no dysplasia or malignancy. Special stains for H. pylori are positive. Final diagnosis: Gastric biopsy: ? Chronic active gastritis. ? Warthin-Starry stain positive for H. pylori. ? Negative for intestinal metaplasia, dysplasia, or malignancy. Select the appropriate ICD-10-CM and CPT code(s):

Description: Microscopic hematuria with lateral lobe obstruction, mild. Preoperative Diagnosis: Microscopic hematuria. Postoperative Diagnosis: 1) Microscopic hematuria with lateral lobe obstruction, mild. 2) Mild benign prostatic hyperplasia. Procedure Performed: Flexible cystoscopy. Procedure: The patient was placed in the supine position and sterilely prepped and draped in the usual fashion. After 2% lidocaine was instilled, the anterior urethra is normal. The prostatic urethra reveals mild lateral lobe obstruction. There are no bladder tumors noted. Select the appropriate CPT and ICD-10-CM codes.