Exam 27: Coding and Surgical Procedures

A physician performed a simple mastectomy on both the left and right breasts-19303 mastectomy, simple, complete. Assign the appropriate modifier to be added to 19303 to indicate that both breasts were removed in the same operative session:

A 43-year-old male patient with obstruction of the bile ducts and cholangitis is seeing the gastroenterologist today for a biliary endoscopy. The gastroenterologist finds calculi in the bile duct and removes them. Select the appropriate CPT and ICD-10-CM codes.

Preoperative Diagnosis: Dysfunctional Uterine Bleeding Postoperative Diagnosis: Dysfunctional Uterine Bleeding Operation: Dilation and Curettage Operation Description: A 32-year-old woman was diagnosed with dysfunctional uterine bleeding. The physician ordered a dilation and curettage (D&C) to be performed. Risks of the operation, such as infection, were discussed. The patient understood all risks and wanted to proceed with the operation. Consent was obtained. The patient was prepped and draped in the usual sterile fashion in the operating room. The D&C procedure was performed. The patient was in good stable condition and brought to the recovery room. Select the appropriate CPT and ICD-10-CM codes.

Clinical History: Patient with neuropathy and pain in arm. Diagnosed with possible cervical disc. Study performed: Cervical Myelogram -injection procedure and radiological supervision and interpretation. Impression: Moderate ventral extradural defect C5-6 with bilateral C-6 root encroachments. Select the appropriate CPT and ICD-10-CM codes.

Surgical removal of a lobe of the lung is a:

Clinical History: Patient with neuropathy and pain in arm. Diagnosed with possible cervical disc. Study performed: Cervical Myelogram -injection procedure and radiological supervision and interpretation. Impression: Moderate ventral extradural defect C5-6 with bilateral C-6 root encroachments. Select the appropriate CPT and ICD-10-CM codes.

A patient with severe muscle cramps, pain, and discomfort in his extremities, and an elevated creatinine kinase level, is presenting today for a percutaneous needle muscle biopsy. Select the appropriate CPT and ICD-10-CM codes.

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 of the following CPT codes is NOT a method of drawing blood?

After a work-related accident, a drug screen was performed to determine the presence of alcohol, marijuana, opiates, barbiturates, or amphetamines in the patient's system. A multiplexed screening kit was used and one procedure was performed. All tests were negative. Select the appropriate CPT and ICD-10-CM codes.

A nonhealing burn should be coded as which type of burn?

Preoperative Diagnosis: Advanced primary open angle glaucoma, right eye, with related cortical cataract, right eye. Procedure: Trabeculectomy. Phacoemulsification and posterior chamber IOL insertion. Postoperative Diagnosis: Advanced primary open angle glaucoma, right eye, with related cortical cataract, right eye. Operation: The patient was brought in to the operating room on an eye stretcher and placed in the supine position. A peribulbar block using an equal concentration of 2% lidocaine and 0.5% Marcaine was administered and the right eye was draped and prepped in the usual sterile ophthalmic fashion and the microscope was brought in position. We placed a Lieberman lid speculum between the lid fissures on the right eye, then placed a superior rectus bridle suture to stabilize the eye. We created a superior peritomy using Vannas scissors and Bishop forceps. Next we used the cautery to outline a 3x4mm rectangular scleral flap. After applying mitomycin 0.2 mg/mL to the sclera and conjunctiva for two minutes per the clock, I thoroughly irrigated the area with saline. I then dissected the scleral flap using a #68 Beaver blade. I created a 2.70mm incision on the cornea under the scleral flap using a standard blade and created a primary posterior capsulorhexis using a cystotome and forceps. Hydrodissection of the lens nucleus was performed, then we did the phacoemulsification without difficulty and the area was irrigated with saline and the cortical remnants removed. We inserted an AcrySof® Aspheric IOL Model SN60WF +25 into the capsular sac and centered it without difficulty. We then created the internal sclerostomy under the scleral flap, measuring 1x2.5mm. We removed the limbal material with a Kelly punch. Next we created a peripheral iridectomy using Dewecker scissors and closed the scleral flap using 5 interrupted 10-0 nylon sutures, being attentive to carefully control the tension. When the tension allowed egress of aqueous, we tied off and buried the sutures. We reapproximated the conjunctival flap and suture it into position using 9-0 nylon mattress sutures and 8-0 Vicryl running sutures. We checked intraolcular pressure manually with a cannula and it was within normal limits. We applied Gentamicin 20 mg under the conjunctiva and erythromycin on the conjunctiva. We removed the lid speculum, closed the eyelids and placed a patch and shield over the eye. The patient tolerated the procedure well and was transferred to recovery in good condition. Select the appropriate CPT and ICD-10-CM codes.

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 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. The procedure of the cleft palate repair was performed. No complications noted and the patient returned to the recovery room in good condition. Select the appropriate CPT and ICD-10-CM codes.

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 43-year-old male patient with acute obstruction of the bile ducts and cholangitis is seeing the gastroenterologist today for a biliary endoscopy. The gastroenterologist finds calculi in the bile duct and removes them. 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.

History: 76-year-old female with colonic mass Diagnosis: Invasive adenocarcinoma, 3.4 × 3.0 cm, involving muscularis propria All margins negative. No lymphatic invasion. No metastatic tumor identified. Gross description: Received fresh is a right colon, 32 cm in length. Upon opening of the specimen, there is a 3.4- × 3.0-cm nodular mass. 36 lymph nodes were retrieved. Representative sections are submitted. Microscopic description: Microscopic examination performed Select the appropriate ICD-10-CM and CPT code(s):

The medical term for difficulty breathing is:

Jane Smith is a 44-year-old patient who returns back this month to her primary care physician office for a well woman exam. The exam reveals a normal pelvic exam; no masses in the vaginal and cervical area. Breast exam shows no masses or abnormalities. All other systems are normal. The patient is to return in one year. 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: