Exam 27: Coding and Surgical Procedures

Why is it necessary for a medical coder to use a current edition of the AMA CPT manual?

Jane, an 89-year-old female, lives in an assisted living facility. The physician provides monthly supervision of care for this patient that requires complex and multidisciplinary care modalities, including completion of reports and coordination of care with the staff for the purposes of ongoing management of medications for her diabetes and COPD. The physician spends approximately 35 minutes doing this service. Select the appropriate CPT and ICD-10-CM codes.

The medical term for air in the pleural cavity is:

A 30-year-old male, who is a new patient, is brought into the physicians' office for the treatment of dermatitis. The physician's focus on the problem is a detailed history and examination. The MDM complexity is moderate. Select the appropriate CPT and ICD-10-CM codes.

Which of the following is not a layer of membrane surrounding the brain and spinal cord?

A patient with a significant past medical history consisting of coronary artery disease and hypertension was found to have a tumor in the chest wall. Resection of left chest wall tumor was performed, including transection of three ribs and partial resection of left diaphragm, left lower lobe lung wedge resection, and left chest wall reconstruction with Gore-Tex mesh. The pathology report indicated mesothelioma in the chest wall and lung. Select the appropriate CPT and ICD-10-CM codes.

Procedure performed: Fiber-optic bronchoscopy, bronchial biopsy, bronchial washings, and bronchial brushings Preprocedure diagnosis: Abnormal chest x-ray Postprocedure diagnosis: Inflammation in all lobes, pneumonia; with pleural placquing? consistent with possible candidiasis The patient was already on a ventilator, so the bronchoscope tube was introduced through the ET tube. We saw 2.5 cm above the carina of the trachea, which was red and swollen as was the carina. The right lung: All entrances were patent, but they were all swollen and red, with increased secretions. The left lung was even more involved, with more swelling and more edema and had bloody secretions, especially at the left base. This area from the carina all the way down to the smaller airways on the left side had shown white placquing consistent with possible candidiasis. These areas were brushed, washed, and biopsied. A biopsy specimen was also sent for tissue culture, as well as two biopsy specimens sent for pathology. Sheath brushings were also performed. The patient tolerated the procedure well and was sent back to the ICU. Select the appropriate ICD-10-CM and CPT code(s):

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):

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):

A 62-year-old diabetic female underwent a Whipple procedure for carcinoma of the head of the pancreas. During the procedure, the patient was monitored by the CRNA. Select the appropriate CPT and ICD-10-CM codes.

John underwent disarticulation at the knee as a result of a traumatic crushing injury to the right tibia and fibula caused by a motorcycle accident. Select the appropriate ICD-10-CM and CPT code(s):

Preprocedure diagnosis: Lumbar radiculopathy Postprocedure diagnosis: Lumbar radiculopathy Procedure performed: Lumbar epidural steroid injection Anesthesia given: Local Indications for procedure: This 53-year-old female presents with symptoms consistent with a lumbar radiculopathy. Previous epidural steroid injections have resulted in significant improvement of her pain. This is the second in a series of three of those injections. Description of procedure: The patient was placed in the left lateral decubitus position. The L4-5 interspace was identified with deep palpation. Local infiltration was carried out with 3 cc of 1% lidocaine. The area was prepped and draped in the usual sterile fashion. An 18-gauge Tuohy needle was advanced to the epidural space with the loss-of-resistance technique. Then a mixture of Depo-Medrol 80 mg, normal saline 10 cc, and lidocaine 1% at 5 cc was injected. No complications were encountered, and the patient was returned to the outpatient surgery department in stable condition. Plan: To repeat this procedure in two weeks Select the appropriate ICD-10-CM and CPT code(s):

A condition in which the placenta partially or fully covers the cervix, posing a risk that it may separate from the uterine wall during labor is

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):

Jim Jones is a 32-year-old from Maryland who was in town last week with ESRD. He was seen for four dialysis treatments this month. Select the appropriate ICD-10-CM and CPT code(s):

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 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 patient with chronic recurrent acute sinusitis and nasal polyps presented to the outpatient surgical center for endoscopic frontal sinus exploration with osteomeatal complex resection, anterior ethmoidectomy, and removal of nasal polyps. Select the appropriate CPT and ICD-10-CM codes.

Jeremy is seen at the clinic today by his regular physician for a rash on his arm that developed while camping in the woods this past weekend. After the problem-focused history and examination the physician determines that the problem was caused by poison oak, and Jeremy is diagnosed with allergic contact dermatitis and prescribed corticosteroid skin cream to reduce the inflammation. Select the appropriate ICD-10-CM and CPT code(s):

Specimen site: Right medial cheek Specimen site: Left dorsal hand Gross description: Right medial cheek: The specimen is one gray-white fragment measuring 0.3 × 0.2 cm. Totally submitted in one cassette with a request for levels labeled "A." Left dorsal hand: The specimen is one gray-white fragment measuring 0.3 × 0.3 cm. Totally submitted in one cassette with a request for levels labeled "B." Microscopic description: The right medial cheek shows atypical keratinocytes within the entire thickness of the epidermis extending to the stratum corneum. The lesion appears to have been excised. The dermis shows elastosis. The dorsal hand shows hyperkeratosis. The epidermis is mildly acanthotic. There is extensive dermal elastosis. Final diagnoses: 1) Right medial cheek, biopsy: ? Squamous cell carcinoma in-situ. (See comment.) 2) Left dorsal hand, biopsy: ? Dermal elastosis. ? No malignant changes seen. Comment: The lesion from the cheek appears to reside within the confines of the histologic section. The skin lesion shows no invasive malignancy. Select the appropriate ICD-10-CM and CPT code(s):