Exam 27: Coding and Surgical Procedures

A patient taking warfarin for atrial fibrillation reports to the lab for a venous draw for prothrombin time for her monthly INR evaluation. This is her third such visit in the past 90 days. She will see her physician in two days to review the results. 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):

History: A 73-year-old 81-kg male with a history of non-Hodgkin's lymphoma and moderate in situ adenocarcinoma of the prostate presents for transurethral resection of the prostate (TURP). The preoperative evaluation reveals a history of smoking (60 pack-years), normal ejection fraction and heart valves, and normal chest x-ray and EKG. No other significant findings. Procedure: He was taken to the operating room and monitored as per routine for cystoscopy and TURP. After appropriate preoxygenation, general anesthesia was uneventfully induced with fentanyl, propofol, and rocuronium. The patient was intubated, ventilated, and placed in the lithotomy position. The operative procedure was started without difficulty. After 90 minutes, the patient's temperature had dropped from 35.9°C at the beginning of the case to 32.9°C. Blood was sent to the lab due to the length of the surgery. The patient's vital signs were stable. Shortly thereafter the following values were sent back from the laboratory to the operating room: NA 109 mEq/L, K 4.7 mEq/L, CL 83 mEq/L, Glucose 83 mg/dl, Hct 34. The anesthesiologist informed the surgeon about the findings, and the surgery was then stopped. The patient was transferred to the surgical intensive care unit (SICU). At arrival in the SICU: The patient was still intubated and sedated. The body temperature was 33.5°C. The laboratory measurements revealed NA 107 mEq/L, K 5.7 mEq/L, CL 79 mEq/L, CO2 109 mEq/L, ammonia level of 60 mmol/L, and serum osmolarity of 273. A radial arterial catheter and a central venous catheter were inserted, and rewarming with hot air (Bair Hugger) was initiated. Select the appropriate ICD-10-CM and CPT code(s):

A 55-year-old male presents at his surgeon's office with Gynecomastia. The surgeon decides he will perform a mastectomy of the patient's left breast. Select the appropriate CPT and ICD-10-CM codes.

Mr. Dell is a farrier, and he was kicked in the sacral-coccygeal area by a horse that he was shoeing. The injury was significant enough to require an open treatment to repair the coccygeal fracture. Select the appropriate ICD-10-CM and CPT code(s):

Which term pertains to the heart muscle?

Jimmy, age 4, has a history of repeated ear infections and is in the OR today for myringotomy and eustachian tube inflation to reduce the damage from chronic purulent otitis media. Select the appropriate ICD-10-CM and CPT code(s):

A proctosigmoidoscopy was performed to examine the sigmoid colon, rectum, and anal structure for pus in the stool and melena on a patient with a family history of carcinoma in the colon. During the procedure a biopsy of a lesion was also performed. The pathology report later came back with benign lesion. Select the appropriate CPT and ICD-10-CM codes.

A patient with psoriasis was seen for laser treatment of 300 square centimeters. Select the appropriate CPT and ICD-10-CM codes.

A patient with a recent total detached retina on the left eye underwent scleral buckling. A vitrectomy was also performed in order for the surgeon to adequately visualize the structures using the operating microscope. Select the appropriate CPT and ICD-10-CM codes.

A 48-year-old female comes to her physician for aspiration of her right ring finger where fluid has accumulated due to a past injury of that finger and she continues to have pain. The physician performs arthrocentesis and follows up with an injection of steroid in the same joint. Select the appropriate CPT code.

Smith works for "Doctors to You" and visits Jane, an established patient with this company, in her home. Jane is complaining of nausea, vomiting, and diarrhea for the past three days after eating tuna fish purchased from a local restaurant. After an expanded problem-focused interval history and expanded problem-focused examination, the diagnosis of food poisoning is made, and Jane is administered medication to treat the nausea and given instructions to prevent dehydration and reduce the diarrhea. Select the appropriate CPT and ICD-10-CM codes.

A 48-year-old female comes to her physician for aspiration of her right ring finger where fluid has accumulated due to a past injury of that finger and she continues to have pain. The physician performs arthrocentesis and follows up with an injection of steroid in the same joint. Select the appropriate CPT code.

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.

A patient is seen in the office. His last visit was four years ago, although documentation in his record reveals that the physician has ordered prescription medicine several times in the past three years. The physician performed an expanded problem-focused history; expanded problem focused exam; straightforward medical decision-making. Which CPT code should be reported for the E/M service?

The patient was hypoxemic and had impending respiratory failure. An endotracheal tube was advanced with the capnometer showing appropriate intubation into the airway, and the breath sounds were heard bilaterally in the lungs and not in the abdomen. The cuff was inflated and the endotracheal tube was placed at 24 cm. A chest x-ray confirmed placement. Immediately after intubation the patient had an episode of bradycardia and hypotension. Select the appropriate CPT and ICD-10-CM codes.

Which of the following terms is the report tracing the electronic activity of the heart?

Wanda is visiting her dermatologist to have a biopsy done on some lesions on her back. Dr. Trummel examined the lesions on her back and decided to do a punch biopsy of 4 of them. The pathology report later came back as benign. Select the appropriate CPT and ICD-10-CM codes.

Clinical History: Symptoms of SOB, chest pain on inspiration, as well an oxygen saturation of 84. Study performed: Ventilation and perfusion studies of the lungs. Interpretation: Particularly positive ventilation and perfusion lung scan. There are no segmental defects to suggest a pulmonary embolus. Select the appropriate CPT and ICD-10-CM codes.

Pre-op diagnosis: Left lung abscess Post-op diagnosis: Same Procedure performed: Left upper lobectomy with decortication and drainage Indications: The patient is a 56-year-old female with evidence of a left upper-lobe abscess seen on the MRI. She was admitted with tension pneumothorax, which was treated with double-lumen intubation and a chest tube. Procedure: The patient was brought to the operating room and placed in the supine position, with general intubation from the double-lumen tube. The patient was rolled onto the right lateral decubitus position, with left side up. A posterior lateral thoracotomy was performed. Adhesions were taken down sharply and bluntly and with cautery. Following this a standard artery first left upper lobectomy was carried out utilizing 0 silk and hemoclips. The left upper pulmonary vein was secured with a single application of the stapling machine. The posterior fissure was created with multiple applications of the automatic stapling machine and the bronchus secured with a single application of the bronchus stapling machine. Following this the wound was drained with three 24-French strium chest tubes and hemostasis obtained with spray Tisseel and surgical gauze. The bronchus was sealed with bio glue and the wound closed in layers. A sterile compression dressing was applied, and the patient was returned to the surgical intensive care unit after the double-lumen tube was changed to a single-lumen tube. The patient received 3 units of packed cells intraoperatively to maintain hemostasis. Sponge count and needle count correct × 2. Large abscess in the left upper lobe accounted for approximately 70% of the left upper-lobe parenchyma. Select the appropriate ICD-10-CM and CPT code(s):