Exam 27: Coding and Surgical Procedures

A 36-year-old female who was the driver in a car accident presented with whiplash for chiropractic manipulative treatment of her cervical spine. The chiropractor provided a complete history and examination prior to the treatment plan of one visit a week for 2 months, at which point her status will be reevaluated. Today the first manipulation was performed. Select the appropriate ICD-10-CM and CPT code(s):

Roger was in an altercation with his neighbor and he has 3 wounds. The first is a 15.5cm wound on the face that required a single layer closure, the second is a 25.5cm laceration of the left forearm that required a layered closure of the subcutaneous tissue, and the third laceration is a 10cm wound on the right external ear that required a layered closure. Select the appropriate CPT and ICD-10-CM codes.

Mr. Jones is a patient with recurrent stage IV colon carcinoma of the sigmoid colon. He had previously undergone a laparoscopic low anterior resection (LAR). He was brought to the operating room today and under general anesthesia underwent a laparoscopic lysis of adhesions. The small bowel loops were found to be adherent to the anterior abdominal wall and also near the colostomy. These adhesions were lysed. There was one loop of small bowel that was adherent to the anterior abdominal wall of the RLQ, and this adhesion was not disturbed. Select the appropriate ICD-10-CM and CPT code(s):

Which of the following is not included in the CPT definition of lesion destruction?

A 54-year-old patient made an emergency department visit for gastritis, and it was also noted that the patient had melena based on the laboratory diagnostic tests. The patient was treated and released to follow up with the primary physician. History and examination are detailed. The medical decision making was noted at a moderate complexity. Select the appropriate CPT and ICD-10-CM codes.

CT Scan of the Abdomen and Pelvis History: Malignant testicular neoplasm Technique: Axial CT images of the abdomen and pelvis were obtained with intravenous and oral contrast. Findings: Images of the lung bases are normal. Images of the abdomen show the liver, spleen, gallbladder, pancreas, and adrenal glands to be normal. No mass is seen. There is no evidence of cholelithiasis. A retroaortic left renal vein is seen. No obvious mass or enlarged lymph nodes are noted in the retroperitoneum. Mesenteric structures appear normal. A prominent inferior vena cava is seen. Gas is identified in the left inguinal structures, likely representing previous left orchidectomy and removal of the inguinal ring. No enlarged lymph node is identified in the pelvis. Impression: Left retroaortic renal vein is seen. No adenopathy is noted within the abdomen or pelvis. No enlarged lymph node is seen; no mass is identified. Select the appropriate ICD-10-CM and CPT code(s):

The patient was taken to the OR for draining of the pus from the middle ear. The surgeon accomplished this with an incision in the tympanic membrane. This procedure is called a:

Preoperative Diagnosis: Right knee degenerative arthritis Postoperative Diagnosis: Same Operation Performed: Arthroscopic irrigation and debridement of same with partial synovectomy Estimated Blood Loss: Minimal Complications: None Description of Operation: The patient was placed on the table in supine position. The right lower extremity was prepped and draped without a tourniquet. The knee was injected with 30 mL of normal saline and standard arthroscopy portals were created. The arthroscopy was inserted and a complete diagnostic was performed. The knee was copiously irrigated with 9 L of irrigant. A partial synovectomy was performed in all compartments. Minimal amount of polyethylene wear was noted. The knee was then drained and the arthroscopic instruments were removed. The portals were closed with 4-0 nylon and local anesthetic was injected. A sterile dressing was applied; the patient was awakened from anesthesia and transported to the recovery room in stable condition. Select the appropriate CPT and ICD-10-CM codes.

Electrical stimulation and ultrasound to aid bone healing are included in which of the following codes?

Ted is at the ambulatory care center for an arthrotomy with Dr. Abraham today. Ted is a 23-year-old steel worker who has a foreign body in his carpometacarpal joint. The foreign body has created a severe infection and drainage will need to be done along with the removal of the foreign body. Dr. Abraham made an incision between the 3^rd and 4^th carpometacarpal joints and located the foreign body, which was a sliver of steel. The wound was then packed and dressed. The patient tolerated the procedure and was released with instructions to return to Dr. Abraham's office in 7 days. Select the appropriate CPT and ICD-10-CM codes.

Clinical diagnosis: Cholecystitis and Chronic Calculi Operation: Cholecystectomy Specimen: Gall bladder Pathology Report: Microscopic analysis of specimen measuring 9.0 X 3.0cm. Diagnosis: Chronic cholecystitis, cholelithiasis Select the appropriate CPT and ICD-10-CM codes.

Derek is here today for open tendon surgery in his right shoulder due to a ruptured rotator cuff. Under general anesthesia an incision of 5cm was made in the shoulder. All loose fragments of tendon, bursa, and other debris were removed. There was some subacromial smoothing to make room for the tendon. The tendon was properly placed and the incision was sewn with 5.0 vicryl. The patient tolerated the procedure well and was sent to the floor. Select the appropriate CPT and ICD-10-CM codes.

Patient was admitted with chest pain, R/O MI. The physician ordered the following laboratory tests: Comprehensive metabolic panel, CBC w/differential, Sedimentation rate, PT, troponin level, automated urinalysis w/microscopy. Select the appropriate CPT and ICD-10-CM codes for the laboratory tests.

Dr. Willow is called in to administer general anesthesia to a 3-month-old female patient diagnosed with congenital tracheal stenosis. Dr. Gordon performs a surgical repair of her trachea. The patient is released to the recovery room staff in good condition. Select the appropriate ICD-10-CM and CPT code(s) for Dr. Willow:

Repair incomplete unilateral cleft lip with a cross lip pedicle flap. Select the appropriate CPT and ICD-10-CM codes.

A 28-year-old was in a car accident and is now in the ED due to 3 fingers on his left hand being completely amputated above the metacarpophalangeal joint during the crash. The ED physician calls in an orthopedic surgeon and the patient is taken to surgery. Under surgical microscope his index finger and middle finger were reconnected; however, his 3rd finger was not able to be reconnected due to extensive crush injuries to that finger, so that finger was surgically amputated. Select the appropriate CPT and ICD-10-CM codes.

A 54-year-old patient made an emergency department visit for gastritis, and it was also noted that the patient had melena based on the laboratory diagnostic tests. The patient was treated and released to follow up with the primary physician. History and examination are detailed. The medical decision making was noted at a moderate complexity. Select the appropriate CPT and ICD-10-CM codes.

Preoperative diagnosis: Respiratory insufficiency Postoperative diagnosis: Respiratory insufficiency Operation: Tracheostomy with division of thyroid isthmus Estimated blood loss: Less than 10 mL Fluids: Crystalloid Complications: None Technique: The patient was brought to the operating room and placed in the supine position. He was given general anesthesia through his existing oral intubation tube. The anterior neck was prepped and draped in the usual sterile fashion. Lidocaine 1% with 1:100,000 epinephrine was infiltrated into the skin at the lower neck. A transverse incision was made at the cricoid ring level through skin and subcutaneous fat. The platysmal layer was traversed, and then the strap muscles were separated in the midline. The thyroid isthmus was ligated and divided with #2-0 silk ligatures. An inferiorly based tracheostomy flap was created using the second and third tracheal rings and sewn into place with a #3-0 chromic stitch to the inferior dermis margin. Hemostasis was achieved using suction cautery. At this point, the oral intubation tube was withdrawn, and a #8 Shiley low-pressure cuffed tube was passed into the newly created trach site. The trach ties were tied securely into place, and the cuff was inflated to a comfortable pressure. The patient then received further ventilation through the newly placed trach tube. The patient was then allowed to awaken from general anesthesia and was taken back to the ICU in stable condition. Select the appropriate ICD-10-CM and CPT code(s):

Sally is a long-term alcoholic who has made the decision to receive treatment for her disease. However, before beginning her psychotherapy, Sally is required to undergo a behavioral health screening and alcohol assessment. Select the appropriate CPT and ICD-10-CM codes for these two procedures.

A 72-year-old female presents to her PCP with complaints of a sore, swollen left ankle. The patient has severe osteoporosis and Type II diabetes and states that she "tripped last night on her way to the bathroom" and thinks she sprained her ankle. Her PCP orders an x-ray of her left ankle, and the report showed a pathologic closed fracture of the left lateral malleolus. Closed treatment of the lateral malleolus is performed by an orthopedic surgeon. Select the appropriate CPT and ICD-10-CM codes for the surgeon.