Exam 27: Coding and Surgical Procedures

John, a nine-year-old boy, is being seen today for persistent allergic sinusitis. Today he will undergo percutaneous sequential and incremental allergy testing with biological allergens with 15 various allergens being applied followed by interpretation and report. Select the appropriate CPT and ICD-10-CM codes.

After administering local anesthetic, the physician made a full-thickness elliptical incision through the skin. The arterio-venous malformations and the malignant melanoma including the margin were excised and reconstructive repair of the right lower eyelid was performed. Select the appropriate CPT and ICD-10-CM codes.

The language that is built on medical terminology, anatomy, and pathophysiology and describes services, procedures, and the medical necessity of those services and procedures is referred to as:

Julia was playing baseball in her hardball league and was hit in the face with a line drive. Upon waking she was taken directly to the hospital. She has a fractured mandible, and the orthopedic surgeon is performing a closed treatment with interdental fixation. Select the appropriate CPT and ICD-10-CM codes.

Clinical History: Patient presents with a diagnosis of temporomandibular joint dysfunction. Study performed: Panoramic x-ray of the maxilla and mandible. Select the appropriate CPT and ICD-10-CM codes.

Preoperative Diagnosis: Tonsillitis Postoperative Diagnosis: Tonsillitis Operation: Tonsillectomy Anesthesia: General Operation Description: A 12-year-old patient is diagnosed with tonsillitis and was recommended to have a tonsillectomy. Family consented to the surgery and patient admitted. Patient was positioned supine for the procedure. The right, then the left tonsil was removed. The tonsillar area was irrigated; no bleeding before or after the suturing. The patient tolerated the procedure well. Select the appropriate CPT and ICD-10-CM codes.

Which of the following tumors are considered to be benign?

Patient presents for cesarean section with no other deliveries or pregnancies noted in the chart. She was prepared and draped in the usual sterile manner for an abdominal procedure. An incision was made and carried down through the subcutaneous tissue, muscular fascia, and peritoneum. Once inside the abdominal cavity, a low cervical transverse incision was made in the lower uterine segment after creating a bladder flap by both blunt and sharp dissection. With creation of the bladder flap, a transverse incision was made and the infant was delivered as a vertex. The placenta was then removed as well. With removal of the placenta and baby, cord blood was obtained. The infant was handed off to the nurses in attendance. We then closed the uterine incision in the usual manner. A Foley catheter had been inserted. Clear urine was noted. The patient was then awakened and taken to the recovery room in good condition. Select the appropriate CPT and ICD-10-CM codes for the delivery only.

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):

Joey, age 5, is taken to the OR today for removal of a small foreign body from his right nares. General anesthesia was required due to the significant level of anxiety displayed by the child, as well as the location of the small object. Select the appropriate CPT and ICD-10-CM codes.

A 4-year-old male underwent a frenoplasty using the Z technique to correct his speech difficulty due to ankyloglossia. Select the appropriate ICD-10-CM and CPT code(s):

A 78-year-old male is hospitalized for removal of a foreign object from the left shoulder after a previously performed Neer hemiarthoplasty. Select the appropriate CPT code.

Joseph, age 6, was admitted and an IV started for dehydration due to severe gastroenterocolitis for the previous three days. The physician ordered this IV to be administered over 5 hours. Select the appropriate CPT and ICD-10-CM codes.

The patient was seen by a psychiatrist for post-traumatic stress disorder. This visit was a psychiatric diagnostic evaluation which included a history, mental status examination, and recommendations. The evaluation and treatment plan were communicated to the family as the patient has requested their involvement in his care. Select the appropriate CPT and ICD-10-CM codes.

A patient with thyroid cancer had a thyroidectomy with a radical cervical lymphadenectomy. Select the appropriate CPT and ICD-10-CM codes.

Clinical Indication: Carcinoma of the right breast, mastectomy and chemotherapy completed with no recurrence; now presents with skeletal metastases. Procedure: Multiple tomograms of L. lung show no dominant nodules within the lung. Multiple osteolytic metastases are present in several of the ribs in posteriolateral aspect involving third, fourth, fifth, six, and seventh ribs. Small amount of pleural reaction is noted in the L costophrenic angle. Hilar shadows are unremarkable. Shadow for L breast is absent. Impression: No definite metastatic nodules in L lung. Multiple mixed osteolytic and osteoblastic changes in several ribs in the L chest probably due to metastatic neoplasm. Select the appropriate CPT and ICD-10-CM codes.

Four people were seen in the ED. Which one will receive a diagnosis of poisoning? Patient A: digitalis toxicity Patient B: allergic reaction to contrast dye used for a CT exam Patient C: syncope after taking antihistamine with alcohol Patient D: reaction between two properly administered prescription drugs

An abnormal hump caused by increased convexity of the thoracic spine is called:

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.

A 58-year-old male is undergoing a therapeutic endoscopic retrograde cholangiopancreatography. The gastroenterologist injects the contrast agent, and using fluoroscopy views the hepatobiliary system, collects specimens for testing, and places a biliary stent to relieve the patient's jaundice. Select the appropriate CPT and ICD-10-CM codes.