Exam 27: Coding and Surgical Procedures

Dr. Green works for a house-call physician service. She was called to evaluate a new patient, an 88-year-old bedridden woman who has developed a painful rash on her posterior left side of the trunk, extending from C6 to C7 around the right side and ending midline on the anterior trunk just below the sternum. The physician performs a detailed history and a detailed examination and medical decision making is of low complexity. She diagnoses the patient with shingles. Select the appropriate codes.

A 36-year-old patient is currently diagnosed with glaucoma and is having occurrences of blurry vision. The patient had a gonioscopy performed to determine the type of glaucoma. The physician has determined that the type is open angle. The patient tolerated the procedure well in the outpatient hospital setting and was sent home in good condition. Select the appropriate CPT and ICD-10-CM codes.

A patient with pulmonary artery stenosis was treated with balloon angioplasty of the pulmonary artery to crush the plaque into the walls of the artery. To accomplish this, a catheter was inserted through the skin into the femoral artery and threaded up to the pulmonary artery. Select the appropriate CPT and ICD-10-CM codes.

The area between the lungs that contains the heart, aorta, venae cavae, esophagus, and trachea is the:

A 52-year-old patient was treated for endometriosis with ovarian and endometrial ablation. The surgeon inserted the endoscope through the vagina into the uterus to cauterize the endometrium. He then withdrew the endoscope, applied a new tip, and made three incisions on the lower abdomen. He inserted the endoscope to fulgurate the lesions on each ovary, withdrew the instrument, and closed with sutures. Patient tolerated the procedure well. 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.

A patient presented to the oncology clinic with a diagnosis of testicular tumor of uncertain behavior. The patient brought slides from his orchiectomy which was sent to the pathologist for review and report including a review of the medical records with written report confirming a diagnosis of testicular carcinoma. Select the appropriate CPT and ICD-10-CM codes.

The time associated with coding sequelae (late effects) is:

An 18-year-old female weighing 485 lbs. is presenting today for a laparoscopic gastric bypass and roux-en-y gastroenterostomy for morbid obesity. Since the patient has a BMI of 73.7, the gastroenterologist feels it is necessary to remove at least 175cm. Select the appropriate CPT and ICD-10-CM codes.

Joan underwent excision of a benign lesion of the right leg, 4 cm × 4 cm, with a rotation flap to repair the incision site. The flap measures 12 cm × 5 cm. Select the appropriate ICD-10-CM and CPT code(s):

Clinical history: Nevus, R pinna Postoperative diagnosis: same Tissue/specimen: skin of external ear nevus of R pinna Impression: microscopic sections show the specimen shows a nevus identified as a melanoma of right ear and auricular canal. Select the appropriate CPT and ICD-10-CM codes.

Mr. Jones, a new patient with a history of prostate cancer 6 years ago, presented today with pain in his lower back and weakness in his extremities. He brought films from x-rays taken earlier in the week and his previous records from his internal medicine physician. The physician takes a comprehensive PMFSH and ROS and performs a comprehensive examination. Based on review of the records and his findings, the physician's diagnosis is metastatic prostate cancer to the sacral vertebrae. The physician discussed treatment options with the patient including risks and benefits. Select the appropriate ICD-10-CM and CPT code(s):

Sam underwent scleral buckling for repair of a detached retina of the right eye with cryotherapy and drainage of subretinal fluid. Select the appropriate ICD-10-CM and CPT code(s):

ESWL was performed on Mrs. Wilson's left kidney 1 week ago; now ESWL is being performed on her right kidney. She has 4 stones being removed today: 2 in the renal pelvis and 2 in the calyx. Under local anesthesia, the ESWL is performed and all 4 stones are successfully destroyed. Select the appropriate CPT and ICD-10-CM codes.

A 34-year-old infertility patient with a history of repeated miscarriages and dysmenorrhea is being seen today to evaluate the patency of her fallopian tubes. The physician suspects that there might be occlusions that are preventing the egg from implanting or preventing sperm from moving through. A transcervical catheter is used to view the fallopian tubes for patency, and a hysterosalpingography is also performed. Select the appropriate CPT and ICD-10-CM codes.

Gregory underwent a prostatomy for drainage of a complicated prostatic abscess. Select the appropriate ICD-10-CM and CPT code(s):

The surgeon applies a cranial halo with eight pins in order to stabilize the cervical spine on a 6-year-old patient with osteogenesis imperfecta. Select the appropriate CPT and ICD-10-CM codes.

The physician used cryotherapy to correct an ingrown eyelash on the left upper lid. Select the appropriate CPT and ICD-10-CM codes.

Upon orders from Dr. Clyos, a portable x-ray machine was transported to the city nursing home for chest x-rays of a patient with possible tuberculosis. The diagnosis was nodular lesions and patchy infiltrates in the upper lobes. Select the appropriate ICD-10-CM and CPT code(s):

Jim went to the doctor for removal of his skin tags. The physician noted 32 skin tags on his back. Using a scalpel the physician removed all of the skin tags and gave Mr. Evans an antibiotic cream prescription to use for the next 7-10 days. Select the appropriate CPT and ICD-10-CM codes.