Exam 27: Coding and Surgical Procedures

A 1-year-old female underwent a uvulopalatopharyngoplasty to repair a congenital bilateral cleft lip and cleft hard palate. 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.

Preoperative diagnosis: Right subdural hematoma Postoperative diagnosis: Right subdural hematoma Procedure performed: Right temporoparietal craniotomy for evacuation of subdural hematoma Anesthesia: General endotracheal Complications: None Conditions: Stable Indications for procedure: Mr. Green is a 45-year-old male with a known history of alcoholism. He reported falling today, with loss of consciousness for about 20 minutes. Upon arrival at the ED, he was minimally responsive, with some spontaneous movement on the right side. He was intubated and taken to CT, which demonstrated a large right temporal subdural hematoma with 2.5-cm midline shift and effacement of the right lateral ventricle. Description of procedure: The patient was brought to the OR already intubated. General anesthesia was induced. He was given Ancef for preoperative prophylactic IV antibiotics. Lacri-Lube was placed in both eyes, which were then taped shut. A Foley was placed. The patient was positioned supine on the operating room table with the right side elevated with a gel roll. The head was secured in the three-point Mayfield head-holder with the right side up. All pressure points were inspected and padded adequately. The patient's scalp was clipped, prepped, and draped in standard sterile surgical fashion. Local anesthetic was infiltrated along the line of the planned skin incision. A right temporoparietal inverted-question-mark incision was performed with a #10 blade down to the level of the periosteum. The scalp flap, along with the muscle and periosteum, was elevated and reflected anteriorly and held in place with fishhooks. Raney clips were applied to the skin edges. Using the high-speed Midas Rex drill with the perforator bit, burr holes were placed in the temporoparietal region, and they were connected with the B1 and footplate. The bone flap was elevated from the dura and set aside. The underlying brain appeared to be tense. The dura was opened with a 15-blade, and a large amount of subdural hematoma was immediately released. The subdural space was copiously irrigated, and hemostasis was achieved. Select the appropriate ICD-10-CM and CPT code(s):

A 76-year-old female was admitted for intravenous antibiotic therapy to treat pneumonia due to pseudomonas bacteria, and a level 3 initial inpatient visit was provided. On the second and third days, the patient had not yet responded to treatment, which was noted after an expanded problem-focused examination and interval history. On day 4, the patient showed significant improvement and the doctor recorded a problem-focused history and examination. On day 5, the patient was discharged home and the doctor spent 30 minutes in discharge day management. Select the appropriate CPT and ICD-10-CM codes for the physician visits.

Joey, a 5-year-old boy, was seen today for immunizations prior to beginning school. After counseling by the PA, he received diphtheria, tetanus toxoid, acellular pertussis, haemophilus influenza Type B, and polio virus as a single injection. Additionally, he received MMRV subcutaneously. Select the appropriate CPT and ICD-10-CM codes.

Preoperative diagnoses: 1)Sick sinus syndrome, status post-pacemaker insertion. 2)Infected pacemaker with exposed wires. 3)Coronary artery disease with history of coronary artery bypass graft. 4)Essential hypertension. Postoperative diagnoses: 1)Sick sinus syndrome, status post-pacemaker insertion. 2)Infected pacemaker with exposed wires. 3)Coronary artery disease with history of coronary artery bypass graft. 4)Essential hypertension. Operations performed: 1)Explant of pacemaker generator and two wires under fluoroscopic guidance and xenon laser. 2)Pocket revision. 3)Intraoperative transesophageal echocardiography with interpretation. Select the appropriate ICD-10-CM and CPT code(s):

10-year-old Susie Patterson had a fall and an injury occurred. She was taken to the emergency room, where the physician ordered an x-ray to be performed. The radiologist confirmed that she had a bimalleolar fracture. A temporary splint was applied, and she will follow up with the orthopedic specialist to obtain a permanent cast. Patient was discharged in stable condition. Identify the anatomic site of injury.

Pyogenic arthritis in the right elbow due to methicillin susceptible staphylococcus aureus has caused continual extreme pain to the patient. Elbow replacement, arthroplasty, is recommended. The physician began the replacement procedure by removing the damaged joint components. They were then replaced with plastic implants. One implant was attached to the humerus, the other to the ulna, and the two were connected to form a hinge. The patient tolerated the procedure well and was released to the recovery room. Select the appropriate CPT and ICD-10-CM codes.

Medicare Part A pays for all of the following except:

A 40-year-old patient had 27 skin tags removed in the physician's office. Patient tolerated the procedure well and was instructed to return for a follow up visit in ten days. Select the appropriate CPT and ICD-10-CM codes.

Mrs. Jones presented with pain in the right upper quadrant. Upon a CT of the abdomen and an ultrasound of the gallbladder, a diagnosis of cholelithiasis and acute cholecystitis was confirmed, and the patient was taken to the operating room. The patient underwent a laparoscopic cholecystectomy with a normal intraoperative cholangiogram to remove the gallstones. Select the appropriate ICD-10-CM and CPT code(s):

The patient is seen in the OB/GYN office for follow-up postpartum. She had been seen by her previous physician throughout her pregnancy, but has relocated since the normal vaginal delivery of her daughter 6 weeks ago. 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. 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 was admitted. Patient was positioned supine for the procedure. The right and the left tonsils were removed. The tonsillar area was irrigated. There was no bleeding before or after the suturing. The patient tolerated the procedure well. Select the appropriate CPT code for the anesthesia service, as well as the ICD-10-CM code.

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.

A 22-year-old woman was diagnosed as being 8 weeks pregnant. This is her first pregnancy. The proper term to describe her condition is

Clinical history: Shortness of breath - crackles and change in sound in base of lungs. Study performed: Chest X-ray, PA and lateral. Impression: Poor inspiratory effort which accentuates the basilar lung markings and cardiac silhouette, partially limiting evaluation. Small vertically oriented linear infiltrate subsegmental atelectasis is noted in the L retrocardiac region adjacent to the diaphragm. There is minimal hazy increased density and decreased definition in the L costophrenic angle suggesting pleural effusion. Segmental atelectasis and some pleural effusion. Select the appropriate CPT and ICD-10-CM codes.

Practice management programs are used to:

A 76 year old female is admitted for IV antibiotic therapy to treat pneumonia due to pseudomonas bacteria and a level 3 initial inpatient visit was provided. On days 2 and 3, the patient had not yet responded to treatment as noted after an expanded problem-focused exam and history. On day 4, the patient showed significant improvement and the physician recorded a problem-focused history and exam. On day 5, the patient was discharged to home and the physician spent 30 minutes in discharge day management. Select the appropriate CPT codes for the physician visits from the admit to the discharge.

Preoperative Diagnosis: Dysfunctional Uterine Bleeding Postoperative Diagnosis: Dysfunctional Uterine Bleeding Operation: Dilation and Curettage Operation Description: A 32-year-old woman was diagnosed with dysfunctional uterine bleeding. The physician ordered a dilation and curettage (D&C) to be performed. Risks of the operation, such as infection, were discussed. The patient understood all risks and wanted to proceed with the operation. Consent was obtained. The patient was prepped and draped in the usual sterile fashion in the operating room. The D&C procedure was performed. The patient was in good stable condition and brought to the recovery room. Select the appropriate CPT and ICD-10-CM codes.