Exam 27: Coding and Surgical Procedures

Choose the appropriate CPT code for a care plan oversight service for a patient under the care of home health agency performed by a physician for 45 minutes.

A 43-year-old male patient with obstruction of the bile ducts and cholangitis is seeing the gastroenterologist today for a biliary endoscopy. The gastroenterologist finds calculi in the bile duct and removes them. Select the appropriate CPT and ICD-10-CM codes.

A patient was admitted with a hernia of the diaphragm. The medical term for this disease is

Mrs. Mustin undergoes insertion of a left custom breast prosthesis 3 months after a mastectomy for breast cancer. The patient needed to undergo radiation to that area prior to the insertion of the prosthesis. Select the appropriate ICD-10-CM and CPT code(s):

Preoperative diagnosis: Left hydrocele Postoperative diagnosis: Left hydrocele Procedure performed: Left hydrocelectomy Procedure description: The initial incision was made, and the left hydrocele was delivered out of the wound and incised. The hydrocele was emptied of about 500 mL and then incised completely. About 90% of the hydrocele sac was removed with the Bovie. The hydrocele sac was involuted and sewn to itself using running 3-0 Vicryl in the manner of Jaboulay. The testicle was replaced in the left scrotum, and the patient tolerated the procedure well. Select the appropriate ICD-10-CM and CPT code(s):

Procedure performed: Fiber-optic bronchoscopy, bronchial biopsy, bronchial washings, and bronchial brushings Preprocedure diagnosis: Abnormal chest x-ray Postprocedure diagnosis: Inflammation in all lobes, pneumonia; with pleural placquing? consistent with possible candidiasis The patient was already on a ventilator, so the bronchoscope tube was introduced through the ET tube. We saw 2.5 cm above the carina of the trachea, which was red and swollen as was the carina. The right lung: All entrances were patent, but they were all swollen and red, with increased secretions. The left lung was even more involved, with more swelling and more edema and had bloody secretions, especially at the left base. This area from the carina all the way down to the smaller airways on the left side had shown white placquing consistent with possible candidiasis. These areas were brushed, washed, and biopsied. A biopsy specimen was also sent for tissue culture, as well as two biopsy specimens sent for pathology. Sheath brushings were also performed. The patient tolerated the procedure well and was sent back to the ICU. Select the appropriate ICD-10-CM and CPT code(s):

A patient was seen by the physician today for follow-up testing for exophthalmos. The meaning of this term is

What is the Level II HCPCS code for a non-covered item or service?

Mary Torres presents at her endocrinologist's office for IDDM. She states that she ran out of insulin the day before her visit. A blood glucose is performed and the result is 415. The physician writes an order for his nurse to give Mary 13 units of regular insulin. Select the appropriate HCPCS code for the medication only.

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.

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):

Examination: Gastric-emptying study Reason for the examination: This is a study of elimination for gastroparesis, abdominal cramping, and pain. Interpretation: One millicurie of technetium-99m sulfur colloid was given through a gastrostomy tube in saline. The normal half-time of clearance of liquid material from the stomach is 12 minutes. The patient's clearance is 50 minutes, which is a fourfold increase in time and is compatible with a marked delay in gastric emptying. Select the appropriate ICD-10-CM and CPT code(s):

A 45-year-old patient with BCBS is seen by a consultant at the request of her internal medicine physician for opinion and management recommendations regarding her subacute bronchitis. The consultant performs a comprehensive history and exam with decision making of moderate complexity. He returns the patient to her primary physician and sends a report discussing his findings and recommendations. Select the appropriate CPT and ICD-10-CM codes.

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:

Clinical History: Herniated cervical disc C5-6 with myelopathy Source of Specimen: Cervical disc tissue C5-6 Pathology Report: The specimen consists of multiple irregular fragments of fibrocartilage, aggregating 2.5 X 1.5 X 1.2cm. It is blue stained. There is no gross evidence of malignancy. Diagnosis: Degenerating Fibrocartilage consistent with disc C5-6 Select the appropriate CPT and ICD-10-CM codes.

Bill was involved in a MVA. He was taken to the ED where the following was performed: A 3 cm simple repair of the left ear, an intermediate repair of the left thigh which was 7.8 cm, and an intermediate repair of the left calf muscle which was 2.0 cm. Select the appropriate CPT code(s) for the repairs only.

Which of these combining forms does not refer to part of the intestine?

Description: CT scan of the abdomen and pelvis without and with intravenous contrast. Exam: CT scan of the abdomen and pelvis without and with intravenous contrast. Clinical Indication: Left lower quadrant abdominal pain. Comparison: None. Findings: CT scan of the abdomen and pelvis was performed without and with intravenous contrast. Total of 100 mL of Isovue was administered intravenously. Oral contrast was also administered. The lung bases are clear. The liver is enlarged and decreased in attenuation. There are no focal liver masses. The adrenal glands, pancreas, spleen, and right kidney are normal. A 9-mm simple cyst is present in the inferior pole of the left kidney. There is no hydronephrosis or hydroureter. The appendix is nonremarkable. There are multiple diverticula in the rectosigmoid. There is evidence of focal wall thickening in the sigmoid colon with adjacent fat stranding in association with a diverticulum. These findings are consistent with diverticulitis. No pneumoperitoneum is identified. There is no ascites or focal fluid collection. The aorta is normal in contour and caliber. Impression: Findings consistent with diverticulitis. Select the appropriate CPT and ICD-10-CM codes.

The purpose of the medical record includes:

The ______ consists of specialized heart muscle cells that conduct electrical impulses from the AV node to the ventricles.