Exam 27: Coding and Surgical Procedures

History: 76-year-old female with colonic mass Diagnosis: Invasive adenocarcinoma, 3.4 × 3.0 cm, involving muscularis propria All margins negative. No lymphatic invasion. No metastatic tumor identified. Gross description: Received fresh is a right colon, 32 cm in length. Upon opening of the specimen, there is a 3.4- × 3.0-cm nodular mass. 36 lymph nodes were retrieved. Representative sections are submitted. Microscopic description: Microscopic examination performed Select the appropriate ICD-10-CM and CPT code(s):

Sally was seen today in her first trimester for her prenatal blood work. The blood work ordered is complete blood count with automated differential, Hepatitis B surface antigen, rubella antibody, syphilis test, RBC antibody screen, blood typing, Rh typing and automated urinalysis with microscopy. Select the appropriate CPT and ICD-10-CM codes.

A 36-year-old female developed a sebaceous cyst on her left upper thigh. Lidocaine was injected to the area without complication. An elliptical incision around the cyst was made with a total excised diameter of .8 cm. After excision the wound was irrigated and the wound was closed with 3-0 Vicryl. Select the appropriate CPT and ICD-10-CM codes.

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):

Select the appropriate CPT and ICD-10-CM codes for Marsupialization removing of multiple milia comedones due to severe acne.

The coiled tubules on top of the testicles that hold the testicles in place are called:

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 27-year-old patient saw the doctor in the office and complained of jaw pain. The doctor ordered an x-ray of the temporomandibular joint of the right and left side to include an open and closed orifice view. The radiologist findings included that the patient has TMJD. Select the appropriate CPT and ICD-10-CM codes for the radiology service.

Holter Monitor Report History: This is a 36-year-old male referred for evaluation of syncope episodes and dizziness. He also has a history of depression and anxiety. A Holter monitor was placed on April 2 for 24 hours. Recording revealed sinus rhythm with three VPCs and three isolated APCs. There were no SVTs, no VTs, and no pauses. The patient had multiple complaints of dizziness, anxiety, panic, and feeling near syncopal. Rhythms at these times documented normal sinus rhythm at rates between 80 and 104 beats per minute. No significant arrhythmias. Impression: Normal Holter Select the appropriate ICD-10-CM and CPT code(s):

A patient was seen for administration of a gastroesophageal reflux test. The pH electrodes were inserted through the nose. The physician supervised the procedure, reviewed the results, and determined the test was positive for GERD. Select the appropriate CPT and ICD-10-CM codes.

Jones accompanied a newborn girl with respiratory failure who had been born 23 hours earlier from the community hospital to the university children's hospital. The ride takes 95 minutes. Dr. Jones provided critical care services to the infant during the ambulance ride. The patient was admitted to the neonatal ICU at the new facility. 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.

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 26-year-old female was given an epidural during labor for pain management. As a result of cephalopelvic distortion, the decision was made to perform a cesarean section. Select the appropriate CPT and ICD-10-CM codes for anesthesia.

A 65-year-old male with severe droopy upper eyelids that also have severe spider veins along with skin plaques presents to the ambulatory surgery center for a non-cosmetic blepharoplasty of his upper eyelids. The diagnosis was pseudoptosis causing visual impairment along with a severe case of acne rosacea. Select the appropriate CPT and ICD-10-CM codes.

Which of the following is considered an inhalation drug?

Sally, a 3-year-old girl, has been fitted with a cochlear implant due to profound deafness. She is seen today for aural rehabilitation. Sally worked with the audiologist today for 1.25 hours making good progress. Select the appropriate CPT and ICD-10-CM codes.

A disease caused by overproduction of the growth hormone after puberty is:

Preoperative Diagnosis: Herniated nucleus pulposus of L5-S1 on the left. Postoperative Diagnosis: Herniated nucleus pulposus of L5-S1 on the left. Procedure Performed: Microscopic assisted lumbar laminotomy with discectomy at L5-S1 on the left. Surgical Indications: The patient is a 51-year-old female who has had unrelenting low back pain that radiates down her left leg for the past several months. The symptoms were not helped by conservative treatments and were interfering with all aspects of daily living and her job. Procedure: The patient was taken to the operating room and after anesthesia was administered, she was placed on the Jackson spinal table with the Wilson attachment in the prone position. Palpation revealed the iliac crest and suspected L5-S1 interspace. The lumbar spine was prepped and draped in the usual sterile fashion. A midline incision was made over the spinal process of L5 to S1. Skin and subcutaneous tissue were divided sharply. Electrocautery provided hemostasis. Electrocautery was then utilized to dissect through the subcutaneous tissues to the lumbar fascia. On the left side, superior aspect dissection was carried out with the Cobb elevator and electrocautery. This revealed the interspace of level of L5-S1 on the left. A Kocher clamp was placed between the spinous processes of L5-S1. X-ray confirmed the L5-S1 interval. An angled curet was used to detach the ligamentum flavum from its bony attachments at the inferior edge of the L5 lamina and the superior edge of S1 lamina. Dissection was undertaken and the ligamentum flavum was removed. Laminotomy was created with Kerrison rongeur, both proximally and distally. The microscope was positioned and a blunt Penfield elevator was utilized to dissect and identify the L5-S1 nerve root on the left. It was noted to be tented over a disc extrusion. The nerve root was retracted with a nerve root retractor. This revealed a subligamentous disc herniation at the L5-S1 disc space and neuroforaminal area. A #15 Bard-Parker blade was utilized to create an annulotomy. Medially, disc material was extruding through this annulotomy. Two tier rongeur was then utilized to grasp the disc material and the disc was removed from the interspace. Additional disc material was then removed, both to the right and left of the annulotomy. The Penfield elevator was placed in the disc space of L5-S1 and a crosstable x-ray confirmed this level. Nerve root was inspected exhibiting the foramina. A foraminotomy was created with a Kerrison rongeur. Then the nerve root was again inspected and determined to be free of tension. A free fat graft was then harvested from the subcutaneous tissues and placed over the exposed dura. Lumbar fascia was then approximated with #1 Vicryl interrupted sutures, subcutaneous tissue with #2-0 Vicryl interrupted sutures, and #4-0 undyed Vicryl was utilized to approximate the skin. Compression dressing was applied. Estimated blood loss was less than 50 cc. She tolerated the procedure well and was taken to the recovery room in satisfactory condition. Select the appropriate CPT and ICD-10-CM codes.

CPT codes are considered HCPCS _______________codes: