Exam 27: Coding and Surgical Procedures

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.

A 36-year-old female who was the driver in a car accident presented with whiplash for chiropractic manipulative treatment of her cervical spine. The chiropractor provided a complete history and examination prior to the treatment plan of one visit a week for 2 months, at which point her status will be reevaluated. Today the first manipulation was performed. Select the appropriate ICD-10-CM and CPT code(s):

A patient with pancreatic cancer was found to have a lung mass. A flexible bronchoscopy, transbronchial lung biopsy, brushing and washing were performed. The surgeon identified a left perihilar mass and mucosal abnormality in the posterior subsegment of the left upper lobe. The pathology finding was metastasis to the lung. Select the appropriate CPT and ICD-10-CM codes.

Fred, a 75-year-old male, undergoes surgical placement of a permanent transvenous pacemaker for treatment of symptomatic bradycardia as a result of a bundle branch block. 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):

Preoperative Diagnosis: Uterine Mass Postoperative Diagnosis: Uterine Mass Operation: Hysteroscopy Operation Description: A 43-year-old patient was diagnosed with a uterine mass as noted on an ultrasound. Patient was administered general anesthesia upon arrival to the operating room. The patient was prepped. The hysteroscope was introduced and biopsy was obtained. Specimen was sent to pathology. Patient tolerated the procedure well. Select the appropriate CPT and ICD-10-CM codes.

Preoperative Diagnosis: Advanced primary open angle glaucoma, right eye, with related cortical cataract, right eye. Procedure: Trabeculectomy. Phacoemulsification and posterior chamber IOL insertion. Postoperative Diagnosis: Advanced primary open angle glaucoma, right eye, with related cortical cataract, right eye. Operation: The patient was brought in to the operating room on an eye stretcher and placed in the supine position. A peribulbar block using an equal concentration of 2% lidocaine and 0.5% Marcaine was administered and the right eye was draped and prepped in the usual sterile ophthalmic fashion and the microscope was brought in position. We placed a Lieberman lid speculum between the lid fissures on the right eye, then placed a superior rectus bridle suture to stabilize the eye. We created a superior peritomy using Vannas scissors and Bishop forceps. Next we used the cautery to outline a 3x4mm rectangular scleral flap. After applying mitomycin 0.2 mg/mL to the sclera and conjunctiva for two minutes per the clock, I thoroughly irrigated the area with saline. I then dissected the scleral flap using a #68 Beaver blade. I created a 2.70mm incision on the cornea under the scleral flap using a standard blade and created a primary posterior capsulorhexis using a cystotome and forceps. Hydrodissection of the lens nucleus was performed, then we did the phacoemulsification without difficulty and the area was irrigated with saline and the cortical remnants removed. We inserted an AcrySof® Aspheric IOL Model SN60WF +25 into the capsular sac and centered it without difficulty. We then created the internal sclerostomy under the scleral flap, measuring 1x2.5mm. We removed the limbal material with a Kelly punch. Next we created a peripheral iridectomy using Dewecker scissors and closed the scleral flap using 5 interrupted 10-0 nylon sutures, being attentive to carefully control the tension. When the tension allowed egress of aqueous, we tied off and buried the sutures. We reapproximated the conjunctival flap and suture it into position using 9-0 nylon mattress sutures and 8-0 Vicryl running sutures. We checked intraolcular pressure manually with a cannula and it was within normal limits. We applied Gentamicin 20 mg under the conjunctiva and erythromycin on the conjunctiva. We removed the lid speculum, closed the eyelids and placed a patch and shield over the eye. The patient tolerated the procedure well and was transferred to recovery in good condition. 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.

White blood cells include

The surgeon performed endovascular repair on a patient with an aneurysm in the descending thoracic aorta under fluoroscopic guidance, which was directed separately by the radiologist. An endoprosthesis was placed as well as an extension to the origin of the celiac artery. Select the appropriate CPT and ICD-10-CM codes.

John Smith is seen by his PCP Dr. Ron Blue at home for his monthly visit in regards to monitoring his diabetes. John's diabetes is still stable as noted the previous month. No changes were made to his medications. The history is problem focused and exam is expanded problem focused. Medical decision making is noted as moderate. Select the appropriate CPT and ICD-10-CM codes.

An eating disorder that is characterized by a body image of disturbed perception accompanied by an intense fear of gaining weight resulting in not eating and producing side effects such as cachexia and hair loss is called

Jerry is a 55-year-old diabetic with ESRD. At the beginning of September, Jerry began home-based dialysis services. However, on September 18, he was admitted to the hospital where he remained until September 25 when he was discharged home. Dialysis continued on alternate days while he was in the hospital, and physician visits with expanded problem-focused history and examinations were done on those days in between. Select the appropriate CPT and ICD-10-CM codes.

Jerome, a 15-year-old male, is seen by the dermatologist today for treatment of his acne vulgaris. The physician uses liquid nitrogen to destroy lesions on the left side of his face. Select the appropriate ICD-10-CM and CPT code(s):

A patient was brought to the OR today for exploratory thoracotomy. Previous x-rays demonstrated a small foreign body in the pleural space. Exploration of the area revealed a small piece of shrapnel from a previous shooting accident. Under general anesthesia, the incision was made into the pleural space and the shrapnel was removed. Select the appropriate CPT and ICD-10-CM codes.

Preoperative Diagnosis: Pulmonary nodule, left lower lobe Postoperative Diagnosis: Pathology report came back as squamous cell carcinoma of the left lower lobe Procedure: Left lower lobectomy Operation: General endotracheal anesthesia was administered satisfactorily. With the patient in the left lateral decubitus position, we made a left posterolateral thoracotomy with resection of the sixth rib. I could identify the lesion in the lateral segment of the left lower lobe. I carefully dissected the lobe out, being certain that the lesion was peripheral. I then dissected down and identified the vein to the left lower lobe, and tied it with 0 silk suture ligated. I then dissected down and identified two arteries to the lower lobe, and tied each of these. I carefully removed the fissure between the upper lobe and lower lobe using the stapler. I dissected out some nodes for staging purposes. I palpated the superior mediastinum and did not find any abnormalities. I placed a #32 chest tube in the wound, then closed it with 1 Vicryl and 0 Vicryl on the fascia, 3-0 Plain on the subcutaneous and skin staples on the skin. Estimated blood loss was 250 cc. We administered an epidural and removed the patient to the recovery room in stable condition. Select the appropriate CPT and ICD-10-CM codes.

A patient is seen in the office. His last visit was four years ago, although documentation in his record reveals that the physician has ordered prescription medicine several times in the past three years. The physician performed an expanded problem-focused history; expanded problem focused exam; straightforward medical decision-making. Which CPT code should be reported for the E/M service?

A 53-year-old male has been plagued by intermittent severe pain caused by his trigeminal neuralgia which interferes with his common daily activities. He has developed sleep deprivation, depression, and loss of appetite. Today he presents for destruction of the trigeminal nerve by neurolytic agent. Select the appropriate CPT and ICD-10-CM codes.

Preoperative Diagnosis: Pericardial Cyst Postoperative Diagnosis: Same Procedure: Thorascopy, surgical: with excision of pericardial cyst. Using VATS, the cyst was visualized and removed. The patient was sent to the ICU in good condition. 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):