Exam 27: Coding and Surgical Procedures

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.

A patient is placed on a ventilator as a result of a closed head injury with loss of consciousness due to a car accident. Select the appropriate CPT and ICD-10-CM codes for physician management on the initial and three subsequent days while the patient is in the hospital.

Mrs. Jones is in the operating room today for repair of a nontraumatic tear of the rotator cuff of the right shoulder. The physician performs an arthroscopy subacromial decompression with an open repair of the rotator cuff. Select the appropriate ICD-10-CM and CPT code(s):

The surgeon performed a correction of hallux valgus with sesamoidectomy using the Joplin procedure on the left foot to correct a bunion. Select the appropriate ICD-10-CM and CPT code(s):

Description: Microscopic hematuria with lateral lobe obstruction, mild. Preoperative Diagnosis: Microscopic hematuria. Postoperative Diagnosis: 1) Microscopic hematuria with lateral lobe obstruction, mild. 2) Mild benign prostatic hyperplasia. Procedure Performed: Flexible cystoscopy. Procedure: The patient was placed in the supine position and sterilely prepped and draped in the usual fashion. After 2% lidocaine was instilled, the anterior urethra is normal. The prostatic urethra reveals mild lateral lobe obstruction. There are no bladder tumors noted. Select the appropriate CPT and ICD-10-CM codes.

Pre-operative Diagnosis: Tumor on muscle of right arm Post-operative Diagnosis: same After localized anesthesia, a percutaneous bore needle was used to pierce into the muscle to obtain a biopsy of the muscle tissue. Tissue sample will be sent to pathology. No complications resulted to the patient, and he left the office in good condition. Select the appropriate CPT and ICD-10-CM codes.

Which of the following statements is false for Diagnostic Ultrasound?

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 code for the anesthesia service, as well as the ICD-10-CM code.

The patient, who has complained of lower back pain and numbness of her legs, underwent an EMG of both legs with related spinal areas and 8 individual nerve conduction studies were performed. Interpretation and report revealed myelopathy. Select the appropriate CPT and ICD-10-CM codes.

Procedure: Permanent pacemaker implantation Indication for the procedure: Sick sinus syndrome with decreased mentation and confusion Description of the procedure: After a detailed description of the procedure, indications, and potential risks of permanent pacemaker implantation was given to the patient as well as the patient's daughter, informed consent was obtained. The patient was transferred to the cardiac catheterization lab. A left subclavian area was prepared and draped in the usual sterile manner, and the left subclavian vein was accessed by Seldinger technique. A guidewire was placed. The left subclavian vein was accessed, and a separate guidewire was also placed. Following this, a deep subcutaneous pacemaker pocket was created using the blunt dissection technique without any excessive bleeding. Following this, a French-7 introducer sheath was advanced over the guidewire, and the guidewire was removed. A Medtronic bipolar endocardial lead, model #5054 and serial #LEH025605V, was advanced under fluoroscopic guidance, and the tip of the pacemaker lead was positioned in the right ventricular apex. Following this, the French-9.5 introducer sheath was advanced over a separate guidewire under fluoroscopic guidance, and the guidewire was removed. Through this sheath, a bipolar atrial screw-in lead by Medtronic, model #4568, was selected. It was positioned in the right atrial appendage, and the lead was screwed in. Following this, the stimulation thresholds were obtained for the atrial lead. The amplitude was millivolts (mv) of resistance of 549 ohms, with pulse rate of 0.5 ms. Following the ventricular stimulation, threshold perimeters were obtained, including R-wave entry of 4.6 mv with resistance of 1,427 ohms, with a pulse wave of 0.5 ms. Minimum-stimulation threshold voltage was 0.4 volt for the ventricular lead, and minimal-stimulation voltage was 2 volts for the atrial lead. Select the appropriate ICD-10-CM and CPT code(s):

A mother brings in her 3-year-old son for a well-child checkup. In addition to the physical examination for this established patient, the physician administers the DTP vaccine via IM injection and discusses the vaccines and possible side effects with the mother. Select the appropriate CPT and ICD-10-CM codes.

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.

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.

CARDIAC CATH LAB REPORT History: The patient is a 44-year-old with a family history of coronary artery disease. He is a heavy cigarette smoker with dependence. He had an electrocardiogram showing an old anterior septal myocardial infarction. MRI showed a fixed anterior defect. He is referred today for coronary angiography due to episodes of chest pain. Description of the Procedure: The patient arrived in the procedure room and was administered 100 mcg Fentanyl and 2 mg Versed. 1% lidocaine was infiltrated over the right femoral artery. A 6-French sheath was placed in the right femoral artery. Diagnostic coronary angiography was performed with a 6-French JL-4 and 6-French JR-4 diagnostic catheters. There was no aortic stenosis on left heart pullback. There was no significant obstructive coronary artery in the right coronary artery, the left circumflex artery or left anterior descending coronary artery. There is a 10% to 20% stenosis in the distal left main. Hemodynamic measurements were taken and repeated to evaluate hemodynamic response. Opening aortic pressure was 103/58. Following coronary angiography, the left ventricular pressure was 107/12. Following coronary angiography, a 6-French pigtail catheter was placed in the left ventricle where left ventriculography was performed with 36 cc of contrast injected at 12 cc per second for 2 minutes. The left ventricular systolic function is normal. There are no regional wall motion abnormalities and no mitral regurgitation. At the conclusion of the procedure, the catheter and sheath were removed and Angio-Seal plug was deployed. Impression: There is no significant obstructive coronary artery disease. There is plaque in the distal left main, but no significant obstruction. Left ventricular systolic function is normal. There is no evidence of previous anterior wall myocardial infarction. Plan: Patient is urged to discontinue smoking and was referred to a smoking cessation program. Continue daily low-dose aspirin therapy. Nitroglycerin as needed. Select the appropriate CPT and ICD-10-CM codes.

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.

A staph infection that responds to commonly used antibiotics is a(n)

A 38-year-old male was seen today for complete and standing x-rays of L knee following injury sustained playing hockey. Impression: torn medial meniscus with degenerative joint disease, L. knee. Select the appropriate CPT and ICD-10-CM codes.

Ms. Tammie Jones needs a dry pressure mattress because of her recurrent lumbar decubitus ulcer. Select the appropriate HCPCS code.

A 6-hour-old critically ill infant undergoes on-pump anesthesia for emergency repair of transposition of the great vessels. Select the appropriate CPT and ICD-10-CM codes.

Pre-op diagnosis: Left lung abscess Post-op diagnosis: Same Procedure performed: Left upper lobectomy with decortication and drainage Indications: The patient is a 56-year-old female with evidence of a left upper-lobe abscess seen on the MRI. She was admitted with tension pneumothorax, which was treated with double-lumen intubation and a chest tube. Procedure: The patient was brought to the operating room and placed in the supine position, with general intubation from the double-lumen tube. The patient was rolled onto the right lateral decubitus position, with left side up. A posterior lateral thoracotomy was performed. Adhesions were taken down sharply and bluntly and with cautery. Following this a standard artery first left upper lobectomy was carried out utilizing 0 silk and hemoclips. The left upper pulmonary vein was secured with a single application of the stapling machine. The posterior fissure was created with multiple applications of the automatic stapling machine and the bronchus secured with a single application of the bronchus stapling machine. Following this the wound was drained with three 24-French strium chest tubes and hemostasis obtained with spray Tisseel and surgical gauze. The bronchus was sealed with bio glue and the wound closed in layers. A sterile compression dressing was applied, and the patient was returned to the surgical intensive care unit after the double-lumen tube was changed to a single-lumen tube. The patient received 3 units of packed cells intraoperatively to maintain hemostasis. Sponge count and needle count correct × 2. Large abscess in the left upper lobe accounted for approximately 70% of the left upper-lobe parenchyma. Select the appropriate ICD-10-CM and CPT code(s):