Exam 27: Coding and Surgical Procedures

Procedures: Craniotomy for a patient with benign clinoidal meningioma. The surgeon carried out a stereotactic osteoplastic craniotomy along with resection of clinoidal/sphenoid wing mass. For the microdissection an intraoperative microscope was used. Prior to decompressing the superior orbital fissure, the tumor was extirpated through the opticocarotid, carotid oculomotor, as well as prechiasmatic spaces. Select the appropriate CPT and ICD-10-CM codes.

Clinical history: Carcinoma of the breast with skeletal metastasis. Study performed: Total Body Bone Scan. Impression: Abnormal total body bone scan with abnormalities noted in the ribs and spine and possibly within the skull. Select the appropriate CPT and ICD-10-CM codes.

A 54-year-old patient presented to the emergency room with a gunshot wound in the back exiting through the front. A CT scan shows some renal damage to the right kidney and a renal exploration is ordered. The surgeon has been called in and the patient is taken to surgery to examine the renal structure. Making an incision over the gunshot wound, the surgeon examines both the blood vessels and the kidney. The trauma has caused a hematoma to the kidney, which has not spread, so the surgeon closes and the patient is sent to the floor for observation. Select the appropriate CPT and ICD-10-CM codes.

Procedure Description: Under anesthesia via endotracheal intubation, the ears were inspected with the operating microscope. Anterior inferior quadrant myringotomy incisions were performed bilaterally. Armstrong tubes were inserted. Diagnosis: Recurrent acute otitis media, bilateral middle ear effusions Select the appropriate CPT and ICD-10-CM codes.

The maintenance of a stable internal physical state is

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.

Timothy presents at Dr. Smith's office today with multiple painful lumps on his left upper arm. His skin is warm, red, and swollen. Dr. Smith determines that these are abscesses of a staphylococcus nature and will need to be incised and drained to remove the pus. Using a scalpel, all 8 lumps were incised, packed, and dressed. Timothy is given a prescription and told to return in 7 days for a wound check. Select the appropriate CPT and ICD-10-CM codes.

This is a new 35-year-old male who is experiencing a piercing ringing sound in his left ear that began 6 months ago. The ringing interferes with his daily life, and he has problems sleeping. The patient is taken to a testing suite for a bilateral tinnitus assessment; pitch frequency matching loudness and masking procedures are included. The findings of the testing indicate a positive determination of tinnitus, acute tinnitus. Follow-up masking therapy scheduled. Select the appropriate ICD-10-CM and CPT code(s):

A 55-year-old established female patient was seen for management of uncontrolled diabetes due to taking oral corticosteroids for rheumatoid arthritis. She reported elevated glucose readings of 180, 210, 195, and 205 in recent weeks. The physician performed a brief history to update her record since the last visit, a detailed examination, and medical decision making of high complexity. He counseled the patient on diet and lifestyle factors and prevention of serious diabetic manifestations. He decided to start her on insulin to see how she responds. Select the appropriate CPT and ICD-10-CM codes.

The patient was hypoxemic and had impending respiratory failure. An endotracheal tube was advanced with the capnometer showing appropriate intubation into the airway, and the breath sounds were heard bilaterally in the lungs and not in the abdomen. The cuff was inflated and the endotracheal tube was placed at 24 cm. A chest x-ray confirmed placement. Immediately after intubation the patient had an episode of bradycardia and hypotension. Select the appropriate CPT and ICD-10-CM codes.

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.

Jane is seen by the plastic surgeon today for injection of three units of Botox into her face, including her forehead and glabellar frown lines for cosmetic reasons. Select the appropriate CPT and ICD-10-CM codes for the injections and medication.

Clinical Indication: Carcinoma of the right breast, mastectomy and chemotherapy completed with no recurrence; now presents with skeletal metastases. Procedure: Multiple tomograms of L. lung show no dominant nodules within the lung. Multiple osteolytic metastases are present in several of the ribs in posteriolateral aspect involving third, fourth, fifth, six, and seventh ribs. Small amount of pleural reaction is noted in the L costophrenic angle. Hilar shadows are unremarkable. Shadow for L breast is absent. Impression: No definite metastatic nodules in L lung. Multiple mixed osteolytic and osteoblastic changes in several ribs in the L chest probably due to metastatic neoplasm. Select the appropriate CPT and ICD-10-CM codes.

Dr. Green works for a house-call physician service. She was called to evaluate a new patient, an 88-year-old bedridden woman who has developed a painful rash on her posterior left side of the trunk, extending from C6 to C7 around the right side and ending midline on the anterior trunk just below the sternum. The physician performs a detailed history and a detailed examination and medical decision making is of low complexity. She diagnoses the patient with shingles. Select the appropriate codes.

Mrs. Jones was brought to the OR for open reduction by posterior approach of fractures to vertebrae at L4 and L5 as a result of a car accident. Select the appropriate ICD-10-CM and CPT code(s):

Mary was seen today for a surgical hysteroscopy with lysis of intrauterine adhesions. Select the appropriate ICD-10-CM and CPT code(s):

Sam underwent scleral buckling for repair of a detached retina of the right eye with cryotherapy and drainage of subretinal fluid. Select the appropriate ICD-10-CM and CPT code(s):

An 81-year-old patient, Marge, fractured the proximal end head of her femur on Thanksgiving while standing and cooking dinner. She has a history of osteoporosis and received radiation therapy 3 years ago in this area for a thigh muscle tumor. She is going to surgery today for an open treatment of femoral fracture with internal fixation. Select the appropriate CPT and ICD-10-CM codes.

An 18-year-old female weighing 485 lbs. is presenting today for a laparoscopic gastric bypass and roux-en-y gastroenterostomy for morbid obesity. Since the patient has a BMI of 73.7, the gastroenterologist feels it is necessary to remove at least 175cm. Select the appropriate CPT and ICD-10-CM codes.

Preoperative diagnosis: Respiratory insufficiency Postoperative diagnosis: Respiratory insufficiency Operation: Tracheostomy with division of thyroid isthmus Estimated blood loss: Less than 10 mL Fluids: Crystalloid Complications: None Technique: The patient was brought to the operating room and placed in the supine position. He was given general anesthesia through his existing oral intubation tube. The anterior neck was prepped and draped in the usual sterile fashion. Lidocaine 1% with 1:100,000 epinephrine was infiltrated into the skin at the lower neck. A transverse incision was made at the cricoid ring level through skin and subcutaneous fat. The platysmal layer was traversed, and then the strap muscles were separated in the midline. The thyroid isthmus was ligated and divided with #2-0 silk ligatures. An inferiorly based tracheostomy flap was created using the second and third tracheal rings and sewn into place with a #3-0 chromic stitch to the inferior dermis margin. Hemostasis was achieved using suction cautery. At this point, the oral intubation tube was withdrawn, and a #8 Shiley low-pressure cuffed tube was passed into the newly created trach site. The trach ties were tied securely into place, and the cuff was inflated to a comfortable pressure. The patient then received further ventilation through the newly placed trach tube. The patient was then allowed to awaken from general anesthesia and was taken back to the ICU in stable condition. Select the appropriate ICD-10-CM and CPT code(s):