Exam 27: Coding and Surgical Procedures

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.

Jeff has detected a mass in his right testicle and undergoes needle biopsy of the mass. Select the appropriate ICD-10-CM and CPT code(s):

Anesthesia was provided for a 75-year-old patient who was having a biopsy performed on the salivary gland to determine the nature of a mass. He also had chronic essential benign hypertension. Select the appropriate CPT codes for the anesthesia service, as well as the ICD-10-CM codes.

Jane, an 89-year-old female, lives in an assisted living facility. The physician provides monthly supervision of care for this patient that requires complex and multidisciplinary care modalities, including completion of reports and coordination of care with the staff for the purposes of ongoing management of medications for her diabetes and COPD. The physician spends approximately 35 minutes doing this service. Select the appropriate CPT and ICD-10-CM codes.

Preoperative Diagnosis: Right knee degenerative arthritis Postoperative Diagnosis: Same Operation Performed: Arthroscopic irrigation and debridement of same with partial synovectomy Estimated Blood Loss: Minimal Complications: None Description of Operation: The patient was placed on the table in supine position. The right lower extremity was prepped and draped without a tourniquet. The knee was injected with 30 mL of normal saline and standard arthroscopy portals were created. The arthroscopy was inserted and a complete diagnostic was performed. The knee was copiously irrigated with 9 L of irrigant. A partial synovectomy was performed in all compartments. Minimal amount of polyethylene wear was noted. The knee was then drained and the arthroscopic instruments were removed. The portals were closed with 4-0 nylon and local anesthetic was injected. A sterile dressing was applied; the patient was awakened from anesthesia and transported to the recovery room in stable condition. Select the appropriate CPT and ICD-10-CM codes.

Doug, a 45-year-old patient with ESRD, receives a unilateral cadaver kidney transplant. The surgeon performs the backbench work in addition to the transplant. Select the appropriate ICD-10-CM and CPT code(s):

Dr. Black, a cardiologist, today is seeing Mrs. Smythe, a 72-year-old Medicare patient, at the request of her internist regarding her chronic atrial fibrillation. After a comprehensive history, comprehensive cardiology-specific examination, and decision making of moderate complexity, Dr. Black prescribes some adjustments to her medications and sends a letter to her internist with his findings and suggested follow-up. Select the appropriate CPT and ICD-10-CM codes.

A 10-year-old male is seen in the emergency department for epistaxis. The hemorrhaging was controlled with nasal packing. The physician performs a detailed history and examination. The MDM complexity is moderate. Selectthe appropriate CPT and ICD-10-CM codes.

A wart is an example of a

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?

The patient has type 2 diabetes mellitus that is controlled with insulin and complicated by proliferative retinopathy, gangrene, and ketonuria. Identify the correct ICD-10-CM codes:

Which of the following terms is the report tracing the electronic activity of the heart?

Mr. Derek is here today for open tendon surgery in his right shoulder due to a ruptured rotator cuff. Under general anesthesia an incision of 5cm was made in the shoulder. All loose fragments of tendon, bursa, and other debris were removed. There was some subacromial smoothing to make room for the tendon. The tendon was properly placed and the incision was sewn with 5.0 vicryl. The patient tolerated the procedure well and was sent to the floor. Select the appropriate CPT and ICD-10-CM codes.

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.

Jane, an 89-year-old female, lives in an assisted living facility. The physician provides monthly supervision of care for this patient that requires complex and multidisciplinary care modalities, including completion of reports and coordination of care with the staff for the purposes of ongoing management of medications for her diabetes and COPD. The physician spends approximately 35 minutes doing this service. Select the appropriate CPT and ICD-10-CM codes.

A urinalysis by tablet reagent for glucose and ketones, non-automated without microscopy was performed. Select the appropriate CPT code.

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):

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 surgeon performs an arthrodesis of the right wrist on a patient who suffers from chronic pain that is non-responsive to the corticosteroid injections. Select the appropriate CPT and ICD-10-CM codes.

Tommy was climbing the tree in front of his house, fell, and sustained a greenstick fracture of the ulna of his left arm. The orthopedic surgeon performed a closed manipulation and applied a short arm cast. Select the appropriate ICD-10-CM and CPT code(s):