Exam 27: Coding and Surgical Procedures

A 76-year-old female was admitted for intravenous antibiotic therapy to treat pneumonia due to pseudomonas bacteria, and a level 3 initial inpatient visit was provided. On the second and third days, the patient had not yet responded to treatment, which was noted after an expanded problem-focused examination and interval history. On day 4, the patient showed significant improvement and the doctor recorded a problem-focused history and examination. On day 5, the patient was discharged home and the doctor spent 30 minutes in discharge day management. Select the appropriate CPT and ICD-10-CM codes for the physician visits.

The patient was seen for I&D of a subfascia soft tissue abscess on the left thigh. Code this procedure with the appropriate ICD-10-CM and CPT code(s):

Diagnostic esophagogastroduodenoscopy was performed for a patient with suspected ulcers. The endoscope was inserted in the pharynx and was passed all the way through to the jejunum, which revealed ulcers of the stomach, pylorus, and duodenum. The patient tolerated the procedure well and was sent home with prescriptions and a referral to a nutritionist. Select the appropriate CPT and ICD-10-CM codes.

ESWL was performed on Mrs. Wilson's left kidney 1 week ago; now ESWL is being performed on her right kidney. She has 4 stones being removed today: 2 in the renal pelvis and 2 in the calyx. Under local anesthesia, the ESWL is performed and all 4 stones are successfully destroyed. Select the appropriate CPT and ICD-10-CM codes.

Patient underwent nasal endoscopy in the office of the ENT physician with removal of two pedunculated nasal polyps from the R nasal cavity. The patient tolerated the procedure well and was given an appointment to RTC in two weeks for follow up. Select the appropriate CPT and ICD-10-CM codes.

Clinical History: Symptoms of SOB, chest pain on inspiration, as well an oxygen saturation of 84. Study performed: Ventilation and perfusion studies of the lungs. Interpretation: Particularly positive ventilation and perfusion lung scan. There are no segmental defects to suggest a pulmonary embolus. Select the appropriate CPT and ICD-10-CM codes.

A 26-year-old female patient with uterine polyps is sent for a hysterosalpingography. Under contrast the full uterus and fallopian tubes are visualized. 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.

The Mohs micrographic technique is used for removal of complex or ill-defined skin cancers. During this procedure, the physician acts as:

Preoperative Diagnosis: Ovarian Cyst Postoperative Diagnosis: Ovarian Cyst Operation: I&D of ovarian cyst Operation Description: A 20-year-old female patient was diagnosed with a left ovarian cyst. After being admitted, the patient was prepped in the surgical suite for the drainage of the ovarian cyst, using an abdominal approach. The left ovarian cyst was drained. Patient tolerated the procedure well. 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.

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.

The lab performs the following tests for a patient who presents to the emergency department with signs of Luetscher's syndrome: comprehensive metabolic panel, complete CBC automated, automated differential WBC count, TSH. Select the appropriate CPT and ICD-10-CM codes.

A patient with stage V CKD and on hemodialysis was seen for an access flow study. The physician used the indicator method to evaluate blood flow in the AV fistula. Select the appropriate CPT and ICD-10-CM codes.

The patient underwent an abdominal pan-hysterectomy to remove a malignant hydatidiform mole. Select the appropriate ICD-10-CM and CPT code(s):

Pneumonia that is typically diffuse and bilateral is

John, a nine-year-old boy, is being seen today for persistent allergic sinusitis. Today he will undergo percutaneous sequential and incremental allergy testing with biological allergens with 15 various allergens being applied followed by interpretation and report. Select the appropriate CPT and ICD-10-CM codes.

A 14-year-old boy who is a new patient presents with acute contact dermatitis. During the expanded problem-focused history, the doctor learns that the boy just came back from a camping trip and was out in the woods when his skin began to itch. The examination was also expanded. The physician sends the patient home with a prescription and instructs him to return if the condition does not improve in a few days. While checking all of the patient's immunizations, the physician notes that the patient is in need of a tetanus vaccination, so that is also given. Select the appropriate CPT and ICD-10-CM codes.

A 27-year-old female comes to her OB/GYN office for removal of her Norplant capsule because it is at the end of its efficacy. She is undecided on whether to have this capsule replaced. After discussion with her physician, she decides to continue the Norplant as a contraceptive. Select the appropriate CPT and ICD-10-CM codes.

A patient underwent fine-needle aspiration without imaging guidance of a thyroid cyst. Select the appropriate ICD-10-CM and CPT code(s):