Exam 27: Coding and Surgical Procedures

Preoperative Diagnosis: Gallstones Postoperative Diagnosis: Cholelithiasis Operation: Cholecystectomy Operation Description: A 52-year-old patient is diagnosed with gallstones. The patient was consulted by the surgeon and it was recommended that a cholecystectomy be scheduled. Patient reviewed the risks and the consent was signed. The procedure went well and the patient left to the recovery room in good condition. Select the appropriate CPT and ICD-10-CM codes.

Specimen site: Gastric biopsy Gross description: Gastric biopsy: Received in formalin, the specimen consists of two fragments of gray-brown mucosa, each measuring approximately 0.3 centimeter in diameter. Totally submitted for routine and special stains and additional levels. Microscopic description: Sections show benign-appearing gastric mucosa with acute and chronic inflammatory cells within the lamina propria. The surface and pit-lining epithelium are also infiltrated with neutrophils. There is no dysplasia or malignancy. Special stains for H. pylori are positive. Final diagnosis: Gastric biopsy: ? Chronic active gastritis. ? Warthin-Starry stain positive for H. pylori. ? Negative for intestinal metaplasia, dysplasia, or malignancy. Select the appropriate ICD-10-CM and CPT code(s):

Government health insurance programs include all of the following except:

After administering local anesthetic, the physician made a full-thickness elliptical incision through the skin. The arterio-venous malformations and the malignant melanoma including the margin were excised and reconstructive repair of the right lower eyelid was performed. Select the appropriate CPT and ICD-10-CM codes.

Sally was seen in the ED for an acute onset of lower abdominal pain. US determined the presence of bilateral twisted ovarian cysts. Sally was taken to the OR for removal of both cysts. Select the appropriate ICD-10-CM and CPT code(s):

Marc will be having a kidney transplant due to end stage renal disease caused by malignant hypertension. The donor is his cousin Sidney. Under general anesthesia, Sidney undergoes a radical nephrectomy; the surgeon then does his backbench work to dissect and remove any fat and prepares the ureters, veins, and arteries. Next the surgeon performs a renal nephrectomy and allo-transplantation on Will. Select the appropriate CPT and ICD-10-CM codes.

The _____ gland controls most of the activity of the endocrine system.

Holter Monitor Report History: This is a 36-year-old male referred for evaluation of syncope episodes and dizziness. He also has a history of depression and anxiety. A Holter monitor was placed on April 2 for 24 hours. Recording revealed sinus rhythm with three VPCs and three isolated APCs. There were no SVTs, no VTs, and no pauses. The patient had multiple complaints of dizziness, anxiety, panic, and feeling near syncopal. Rhythms at these times documented normal sinus rhythm at rates between 80 and 104 beats per minute. No significant arrhythmias. Impression: Normal Holter Select the appropriate ICD-10-CM and CPT code(s):