Exam 27: Coding and Surgical Procedures

Ted is at the ambulatory care center for an arthrotomy with Dr. Abraham today. Ted is a 23-year-old steel worker who has a foreign body in his carpometacarpal joint. The foreign body has created a severe infection and drainage will need to be done along with the removal of the foreign body. Dr. Abraham made an incision between the 3^rd and 4^th carpometacarpal joints and located the foreign body, which was a sliver of steel. The wound was then packed and dressed. The patient tolerated the procedure and was released with instructions to return to Dr. Abraham's office in 7 days. Select the appropriate CPT and ICD-10-CM codes.

A 66-year-old female with CHF, atrial fibrillation, and type II diabetes was admitted with right pleural effusion demonstrated on x-ray, as well as shortness of breath and dyspnea on exertion. A video-assisted thoracic surgery (VATS) pleurodesis was performed. A 10-mm port was placed and the effusion was drained by placing a sucker into the port site. An additional anterior port was then placed in similar fashion and the effusion was drained with a sucker. A 32 curved chest tube was placed and secured with nylon. The other port site was also closed. Select the appropriate CPT and ICD-10-CM codes.

A 65-year-old male with severe droopy upper eyelids that also have severe spider veins along with skin plaques presents to the ambulatory surgery center for a non-cosmetic blepharoplasty of his upper eyelids. The diagnosis was pseudoptosis causing visual impairment along with a severe case of acne rosacea. Select the appropriate CPT and ICD-10-CM codes.

Dr. Helter, a gastroenterologist, is placing a feeding tube for a patient with gastroparesis in the outpatient surgery department of Community General Hospital. After the long gastrointestinal tube feeding tube was inserted, a KUB was done to verify the position in the duodenum. Select the appropriate CPT and ICD-10-CM codes.

What Level II modifier is used when a service is performed without the presence of a teaching physician under the primary care exception?

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 43-year-old male came into the doctor's office to have a hemorrhoidopexy by stapling for his second-degree hemorrhoids. He was very uneasy since he had never had this procedure before. Dr. Hanson administered an IV of Versed, for the anxiety. The procedure is not really painful, so there was no need for a full anesthetic or painkiller. Myrtle Pape, a certified registered nurse anesthetist (CRNA), sat with the patient throughout the procedure to ensure his safety and comfort level. The procedure was complete in one stage, taking 30 minutes.Select the appropriate ICD-10-CM and CPT code(s):

The area between the lungs that contains the heart, aorta, venae cavae, esophagus, and trachea is the:

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):

Dr. Medevial sees Daphnee age 45, for her annual preventative exam. Since Daphnee is an established patient, Dr. Medevial wants a CBC. The CBC is drawn by the nurse, but due to equipment failure, the tube will be sent to MetCare Labs for processing. MetCare labs will be paid directly by Dr. Medevial for the processing. Select the appropriate CPT and ICD-10-CM codes.

Preoperative Diagnosis: Urethritis Postoperative Diagnosis: Urethritis Operation: Urethral biopsy Operation Description: A 22-year-old male was diagnosed with urethritis. The PCP referred the patient to an urologist, who ordered a urethral biopsy. The patient understood the risks and consent was obtained. The patient was prepped and the biopsy obtained then sent to pathology. Patient left the procedure room in stable condition. Select the appropriate CPT and ICD-10-CM codes.

A 62-year-old female patient with metastatic lung cancer reports to the infusion center for chemotherapy. She receives a subarachnoid injection consisting of doxorubicin, cyclophosphamide, and etoposide via a subcutaneous reservoir. Select the appropriate CPT and ICD-10-CM codes.

Smith works for "Doctors to You" and visits Jane, an established patient with this company, in her home. Jane is complaining of nausea, vomiting, and diarrhea for the past three days after eating tuna fish purchased from a local restaurant. After an expanded problem-focused interval history and expanded problem-focused examination, the diagnosis of food poisoning is made, and Jane is administered medication to treat the nausea and given instructions to prevent dehydration and reduce the diarrhea. Select the appropriate CPT and ICD-10-CM codes.

A patient underwent fine needle aspiration of a cyst on the L breast and another on the R breast. Both aspirates were properly labeled and sent to cytopathology for interpretation and report. Pathology report demonstrated cells consistent with fibrocystic breast disease; no malignancy was noted. Select the appropriate CPT and ICD-10-CM codes.

A 24-year-old female patient completed her 40th week of pregnancy. Her physician had noted that her antepartum visits were all within normal ranges. She had a vaginal delivery with episiotomy. A single live newborn was delivered in the hospital. Patient had a successful delivery with no complications. Select the appropriate CPT and ICD-10-CM codes for the delivery only.

The patient underwent blepharoplasty of the left eyelid, including lid margin and tarsus with a full-thickness skin graft for paralytic ptosis. Select the appropriate ICD-10-CM and CPT code(s):

Dr. Medevial sees Daphnee age 45, for her annual preventative exam. Since Daphnee is an established patient, Dr. Medevial wants a CBC. The CBC is drawn by the nurse, but due to equipment failure, the tube will be sent to MetCare Labs for processing. MetCare labs will be paid directly by Dr. Medevial for the processing. Select the appropriate CPT and ICD-10-CM codes.

10-year-old Susie Patterson had a fall and an injury occurred. She was taken to the emergency room, where the physician ordered an x-ray to be performed. The radiologist confirmed that she had a bimalleolar fracture. A temporary splint was applied, and she will follow up with the orthopedic specialist to obtain a permanent cast. Patient was discharged in stable condition. Identify the anatomic site of injury.

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.

A patient diagnosed with myasthenia gravis in crisis undergoes partial removal of the thymus gland using a transthoracic approach. Select the appropriate ICD-10-CM and CPT code(s):