Exam 27: Coding and Surgical Procedures

The patient is an otherwise healthy 67-year-old male who sustained a fall three weeks ago. The patient is presenting with pain localized to his left knee. On exam the patient was unable to actively abduct and or externally rotate the knee secondary to pain and weakness. MRI demonstrated a displaced tibial tuberosity fracture. The surgeon performed an arthroscopic reduction and internal fixation of displaced greater tuberosity fracture with manipulation. Select the appropriate CPT and ICD-10-CM codes.

Roger was in an altercation with his neighbor and he has 3 wounds. The first is a 15.5cm wound on the face that required a single layer closure, the second is a 25.5cm laceration of the left forearm that required a layered closure of the subcutaneous tissue, and the third laceration is a 10cm wound on the right external ear that required a layered closure. Select the appropriate CPT and ICD-10-CM codes.

Dr. Mathis has been called to the ICU to provide care for a 37-year-old male patient who has received second-degree burns over 50% of his body. Dr. Mathis provides support from 1 p.m. to 3 p.m. After leaving the unit to do his rounds, Dr. Mathis is called back around 5 p.m., and he provides critical care support to the patient until 6 p.m. Select the appropriate CPT codes.

A patient presents to his physician today complaining of pain in the left gluteal area. The physician gathers an expanded problem-focused history and performs an expanded problem-focused examination and decision making of straightforward complexity, determining that the cause of the pain is an infected sebaceous cyst in this area. An incision and drainage of the cyst is performed. Select the appropriate ICD-10-CM and CPT code(s):

A 22-year-old woman was diagnosed as being 8 weeks pregnant. This is her first pregnancy. The proper term to describe her condition is

History: The patient is a 79-year-old male with dyspepsia and weight loss. A recent supraclavicular lymph node biopsy revealed signet-ring cell adenocarcinoma. Specimen site: Stomach Gross description: Received in formalin is a 10.0- × 6.5- × 3.2-cm segment of stomach, with a palpable firm 4.0- × 2.2-cm mass on the designated lesser curvature. The external surface of the specimen is unremarkable and inked black. The cut surfaces demonstrate the mass and adjacent firm areas of nodularity. The remainder of the gastric mucosa is unremarkable. Six lymph node candidates and representative sections of the stomach are submitted. Microscopic description: Microscopic examination was performed. See synoptic report. The uninvolved stomach shows chronic inactive gastritis with intestinal metaplasia. Diagnosis: Stomach (proximal): Invasive adenocarcinoma Comment: Signet-ring cell carcinomas are not typically graded but are high-grade and would correspond to grade 3. Select the appropriate ICD-10-CM and CPT code(s):

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.

A 45-year-old female presents to the oncology office today for chemotherapy treatment. The first listed diagnosis could would be:

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

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):

Sally, a 3-year-old girl, has been fitted with a cochlear implant due to profound deafness. She is seen today for aural rehabilitation. Sally worked with the audiologist today for 1.25 hours making good progress. Select the appropriate CPT and ICD-10-CM codes.

The use of an endoscope to explore the abdominal cavity is

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.

The pathologist was called to perform postmortem examination including gross and microscopic examination on a stillborn infant including the brain. Select the appropriate CPT and ICD-10-CM codes.

Jane, a 75-year-old female, was brought to the OR today for operative ablation of her paroxysmal atrial fibrillation via a combined Wolff-Parkinson-White atrio-ventricular node tissue ablation and reconstruction of the atria using the MAZE procedure. Cardiopulmonary bypass was not required. The patient tolerated the procedure well and was sent to ICU for continued monitoring. Select the appropriate CPT and ICD-10-CM codes.

A patient with morbid obesity presents for laparoscopic revision of a previous gastro-restrictive procedure. Select the appropriate ICD-10-CM and CPT code(s):

George presented with chronic intractable pain of unknown origin in his left leg. The neurologist used stereotaxis to create a lesion in the spinal cord in order to attempt to block the pain and provide sustainable relief. Select the appropriate ICD-10-CM and CPT code(s):

A 45-year-old male with pancreatic cancer presents with a distended abdomen. The ultrasound reveals fluid in the peritoneal cavity. The patient undergoes a therapeutic paracentesis with ultrasound imaging guidance to drain the fluid. Select the appropriate ICD-10-CM and CPT code(s):

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.

The Anesthesia reimbursement services follow a formula approved by the American Society of Anesthesiologists (ASA). Identify the correct order for the formula used to calculate the charges and payment.