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Exam 27: Coding and Surgical Procedures

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Question 721

Multiple Choice

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George, a 73-year-old male, is hospitalized for epileptic seizure disorder. He experiences anoxic brain damage, and anesthesia was called to insert the endotracheal tube in order to put the patient on the ventilator. Select the appropriate CPT and ICD-10-CM codes for the anesthesiologist.

A) 31500, G93.1, G40.909
B) 31500, 99100-P5, G40.909, G93.1
C) 31603, G93.1, G40.909
D) 31603, 99100-P5, G93.1, G40.909

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Question 722

Multiple Choice

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Mrs. Mustin undergoes insertion of a left custom breast prosthesis 3 months after a mastectomy for breast cancer. The patient needed to undergo radiation to that area prior to the insertion of the prosthesis. Select the appropriate ICD-10-CM and CPT code(s) :

A) C50.912, 19430
B) Z85.3, 19342
C) Z85.3, 19342, 19396
D) C50.912, 19430, 19396

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Question 723

Multiple Choice

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A 27-year-old patient is seen for ruptured synovium in the right shoulder and right elbow due to a baseball injury. An arthroscopic thermal capsulorrhaphy was performed for multidirectional instability and to prevent dislocation. Select the appropriate CPT and ICD-10-CM codes.

A 49-year-old patient has arthritis of the right and left knee with ongoing pain and swelling. The physician performed an arthrocentesis for the patient's condition. Patient was prepped and fluid withdrawn from the left knee joint. The patient tolerated the procedure well and was instructed to return for a follow up visit in one week to aspirate the right knee joint. Select the appropriate CPT and ICD-10-CM codes.

A patient underwent a 2D echocardiogram including M-mode recording without color Doppler echocardiography for hemorrhagic pericarditis. The report was sent out for interpretation. Select the appropriate CPT and ICD-10-CM codes for the interpreting physician.

The surgeon applies a cranial halo with eight pins in order to stabilize the cervical spine on a 6-year-old patient with osteogenesis imperfecta. Select the appropriate CPT and ICD-10-CM codes.

A patient with tachybrady syndrome received a DDDR permanent pacemaker with a steroid-eluting screw in right atrial lead, a steroid-eluting screw in right ventricular apical lead, and a pulse generator. Select the appropriate CPT and ICD-10-CM codes.

George, a 73-year-old male, is hospitalized for epileptic seizure disorder. He experiences anoxic brain damage, and anesthesia was called to insert the endotracheal tube in order to put the patient on the ventilator. Select the appropriate CPT and ICD-10-CM codes for the anesthesiologist.

Preoperative Diagnosis: Esophageal varices Postoperative Diagnosis: Esophageal varices Operation: Ligation of esophageal varices Operation Description: Patient diagnosed with esophageal varices. The patient had the procedure of a direct ligation of the esophageal varices performed for the condition identified. Upon completion of the procedure the patient went to the recovery room in stable condition. Select the appropriate CPT and ICD-10-CM codes

The patient underwent partial excision of the posterior C7 and L1 and L2 vertebrae to remove intrinsic bony lesions. Two surgeons worked simultaneously as primary surgeons to remove the lesions. Surgeon A removed the lesion at C7, and surgeon B removed the lesions at L1 and L2. Code the services of surgeon B with the appropriate ICD-10-CM and CPT code(s) :

Preoperative Diagnosis: Thyroid goiter. Postoperative Diagnosis: Thyroid goiter. Procedure Performed: Total thyroidectomy. Indications: The patient is a 45-year-old female with Graves' disease. Suppression was attempted but unsuccessful. She presents today with her thyroid goiter. A thyroidectomy was indicated at this time secondary to the patient's chronic condition. A full informed consent was obtained. Procedure: The patient was brought back to surgical suite and given IV access and general endotracheal anesthesia. A 9 cc of 1% lidocaine with 1:100,000 of epinephrine was infiltrated into the area of pre-demarcated above the suprasternal notch. The patient was then prepped and draped in the normal sterile fashion. A #10 blade was then utilized to make an incision in the pre-demarcated and anesthetized area. Unipolar electrocautery was utilized for hemostasis. Finger dissection was carried out in the superior and inferior planes. Platysma was identified and dissected and a subplatysmal plane was created in the superior and inferior, medial and lateral directions. The strap muscles were identified. The midline raphe was not easily identifiable at this time. An incision was made through what appeared to be in the midline raphe and dissection was carried down to the thyroid. Sternohyoid and sternothyroid muscles were identified and separated on the patient's right side and then subsequently on the left side. It was noted at this time that the thyroid lobule on the right side is a bi-lobule. Kitner blunt dissection was utilized to bluntly dissect the overlying thyroid fascia as well as strap muscles off the thyroid, in the lateral direction. This was carried down to the inferior and superior areas. The superior pole of the right lobule was then identified. A hemostat was placed in the cricothyroid groove and the superior pole of the right thyroid was retracted inferiorly. Careful dissection was then carried out in the superior lobe and identified the appropriate vessels and cauterized with bipolar or ligated with the suture ligature. The superior pole was identified. Dissection was then carried down again bluntly separating the inferior and superior lobes. The bilobed right thyroid was then retracted medially. The recurrent laryngeal nerve was then identified and tracked to its insertion. A right dissection was performed to remove the fascial attachments superficial to the recurrent laryngeal nerve. This lobule was then removed from Berry's ligament. There was noted to be no isthmus at this time and the entire right lobule was then sent to pathology for evaluation. Attention was then directed to the patient's left side. In a similar fashion, the sternohyoid and sternothyroid muscles were separated. Blunt dissection was carried out laterally to superiorly once again. A careful dissection was utilized to identify the appropriate structures in the superior pole of the left thyroid and suture ligature as well as bipolar cautery was utilized for hemostasis. Once again, careful attention was made not to injure the nerve in this area. The superior pole was then freed appropriately and blunt dissection was carried down to lateral and inferior aspects. The inferior aspect was then identified. The inferior thyroid artery and vein were then identified and ligated. The left thyroid was then medialized and the recurrent laryngeal nerve was identified. Dissection was then carried out to remove the fascial attachments superficial to the recurrent laryngeal nerve on the side as close to the thyroid gland as possible. The thyroid was then removed from the Berry's ligament and it was then sent to pathology for evaluation. The patient tolerated the procedure well and was transferred to recovery in stable condition. Select the appropriate CPT and ICD-10-CM codes.

Mary, age 53, underwent a laparoscopic assisted vaginal hysterectomy for menometrorrhagia. Select the appropriate CPT and ICD-10-CM codes for the anesthesiologist.

A patient underwent a 2D echocardiogram including M-mode recording without color Doppler echocardiography for hemorrhagic pericarditis. The report was sent out for interpretation. Select the appropriate CPT and ICD-10-CM codes for the interpreting physician.

A patient with intractable pain from the left lower extremity due to varicose veins elected for ligation and stripping. The left greater saphenous vein was stripped to the level of the knee, and multiple left lower extremity varicose veins were also stripped. Select the appropriate CPT and ICD-10-CM codes.

Sally was seen today for a percutaneous aspiration of a cyst of the left kidney with a translumbar renal cyst study. Select the appropriate ICD-10-CM and CPT code(s) :

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.

Preoperative Diagnosis: Esophageal varices Postoperative Diagnosis: Esophageal varices Operation: Ligation of esophageal varices Operation Description: Patient diagnosed with esophageal varices. The patient had the procedure of a direct ligation of the esophageal varices performed for the condition identified. Upon completion of the procedure the patient went to the recovery room in stable condition. Select the appropriate CPT and ICD-10-CM codes

Specimen site: Cervical biopsy Pre-operative Diagnosis: Severe squamous dysplasia, consistent with CIN III (high-grade dysplasia) Gross description: Cervical biopsy: One fragment of gray-white tissue, measuring 0.5 centimeters in diameter. Totally submitted with a request for levels. Submitted request for stains. Microscopic description: Sections of the cervical biopsy show high-grade dysplasia, consistent with CIN III. No evidence of invasive malignancy is present. Select the appropriate ICD-10-CM and CPT code(s) :

Which is an example of a pathologic fracture?

Mrs. Carmichael sees her foot and ankle surgeon with open ulcerated areas on the left lower leg and a separate lesion on the right lower leg. The surgeon documents staphylococcal carbuncles which need debridement. He proceeds to excise the skin, subcutaneous tissue, and muscle of a 4.0 cm × 3.0 cm, or 12 sq. cm, lesion in the right lower leg, and an excision of skin and subcutaneous tissue in the left lower leg of 3.0 cm × 8.0 cm, or 24 sq. cm. Select the appropriate CPT and ICD-10-CM codes.