PROCEDURE: Sigmoidoscopy INDICATIONS: Performed for evaluation of anemia, gastrointestinal Bleeding. MEDICATIONS: Fentanyl (Sublazine) .1 mg IV Versed (midazolam) 1 mg IV BIOPSIES: No BRUSHINGS: No PROCEDURE: A history and physical examination were performed. The procedure, indications, potential complications (bleeding, perforation, infection, adverse medication reaction), and alternative available were explained to the patient who appeared to understand and indicated this. Opportunity for questions was provided and informed consent obtained. After placing the patient in the left lateral decubitus position, the sigmoidoscope was inserted into the rectum and under direct visualization advanced to 25 cm. Careful inspection was made as the sigmoidoscope was withdrawn. The quality of the prep was good. The procedure was stopped due to patient discomfort. The patient otherwise tolerated the procedure well. There were no complications. FINDINGS: Was unable to pass scope beyond 25 cm because of stricture was very short bends secondary to multiple previous surgeries. Retroflexed examination of the rectum revealed small hemorrhoids. External hemorrhoids were found. Other than the findings noted above, the visualized colonic segments were normal. IMPRESSION: Internal hemorrhoids. External hemorrhoids Unable to pass scope beyond 25 cm due either to stricture or very sharp bend secondary to multiple surgeries. Unsuccessful Sigmoidoscopy. Otherwise Normal Sigmoidoscopy to 25 cm. External hemorrhoids were found.
INDICATIONS: Iron deficiency anemia with low iron saturation. Positive fecal occult blood test per digital rectal exam. FINDINGS: DIVERTICULOSIS: Sigmoid Colon, Not bleeding; few small diverticulum POLYP: Sigmoid Colon, 5 mm, 45 cm from Anus, pedunculated. Procedure: Snare with cautery, Polyp removed; polyp retrieved. Polyp sent to pathology. HEMORRHOIDS: Internal, Size: Medium. ASSESSMENT: Abnormal examination, see findings above. COMPLICATIONS: None DISPOSITION: After procedure, patient sent to recovery. After recovery, patient sent back to hospital ward.
Heather lost her teeth following a motorcycle accident. She underwent a posterior, bilateral vestibuloplasty, which allows her to wear complete dentures. How would you report this procedure?
An 88-year-old male patient suffering from dementia accidentally pulled out his gastrostomy tube during the night. Dr. Keys, an interventional radiologist, takes him into an angiography suite, administers moderate sedation (an independent observer was present during the procedure), probes the site with a catheter and injects contrast medium for assessment and tube placement. Dr. Keys finds that the entry site remains open and replaced the tube into the proper position. The intra-service time for the procedure took 45 minutes. How would Dr. Keys report his services?
Katherine had a hernioplasty to repair a recurrent ventral incarcerated hernia with implantation of mesh for closure. The surgeon completed debridement for necrotizing soft tissue due to infection. How would you report this procedure?
A 28-year-old patient underwent a proctosigmoidoscopy with ablation of five tumors under moderate sedation. The same provider performed the procedure and the sedation. The intra-service time for the procedure was 30 minutes. How would you report this procedure?
Sharon had a laparoscopic cholecystectomy with cholangiography. How would you report this procedure?
A 67-year-old male patient with a history of carcinoma of the sigmoid colon is referred for a diagnostic colorectal cancer screening. The patient completed all treatment for his cancer in 2004. The physician performed a diagnostic flex sigmoidoscopy exam to screen for recurrent colon cancer and examine the anatomic site. During the exam, the physician found three polyps in the rectosigmoid junction. They were removed by hot biopsy forceps. The path report indicated the polyps were benign. Code the encounter.
Postoperative Diagnosis: Calculi of the gallbladder Procedure: Removal of gallbladder Indications: The patient is a 40-year-old woman who has a six month history of RUQ pain, which ultrasound revealed to be multiple gallstones. She presents for removal of her gallbladder. Procedure: The patient was brought to the OR and prepped and draped in a normal sterile fashion. After adequate general endotracheal anesthesia was obtained, a trocar was placed and CO2 was insufflated into the abdomen until an adequate pneumoperitoneum was achieved. A camera was placed at the umbilicus and the gallbladder and liver bed were visualized. The gallbladder was enlarged and thickened, and there was evidence of chronic inflammatory changes. Two additional ports were placed and graspers were used to free the gallbladder from the liver bed with a combination of sharp dissection and electrocautery. Several attempts were made before it was decided that additional exposure was needed and I converted to an open approach. The trocars were removed and a midline incision was made. At this time, it was clear that there were multiple adhesions in the area, and once these were carefully taken down, we were able to grasp the gallbladder. The cystic duct was carefully ligated and the gallbladder carefully removed from the field. The area was copiously irrigated, and a needle biopsy of the liver was taken. Then the skin was reapproximated in layers. Sponges and needle counts were correct, and the patient was taken to the recovery room in good condition.
A patient with rectal bleeding undergoes a proctosigmoidoscopy. During the proctosigmoidoscopy, the physician identifies internal hemorrhoids. The proctoscope was withdrawn, and the anus was prepped and draped. A field block with Marcaine 0.25% was then placed. Anoscope was inserted. There was a prolapsing hemorrhoid in the anterior midline. This was rubber band ligated by applying two bands. In the posterior midline, there was another hemorrhoid that was banded in the same manner. Code the procedures.
A patient diagnosed with GERD presents to the same day surgery department for an upper GI endoscopy. The procedure is done in order to treat the GERD by delivering thermal energy to the muscle of the gastric cardia and lower esophageal sphincter. Anesthesia was administered and as the physician begins the procedure, the patient’s blood pressure drops to a dangerously low level. The physician decides not to finish the procedure due to the risk it may cause the patient. What are the codes for this procedure and diagnosis?
Preoperative diagnosis: History of prior colon polyps Postoperative diagnosis: Colon polyps, diverticulosis, hemorrhoids Procedure: A rectal exam was performed and revealed small external hemorrhoids. The video colonoscope was passed without difficulty from anus to cecum. The colon was well prepped. The instrument was slowly withdrawn with good views obtained throughout. There was a 3 mm polyp in the proximal ascending colon. This polyp was removed with hot biopsy forceps and retrieved. There was a 4 mm rectal polyp located 10 cm from the anus in the proximal rectum. The polyp was removed by hot biopsy forceps. There was also moderate diverticulosis extending from the hepatic flexure to the distal sigmoid colon. Code the CPT® procedure(s).
A patient with esophageal cancer is brought to the OR for subtotal esophagectomy. A thoracotomy incision is made and the esophagus is identified. The tumor is carefully dissected free of the surrounding structures. No invasion of the aorta or IVC is identified. The cervical esophagus is controlled with pursestring sutures and then transected above the sternal notch. The esophagus is then dissected free of the stomach and the entire specimen is removed from the chest cavity and sent to pathology. The stomach is then pulled into the chest cavity and anastomosed to the remaining cervical esophageal stump. The anastomosis is tested for patency and no leaks are found. Hemostasis is assured. The chest is examined for any signs of additional disease but is grossly free of cancer. The chest is closed in layers and a chest tube is place through a separate stab incision. The patient tolerated the procedure well and was taken to the PACU in stable condition.
Patient with RUQ pain and nausea suspected of having a stone or other obstruction in the biliary tract is brought in for ERCP under radiologic guidance. Procedure: The patient was brought to the hospital outpatient endoscopy suite and placed supine on the table. The mouth and throat were anesthetized. Under radiologic guidance, the scope was inserted through the oropharynx, esophagus, stomach and into the small intestine. The ampulla of Vater was cannulated and filled with contrast. It was clear that there was an obstruction in the common bile duct. The endoscope was advanced retrograde to the point of the obstruction, which was found to be a stone that was removed with a stone basket. The rest of the biliary tract was visualized and no other obstructions or anomalies were found. The scope was removed without difficulty. The patient tolerated the procedure well.
Preoperative Diagnosis: Lower left inguinal pain Postoperative Diagnosis: Inguinal hernia Procedure: This 30-year-old patient presented with lower left inguinal pain and on examination was found to have a left inguinal hernia. The decision to perform a left inguinal hernia repair was made. The procedure was performed in the outpatient hospital surgery center. Risks and benefits of the surgery were discussed with the patient and the patient decided to proceed with the surgery. A skin incision was placed at the umbilicus where the left rectus fascia was incised anteriorly. The rectus muscle was retracted laterally. Balloon dissector was passed below the muscle and above the peritoneum. Insufflation and deinsufflation were done with the balloon removed. The structural balloon was placed in the preperitoneal space and insufflated to 10 mm Hg carbon dioxide. The other trocars were placed in the lower midline times two. The hernia sac was easily identified and was well-defined. It was dissected off the cord anteromedially. It was an indirect sac. It was taken back down and reduced into the peritoneal cavity. Mesh was then tailored and placed overlying the defect, covering the femoral, indirect, and direct spaces, tacked into place. After this was completed, there was good hemostasis. The cord, structures, and vas were left intact. The trocars were removed. The wounds were closed with 0 Vicryl for the fascia, 4-0 for the skin. Steri-Strips were applied. The patient was awakened and carried to the recovery room in good condition, having tolerated the procedure well. What are the correct procedure and diagnostic codes?
Preoperative Diagnosis: Chronic tonsillitis. Chronic adenoiditis. Postoperative Diagnosis: Same. Procedure: Tonsillectomy and adenoidectomy. Patient is a 24-year old male who was taken to the operating room and put under IV sedation by the anesthesia department. An initial curettage of adenoids was done and packing was placed. The left tonsil was then identified and dissected out extracapsular and removed with scissors. Hemostasis was maintained by packing the left tonsil. Next, the right tonsil was identified and incision was made. Dissection was done extracapsular and the right tonsil was then removed. Both the right and left tonsil were sent as specimens as well as adenoid tissue. What are the procedure and diagnosis codes?
Diagnostic upper GI endoscopy of the esophagus, stomach, and duodenum was performed after esophageal balloon dilation (less than 30 mm diameter) was done at the same operative session. Code the procedure(s).
A 52-year-old patient is admitted to the hospital for chronic cholecystitis for which a laparoscopic cholecystectomy will be performed. A transverse infraumbilical incision was made sharply dissecting to the subcutaneous tissue down to the fascia using access under direct vision with a Vesi-Port and a scope was placed into the abdomen. Three other ports were inserted under direct vision. The fundus of the gallbladder was grasped through the lateral port, where multiple adhesions to the gallbladder were taken down sharply and bluntly: The gallbladder appeared chronically inflamed. Dissection was carried out to the right of this identifying a small cystic duct and artery, was clipped twice proximally, once distally and transected. The gallbladder was then taken down from the bed using electrocautery, delivering it into an endo-bag and removing it from the abdominal cavity with the umbilical port. What CPT and ICD-9 codes should be reported?
A 70-year-old female who has a history of symptomatic ventral hernia was advised to undergo laparoscopic evaluation and repair. An incision was made in the epigastrium and dissection was carried down through the subcutaneous tissue. Two 5-mm trocars were placed, one in the left upper quadrant and one in the left lower quadrant and the laparoscope was inserted. Dissection was carried down to the area of the hernia where a small defect was clearly visualized. There was some omentum, which was adhered to the hernia and this was delivered back into the peritoneal cavity. The mesh was tacked on to cover the defect. What procedure code(s) should be used?
The patient is a 50-year-old gentleman who presented to the emergency room with signs and symptoms of acute appendicitis with possible rupture. He has been brought to the operating room. An infraumbilical incision was made which a 5-mm VersaStep trocar was inserted. A 5-mm 0- degree laparoscope was introduced. A second 5-mm trocar was placed suprapubically and a 12-mm trocar in the left lower quadrant. A window was made in the mesoappendix using blunt dissection with no rupture noted. The base of the appendix was then divided and placed into an Endo-catch bag and the 12-mm defect was brought out. Select the appropriate code for this visit:
An 82-year-old female had a CAT scan which revealed evidence of a proximal small bowel obstruction. She was taken to the Operating Room where an elliptical abdominal incision was made, excising the skin and subcutaneous tissue. There were extensive adhesions along the entire length of the small bowel: the omentum and bowel were stuck up to the anterior abdominal wall. Time- consuming tedious lysis of adhesions was performed to free up the entire length of the gastrointestinal tract from the ligament to Treitz to the ileocolic anastomosis. The correct CPT code is:
DIAGNOSIS: 1. Chronic cholecystitis. 2. Chronic cholelithiasis ANESTHESIA: General, tube balanced PROCEDURE: This healthy 42-year-old gentleman was taken to surgery with symptomatic gallbladder disease. In the operating room in the supine position after induction of adequate general anesthesia without event, the anterior abdominal wall was prepped with Hibiclens and alcohol and shaved. Drapes were applied. A routine umbilical port cut down was performed with direct visualization of the peritoneal cavity. A blunt trocar was inserted. Insufflation was carried out. The abdominal contents were examined. There were no gross abnormalities. The gallbladder was tense and thick-walled, but there were no other findings in the pelvis or upper abdominal regions. The remaining three trocars were inserted, and a routine laparoscopic cholecystectomy was performed, identifying the cystic duct, cystic artery, and the top of the common bile duct. Once said structures were identified, the cystic duct and artery were doubly clipped distally and singly proximally and divided. The gallbladder was dissected from the fossa in a retrograde fashion. The specimen was opened on the back table after it had been extracted through the epigastric port with removal of two large cholesterol stones. The mucosa was intact. The wall was definitely thickened with indications of chronic scarring. Re-inspection of the gallbladder fossa showed excellent hemostasis. No bile leakage. The clips were intact. The area was irrigated and suctioned dry. This concluded the procedure. Routine abdominal wall midline closures were carried out. Band-aid dressings were applied, and the patient was sent to the recovery room in satisfactory condition. Routine abdominal wall midline closures were carried out. Band-aid dressings were applied, and the patient was sent to the recovery room in satisfactory condition.
A 13-year-old patient underwent secondary palatoplasty for cleft palate and bilateral tonsillectomy. The CPT codes are:
An obese patient underwent gastric restrictive surgery with gastric bypass for weight reduction with roux-en-Y reconstruction for 100 cm. The surgery was quite difficult due to lots of adhesions. The doctor took 1 hour extra to finish the procedure. The appropriate code he should bill for,
34-year-old male developed a ventral hernia when lifting a 60 pound bag. The patient is in surgery for a ventral herniorrhaphy. The abdomen was entered through a short midline incision revealing the fascial defect. The hernia sac and contents were able to easily be reduced and a large plug of mesh was placed into the fascial defect. The edge of the mesh plug was sutured to the fascia. What procedure code(s) should be used?
55-year-old female has a symptomatic rectocele. She had been admitted and taken to the main OR. An incision is made in the vagina into the perineal body (central tendon of the perineum). Dissection was carried underneath posterior vaginal epithelium all the way over to the rectocele. Fascial tissue was brought together with sutures creating a bridge and the rectocele had been reduced with good support between the vagina and rectum. What procedure code should be reported?
PROCEDURE: Colonoscopy with polypectomy. INDICATIONS: Iron deficiency anemia with low iron saturation. Positive fecal occult blood test per digital rectal exam. ANESTHESIA: Demerol & Versed FINDINGS: DIVERTICULOSIS: Sigmoid Colon, Not bleeding; few small diverticulum POLYP: Sigmoid Colon, 5 mm, 45 cm from Anus, pedunculated. Procedure: Bipolor Cautery, Polyp removed; polyp retrieved. Polyp sent to pathology. HEMORRHOIDS: Internal, Size: Medium DISPOSITION: After procedure, patient sent to recovery. After recovery, patient sent back to hospital ward
PROCEDURE: Sigmoidoscopy INDICATIONS: Performed for evaluation of anemia, gastrointestinal Bleeding. MEDICATIONS: Fentanyl (Sublazine) .1 mg IV Versed (midazolam) 1 mg IV BIOPSIES: No BRUSHINGS: No PROCEDURE: A history and physical examination were performed. The procedure, indications, potential complications (bleeding, perforation, infection, adverse medication reaction), and alternative available were explained to the patient who appeared to understand and indicated this. Opportunity for questions was provided and informed consent obtained. After placing the patient in the left lateral decubitus position, the sigmoidoscope was inserted into the rectum and under direct visualization advanced to 25 cm. Careful inspection was made as the sigmoidoscope was withdrawn. The quality of the prep was good. The procedure was stopped due to patient discomfort. The patient otherwise tolerated the procedure well. There were no complications. FINDINGS: Was unable to pass scope beyond 25 cm because of stricture was very short bends secondary to multiple previous surgeries. Retroflexed examination of the rectum revealed small hemorrhoids. External hemorrhoids were found. Other than the findings noted above, the visualized colonic segments were normal. IMPRESSION: Internal hemorrhoids. External hemorrhoids Unable to pass scope beyond 25 cm due either to stricture or very sharp bend secondary to multiple surgeries. Unsuccessful Sigmoidoscopy. Otherwise Normal Sigmoidoscopy to 25 cm. External hemorrhoids were found.
INDICATIONS: Iron deficiency anemia with low iron saturation. Positive fecal occult blood test per digital rectal exam. FINDINGS: DIVERTICULOSIS: Sigmoid Colon, Not bleeding; few small diverticulum POLYP: Sigmoid Colon, 5 mm, 45 cm from Anus, pedunculated. Procedure: Snare with cautery, Polyp removed; polyp retrieved. Polyp sent to pathology. HEMORRHOIDS: Internal, Size: Medium. ASSESSMENT: Abnormal examination, see findings above. COMPLICATIONS: None DISPOSITION: After procedure, patient sent to recovery. After recovery, patient sent back to hospital ward.
Heather lost her teeth following a motorcycle accident. She underwent a posterior, bilateral vestibuloplasty, which allows her to wear complete dentures. How would you report this procedure?
An 88-year-old male patient suffering from dementia accidentally pulled out his gastrostomy tube during the night. Dr. Keys, an interventional radiologist, takes him into an angiography suite, administers moderate sedation (an independent observer was present during the procedure), probes the site with a catheter and injects contrast medium for assessment and tube placement. Dr. Keys finds that the entry site remains open and replaced the tube into the proper position. The intra-service time for the procedure took 45 minutes. How would Dr. Keys report his services?
A radiologist performs an injection procedure for a sialogram in the hospital and provides interpretation and a written report. Select the CPT codes for the procedure.
A patient came to the hospital with severe abdominal pain and was diagnosed with common bile duct stone. The physician did ERCP with sphincterotomy and retrograde stone removal and provided interpretation and written report. Select the CPT codes for the procedure.
A patient underwent hepatic artery ligation with complex suture repair of a liver laceration following a motor vehicle accident.
A patient with right lower quadrant pain underwent emergent diagnostic laparoscopy. The surgeon found severe appendicitis on laparoscopic examination and did laparoscopic appendectomy. What codes the surgeon should bill for:
Patient underwent flexible sigmoidoscopy to 60 cm with removal of two small polyps using snare technique.
A person with a history of snoring undergoes surgical resection of unnecessary palatal and oropharyngeal tissue (uvulopalatopharyngoplasty). Give the CPT.
In a patient suffering from parotid gland tumour, the doctor needed to removal the whole parotid along with unilateral radical neck dissection. During the surgery the facial nerve was sacrificed and had to be sutured back extracranially. What CPT(s) will the doctor bill for?
A patient of dysphagia is diagnosed with failure of the sphincter to relax at the GE junction. He undergoes flexible esophagoscopy and the surgeon performs a balloon dilation of 45 mm diameter under imaging guidance. Code the CPTs.
What code would you use if the physician performs a pyloroplasty & vagotomy in the same surgical session?
DIAGNOSIS : Leaking from intestinal anastomosis OPERATION: Proximal ileostomy for diversion of colon .Oversew of right colonic fistula PROCEDURE: This patient was taken back to the operating room from the ICU .She was having acute signs of leakage from an anastomosis performed 3 days previously. We took down some of the sutures holding the wound together .We basically exposed this patient’s entire intestine. It was evident that she was leaking from the small bowel as well as from the right colon .This was done in 2 layers & then we freed up enough bowel to try to make an ileostomy proximal to the area of leakage .We were able to do this with great difficulty & there was only a small amount of bowel to be brought out. We brought this out as an ileostomy stoma, realizing that it was of questionable viability & that it should be watched closely. With that accomplished we then packed the wound & returned the patient to the Intensive care unit.
This patient is brought back to the operating room during the post operative period by the same physician to repair an esophagogastrostomy leak, transthoracic approach, done 2 days ago. The patient is status post esophagectomy for cancer. Code the procedure & the diagnosis for the complication.
DIAGNOSIS : Melena OPERATION : Normal endoscopy PROCEDUIRE PERFORMED: The video therapeutic endoscope was passed without difficulty into the oropharynx. The gastroesophageal junction was seen at 40 cm. Inspection of the esophagus revealed no erythema , ulceration ,varices or other mucosal abnormalities. The stomach was entered & the endoscope was advanced to the second duodenum. Inspection of the second duodenum, first duodenum. duodenal bulb & pylorus revealed no abnormalities .Retroflexion reveals no lesions along the curvature. Inspection of the antrum, body & fundus of the stomach revealed no abnormalities .The patient tolerated the procedure well.
The patient was taken to the operating room for a repair of a recurrent strangulated inguinal hernia.
Katherine had a hernioplasty to repair a recurrent ventral incarcerated hernia with implantation of mesh for closure. The surgeon completed debridement for necrotizing soft tissue due to infection. How would you report this procedure?
The 43 yr old female comes in with a peritonsillar abscess; the patient is brought to same-day surgery & given general anesthetic. On examination of the peritonsillar abscess an incision was made & fluid was drained. The area was examined again ,saline was applied & then the area was packed with gauze. The patient tolerated the procedure well.
DIAGNOSIS :Polyps OPERATION: Proctosigmoidioscopy PROCEDURE PERFORMED: The physician inserts the rigid proctosigmoidoscope into the anus & advances the scope. The sigmoid colon & rectal lumen are visualized & the polyps are identified. The two polyps were removed by snare technique. The scope is removed at the completion of the procedure.
Dr.Kildare performed a choledochostomy, explored the common bile duct, drained excess fluid & removed a stone .In addition the physician performed a division of oddi sphincter to open the lower end of the common duct to remove impacted stones.
DIAGNOSIS : Morbid obesity OPERATION: Gastric restrictive procedure with Roux-en-y gastroenterostomy PROCEDURE PERFORMED: The physician places a trochar though an incision above the umbilicus & insufflates the abdominal cavity .The laproscope & additional trochars are placed through small portal incisions. The stomach is mobilized & the proximal stomach is divided with a stapling device along the lesser curvature, leaving only a small a small proximal pouch in continuity with the esophagus. A short limb of the proximal small bowel is divided & the distal end of the short intestinal limb is brought up & anastomosed to the proximal gastric pouch. The other end of the divided bowel is connected back into the small bowel distal to short limb’s gastric anastomosis to restore intestinal continuity.The instruments are removed.
Code peritoneoscopy with laparoscopic partial colectomy and anastamosis.
Code intraoral incision and drainage of hematoma of tongue, submandibular space.
Code proximal subtotal pancreatectomy with total duodenectomy, partial gastrectomy, choledochoenterostomy, and gastrojejunostomy, with pancreatojejunostomy.
A 43-year-old male has a chronic posterior anal fissure. The posterior anal fissure was excised down to the internal sphincter muscle. Which CPT code should be used?
A 55-year-old patient underwent a repair of an initial left inguinal hernia. An incision was made at the groin and a hernia sac was readily identified and cleared from the surrounding tissue and inverted into the preperitoneal space and plugged. Mesh was tacked to the surrounding muscle layers and the placed over the entire floor. The correct COT code(s) is (are):
