Dr. Hanson felt that it was I her side. She mportant to do a ----------------- once yearly on each of her GYN patients to screen for abnormal cells.
When Doris missed her period, her doctor checked for the presence of ------------- in Doris’s urine to see if she was pregnant.
Ellen was 34 weeks pregnant and experiencing bad headaches and blurry vision, with a 10-pound weight gain in 2 days. Dr.Murphy told her to go to the obstetric emergency department because she suspected ---------------
Dr. Harris felt a breast mass when examining Mrs. Clark. She immediately ordered a ------------- for her 42-year-old patient.
Clara knew that she should not ignore her fevers and yellow vaginal discharge and the pain in her side. She had previous episodes of ------- treated with IV antibiotics. She worried that she might have a recurrence.
After years of trying to become. Jill decided to speak to her ------ about in vitro -------------
To harvest her ova, Jill’s physician prescribed hormones to stimulate egg maturation and -------------. Ova were surgically removed and fertilized with sperm cells in a Petri dish.
Next, multiple embryos were implanted into Jill’s ---------------, and she received hormones to ensure the survival of at least one embryo.
The IVF was successful and after ----------------, Jill was told that she would have twins in 8 ½ months.
At 37 weeks, Jill went into labor. Under continuous ----------- two healthy infants were delivered vaginally.
When Fred was a newborn infant, his doctors could feel only one testicle within the scrotum and suggested close monitoring of his condition of ------------
Bob had many sexual partners, one of whom had been diagnosed with -------, a highly communicable STD.
At age 65, Mike had some difficulty with urgency and discomfort when urinating. His doctor did a digital rectal examination to examine his -------------- .
Just after Nick’s birth, his parents had a difficult time deciding whether to have their infant son undergo ---------------
Ted noticed a hard ulcer on his penis and made an appointment with his doctor, a -------------. The doctor viewed a specimen of the ulcer under the microscopic and did a blood test, which revealed that Ted had contracted ----------------, so the ulcer was a -----------------.
After his fifth child was born, Art decided to have a -------to prevent conception of another child. A/an -------- performed the procedure to cut and ligate the -----------.
Twenty-six-year-old Lance noticed a hard testicular mass. His physician prescribed a brief trial with ---- to rule out --------------.The mass remained and Lance underwent -------------. The mass was a -----------------.
Sarah and Steve had been trying to conceive a child for 7 years. Steve had a -------------, which revealed 25% normal sperm count with 10% motility. He was told he had ---------------.
To boost his sperm count, Steve was given -------. As a side effect, this ------gave him a case of acne lasting several months.
Sarah eventually became pregnant. An ultrasound examination showed two embryos with two separate placentas and in separate ---------------sacs. Sarah delivered two healthy ------------ twin girls.
Beginning of the first menstrual period
Branch of medicine concerned with pregnancy and childbirth
Inner lining of the uterus
Finger like ends of the fallopian tube
Female gonads producing ova and hormones
Gynecomastia is a common condition in pregnant woman
Malignant condition of the inner lining of the uterus
Sac on outside of the body enclosing testes
High serum levels of this protein indicated prostatic carcinoma
Manual diagnostic procedure to examine the prostate glands
Ejection of sperm and fluid from the urethra
Reversal of sterilization procedure
Gland at the base of the urinary bladder in males
Destruction of tissue by freezing
Chlamydial infection, gonorrhea, and syphilis are examples of the general category of infections
This is NOT one of three layer of uterus:
Located at the lower end of uterus is the:
Name of stage that describes development of fetus from fertilization to birth is:
Combining form means few:
Combining form means hidden:
This benign lesion is also known as uterine fibroid:
Which of the following is NOT a malposition of fetus?
This gland activates sperm and produces some seminal fluid:
Carries sperm from testes to ejaculatory duct:
Penis contains these erectile tissues:
Also known as Cowper’s gland:
Which of the following is NOT an accessory organ?
This abbreviation describes a surgical resection of prostate that is accomplished by means of an endoscope inserted into urethra:
This abbreviation describes a condition of prostate in which there is an enlargement that is benign:
Combining form meaning male:
What is the condition in which testes do not descend?
Patient presents for the treatment of multiple condyloma on the penis. The excised diameter is 0.8 cm. Code the procedure.
Patient presents for bilateral vasectomy. After the patient is prepped and draped a unilateral vasectomy is performed. Because the vas deferens could not be located on the left side, he will be scheduled for left vasectomy under general anesthesia next week. How would the initial vasectomy be reported?
Using the scenario above, how would you code the return to the operating room for vasectomy on the left side during the postoperative period?
A right side epididymectomy and spermatocelectomy are performed on a 15-year-old male. What code is reported for this procedure?
A newborn has a circumcision. A dorsal penile nerve block was used for anesthesia. The provider used a Plastibell for the circumcision. What CPT codes are reported?
Which gland in the male reproductive system is partly muscular and partly glandular?
What are the reproductive glands located in the scrotum?
The uterine adnexa refers to which two structures of the female reproductive system?
Which of the following are also known as the greater vestibular glands?
The two structures that make up the uterus are:
If you know that the suffix –scopy means to use a scope to examine a body structure, what word means a scope procedure to examine the vagina?
Which of the following structures in the female reproductive system?
Physician performs an incision and drainage of an abscess located on the labia majora? What CPT code is reported?
Patient comes in with the uterine bleeding. Physician performs a diagnostic dilation and curettage by scrapping all sides of the uterus. What CPT code is reported?
A patient delivers twins at 32 weeks gestation for her first pregnancy. The first baby is delivered vaginally, but during the delivery the second baby had turned into a breech position. The physician decides to perform a caesarean delivery for the second baby. What CPT code(s) is/are reported?
A 52-year-old female patient is scheduled for surgery for a right ovarian mass. Through an open incision, the surgeon finds a healthy left ovary. A right ovarian mass is visualised and the decision is made to remove the mass and the right ovary. What CPT code is reported?
A 63-year-old female patient has severe intramural fibroids. The surgeon performs an open total abdominal hysterectomy with removal of the fallopian tubes and ovaries. What CPT code is reported?
Code the CPT and ICD-10 Procedural Codes for the Op Report Below: DIAGNOSIS: Abnormal uterine bleeding PROCEDURE: The patient was transferred to the operating room where she was placed on the operating table, and underwent induction of general anesthesia in the usual technique without difficulty. She was placed in the vaginal surgery stirrups and examined. She was found to have a midposition, normal uterus, and benign adnexa. She was prepped and draped in the usual fashion for the operation. The cervix was grasped with a single-tooth tenaculum. The cervix was progressively dilated to admit the hysteroscope. The uterine cavity was sounded to 2-3/4 inches. The hysteroscope was introduced. The endometrial cavity was noted to have some irregularthickening along the posterior uterine wall, consistent with hyperplasia. This was also consistent with the office biopsy taken preoperatively. No polyp formation was seen definitively. The endometrium was thoroughly curetted and submitted to pathology. The patient was awakened from anesthesia and transferred to the recovery room in satisfactory status.
DIAGNOSES: 1. Hydrocele, right. 2. Epididymitis, right, chronic. ANESTHESIA: General OPERATION: 1. Scrotal exploration. 2. Epididymectomy, right. 3. Hydrocelectomy, right. FINDINGS: Examination prior to, as well as at this procedure revealed the presence of enlargement of the right epididymis with associated hydrocele containing approximately 120 cc of straw-colored fluid. PROCEDURE: With the patient in the supine position and under satisfactory general anesthesia, the genitalia were prepped and draped in a routine sterile manner. A vertical incision was made in the right hemiscrotum, and the testicle and associated tunic delivered into the wound. Utilizing careful sharp and blunt dissection, the hydrocele sac was opened, aspirated, and dissected, as was the epididymis. The vas deferens was transected and ligated in the procedure. The patient's hemiscrotum was then drained with a small Penrose drain placed in a dependent position, followed by serial closure with 3-0 Vicryl. Sterile compressive dressing was applied. Blood loss was negligible. The patient was sent to the recovery room in satisfactory condition.
DIAGNOSIS: Recurrent right Bartholin gland abscess NAME OF OPERATION: Marsupialization of right Bartholin gland PROCEDURE: With the patient in the lithotomy position under satisfactory general anesthesia, the perineum and vagina were prepped and draped in the usual manner. The knife was used to incise an area of skin and exterior portion of the Bartholin gland, which was finished using Metzenbaum scissors. The specimen was sent for pathologic diagnosis. The lining of the gland was then sewn to the external part of the labia using a 3-0 Vicryl running locked suture. Estimated blood loss was 25 cc. The patient tolerated the procedure and anesthesia well and was taken to the recovery area in good condition with no packs or drains in place.
Tom was placed under general anesthesia (by an anesthesiologist) for an excision of a local lesion of the epididymis. How would you report the surgeon’s services?
Heather had a bilateral laparoscopic occlusion of her fallopian tubes using a Falope ring. How would you report this procedure?
A 48-year-old patient with BPH has his prostate removed via a laser enucleation. During this procedure he also has a vasectomy. What code(s) would report this procedure?
What code series would you refer to for patients who have had a previous cesarean delivery and now present with the expectation of a vaginal delivery?
A pregnant patient delivers twins at 30 weeks gestation. The first baby is delivered vaginally, but during this delivery, the second baby has turned into the transverse position during labor. The decision is made to perform a cesarean to deliver the second baby. The OB physician who performed the delivery also performed the prenatal care. The standard coding for this is:
A 30-year-old disabled Medicare patient is scheduled for surgery due to the finding of what looks like an ovarian mass on the right ovary. On entering the abdomen, the surgeon finds an enlarged ovarian cyst on the right, but the ovary is otherwise normal. The left ovary is necrotic looking. The decision is made, based on the patient’s age, to remove the cyst from the right ovary, but performs a left salpingo-oophorectomy. Code this encounter.
A 35-year-old male patient presented to an urologist because he was having continuous yeast infections and irritation on his penis. The physician recommended he have a circumcision. The physician performed the circumcision using a clamp with regional block. Code this procedure.
A 55-year-old man with complaints of an elevated PSA of 6.5 presents to the outpatient surgical facility for prostate biopsies. The patient is placed in the lateral position. Some calcifications were found in the right lobe, with no obvious hypoechogenic abnormality. The base of the prostate was infiltrated and under ultrasonic guidance random needle biopsies were performed.
A colposcope was introduced into the patient’s vagina and under direct visualization through a binocular microscope excessive lesions were revealed in and around the vagina. Electrocautery and laser vaporization were used to destroy the extensive number of vaginal lesions. What are the procedure and diagnosis codes?
A pregnant patient is diagnosed with an incompetent cervix. The physician performs a cervical cerclage to prevent a missed abortion. After inserting a speculum into the vagina to view the cervix, the physician threads heavy suture material around the cervix using purse-string sutures. The sutures are pulled tight to make the opening smaller and prevent spontaneous abortion. What are the procedure and diagnosis codes?
The patient has a positive pregnancy test, but ultrasound does not confirm a gestational sac in the first trimester. The physician diagnoses a blighted ovum and performs a suction D&C. What are the procedure and diagnosis codes?
Alex suffered several injuries to his upper leg muscles and penis when he fell onto the bar of his touring bicycle. The day of the accident, Dr. Green completed muscle repair surgery to Alex’s upper legs. Today, three days after the leg surgeries, Dr. Green took Alex back to the operating suite to complete an unrelated repair to the penis. Dr. Green completed a plastic repair to correct the penal injury. What code(s) would capture today’s procedure?
67-year-old female having urinary incontinence with intrinsic sphincter deficiency is having a cystoscopy performed with a placement of a sling. An incision was made over the mid urethra dissected laterally to urethropelvic ligament. Cystoscopy revealed no penetration of the bladder. The edges of the sling were weaved around the junction of the urethra and brought up to the suprapubic incision. A hemostat was then placed between the sling and the urethra, ensuring no tension. What code should be used for this procedure?
16-day-year old male baby is in the OR for a repeat circumcision due to redundant foreskin that caused circumferential scarring from the original circumcision. Anesthetic was injected and an incision was made at base of the foreskin. Foreskin was pulled back and the excess foreskin was taken off and the two raw skin surfaces were sutured together to create a circumferential anastomosis. Select the appropriate code for this surgery:
5-year-old female has a history of post void dribbling. She was found to have extensive labial adhesions, which have been unresponsive to topical medical management. She is brought to the operating suite in a supine position. Under general anesthesia the labia majora is retracted and the granulating chronic adhesions were incised midline both anteriorly and posteriorly. The adherent granulation tissue was excised on either side. What code should be used for this procedure?
5-year-old male with a history of prematurity was found to have penile curvature, congenital hypospadias. He presents for surgical management for straightening the curvature. Under general anesthesia, bands were placed around the base of the penis and incisions were made degloving the penis circumferentially. The foreskin was divided in Byers flaps and the penile skin was reapproximated at the 12 o’clock position. Two Byers flaps were reapproximated, recreating a mucosal collar which was then criss- crossed and trimmed in the midline in order to accommodate median raphe reconstruction. This was reconstructed with use of a horizontal mattress suture. The shaft skin was then approximated to the mucosal collar with sutures correcting the defect. Which CPT code should be used?
The patient is a 22-year-old who was found to be 7-1/2 weeks pregnant. She has consented for a D&E .She was brought to the operating room where MAC anesthesia was given. She was then placed in the dorsal lithotomy position and a weighted speculum was placed into her posterior vaginal vault. Cervix was identified and dilated. A 6.5-cm suction catheter hooked up to a suction evacuator was placed and products of conception were evacuated. A medium size curette was then used to curette her endometrium. There was noted to be a small amount of remaining products of conception in her left cornua. Once again the suction evacuator was placed and the remaining products of conception were evacuated. At this point she had a good endometrial curetting with no further products of conception noted. Which CPT code should be used?
A 37-year-old female has menorrhagia and wants permanent sterilization. The patient was placed in Allen stirrups in the operating room. Under anesthesia the cervix was dilated and the hysteroscope was advanced to the endometrium into the uterine cavity. No polyps or fibroids were seen. The Novasure was used for endometrial ablation. A knife was then used to make an incision in the right lower quadrant and left lower quadrant with 5-mm trocars inserted under direct visualization with no injury to any abdominal contents. Laparoscopic findings revealed the uterus, ovaries and fallopian tubes to be normal. The appendix was normal as were the upper quadrants. Because of the patient's history of breast cancer and desire for no further children, it was decided to take out both the tubes and ovaries. This had been discussed with the patient prior to surgery. What are the codes for these procedures?
25-year-old female in the OR for ectopic pregnancy. Once the trocars were place a pneumoperitoneum was created and the laparoscope introduced. The left fallopian tube was dilated and was bleeding. The left ovary was normal. The uterus was of normal size, shape and contour. The right ovary and tube were normal. Due to the patient’s body habitus the adnexa could not be visualized to start the surgery. At this point the laparoscopic approach was terminated. The pneumoperitoneum was deflated, and trocar sites were sutured closed. The trocars and laparoscopic instruments had been removed. Open surgery was performed incising a previous transverse scar from a cesarean section. The gestation site was bleeding and all products of conception and clots were removed. The left tube was grasped, clamped and removed in its entirety and passed off to pathology. What code(s) should be used for this procedure?
23-year-old who is pregnant at 39 weeks and 3 days is presenting for a low transverse cesarean section. An abdominal incision is made and was extended superiorly and inferiorly with good visualization of the bladder. The bladder blade was then inserted and the lower uterine segment incised in a transverse fashion with the scalpel. The bladder blade was removed and the infant's head delivered atraumatically. The nose and mouth were suctioned with the bulb suction trap and the cord doubly clamped and cut. The placenta was then removed manually. What code should be reported for this procedure?
