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
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 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?
A laparoscopic removal of the patient’s left testicle was performed on a 34-year-old patient who was diagnosed with testicular cancer. Code the encounter.
A 65-year-old patient presented with ectropion of the right lower eyelid. Repair with tarsal wedge excision is performed for correction. Attention was then directed to the left eye. The patient also had an ectropion of the left lower lid which was repaired by suture repair. Code this procedure.
A 42-year-old patient returns to the hospital neurology clinic for follow-up. He was checked three days prior to this visit where a lumbar puncture was done to find the etology of the patient’s headaches. The headaches have increased in intensity over the past three days. The neurologist examines the patient and finds a CSF leak from the lumbar puncture. A blood patch by epidural injection is performed to repair the leak. Code the services for today’s visit.
Postoperative Diagnosis: Carpal tunnel syndrome right wrist The patient was brought to the operating room and sedated by anesthesia. After sterile prepping and draping of the right hand, wrist and arm the patient’s area of incision was infiltrated with Xylocaine/Marcaine infiltration. After satisfactory anesthesia an Esmarch bandage was used to exsanguinate the right hand and wrist and used about the distal forearm as a tourniquet. A curvilinear incision was made on the palmar aspect of the right wrist. Dissection was carried out through the skin and subcutaneous tissue. Bleeding was controlled. The median nerve and it branches were identified, retracted, and protected at all times. The ligament was incised from proximal to distal. A thorough decompression was carried out. A neurolysis was carried out. The nerve was found to be flattened and ischemic underneath the transverse carpal ligament. The fascia was closed, the tourniquet was released. A dressing was applied and patient was transferred to recovery room. Code this procedure.
A four-year-old with chronic otitis media and fluid buildup in both ears was admitted by her otolaryngologist for a bilateral tympanostomy. The procedure was performed with placement of ventilating tubes. The procedure required general anesthetic due to the patient’s age. Select the procedure code for this procedure
A patient presents to the emergency department with complaint of painful eye. The patient states that her right eye is constantly tearing and is sensitive to light. The physician performs an exam and identifies a corneal foreign body in the right eye. Utilizing a slit lamp, the foreign body is removed. Code the encounter
The physician performs a right thyroid lobectomy. The patient was prepped and draped. After adequate general anesthesia, the neck was incised on the right side and sharp dissection was then used to cut down onto the strap muscles and sternodcleidomastoid muscles. The strap muscles were separated and transected on the right side. A small thyroid lobe was visualized and dissected free. There was no evidence of a tumor. The wound was closed with 3-0 interrupted Vicryl for the platysma, 4-0 Vicryl for the deep tissues and 6-0 fast absorbing gut for the skin. Code the encounter.
Physician performs a medical review and documentation on an 83-year-old patient still hospitalized for confusion for the last two days. She is alert and oriented x 3 today. Reviewing her labs from yesterday,CBC was normal and her BNP was elevated suspecting her confusion is due to congestive heart failure. An echocardiogram is ordered and prescription was given for congestive heart failure. Patient is not safe to return home. What CPT® code should be reported?
42-year-old woman is being discharged today, 2/5/XX. She was admitted to the hospital 2/2/XX for acute diverticulitis. Refer to dictated notes for a detailed description of the history, exam, and assessment and treatment protocol. Patient was also seen in consultation by Dr Z. She was placed on intravenous antibiotics and has made slow steady progress. Today has no abdominal pain. Labs are normal and CT of the abdomen and pelvis showed changes consistent with diverticulitis in the left side of colon. She was given follow up instructions of her medications, what diet to have and to follow up with PCP in 10 to 14 days or return if pain resumes. Total time spent with patient 40 minutes. What CPT® code(s) should be reported?
A plastic surgeon is called to the ED at the request of the emergency department physician to evaluate a patient that arrived with multiple facial fractures after being in an automobile accident for her opinion on the need for reconstructive surgery. The plastic surgeon arrives at the ED, obtains a history of present illness including an extended history of present illness; a system review, including constitutional, musculoskeletal, integumentary, neurologic, and EENMT; and the patient’s social history and past medical history. The plastic surgeon then performs a physical exam including respiratory, cardiovascular, and an extended examination of the skin and bony structures of the patient’s face. The plastic surgeon performs moderate medical decision making, including deciding the patient needs major surgery to repair the injuries. The plastic surgeon schedules the patient for surgery the next day and documents her full note with findings in the ED chart
At the request of the mother’s obstetrician, the physician was called to attend the birth of an infant being delivered at 29 weeks gestation. During delivery, the neonate was pale and bradycardic. Suctioning and bag ventilation on this 1000 gram neonate was performed with 100 percent oxygen. Brachycardia worsened; endotracheal intubation was performed and insertion of an umbilical line for fluid resuscitation. Later this critically ill neonate was moved from the delivery room and admitted to the NCCU with severe respiratory distress and continued hypotension. What are the appropriate procedure codes?
A four-year-old patient presents with pain in the left forearm following a fall from a chair. The injury occurred one hour ago. Her mom applied ice to the injury but it does not appear to help. The ED physician performs a detailed history, expanded problem focused examination and medical decision making of moderate complexity. An X-ray is ordered, which shows a fracture of the distal end of the radius as read by the radiologist. The ED physician consults with an orthopedic surgeon. The ED physician performs moderate conscious sedation with Ketamine for 30 minutes. The fracture is reduced and cast applied by an orthopedic surgeon. The child was monitored with pulse oximetry, cardiac monitor and blood pressure by the ED physician frequently. The patient was discharged with a sling and requested to follow up with the orthopedic surgeon. Code the services performed by the ED physician.
Dr. X performs a follow-up consultation on certain tests that were not available in a nursing facility for a 75- year-old-male that was having chest pain. Today the patient is feeling better after a GI cocktail with Maalox and Xylocaine. The EKG showed an arrhythmia and the chest X-ray came back normal. Dr. X performs a problem focused history. He listens to the patient’s heart and lungs. Dr. X makes the recommendation of repeat cardiac enzymes and EKG and to have a GI evaluation. The PCP accepts the recommendations and implements the plan of care. What CPT® code should be reported for Dr. X?
A 56-year-old receives general anesthesia for an open pleura biopsy. An anesthesiologist medically directing two other cases, and medically directs a CRNA on this case. What are the appropriate codes for both providers?
The anesthesiologist performs an axillary block for postoperative pain management. The patient receives general anesthesia for a carpal tunnel release. What are the appropriate codes?
A healthy 45-year-old is having a needle thyroid biopsy. The anesthesiologist begins to prepare the patient for surgery at 0900. The surgery begins at 0915 and ends at 0945. The anesthesiologist turns over the care of the patient to the recovery room nurse at 1000. What is the appropriate anesthesia code and what is the anesthesia time?
The anesthesiologist performed MAC (monitored anesthesia care) for a patient undergoing an arthroscopy of the right knee. Code the anesthesia service
The physician performs bilateral extremity angiography, the physician only performed the radiological supervision and interpretation
A patient with colon cancer receives seven radiation treatments. During the course of the treatments, the physician views the port films, reviews the treatment parameters, and assesses the patient’s response to the treatment. Code for the radiation treatment management
A 46-year-old female with history of cervical carcinoma. She underwent placement of an ileal conduit, with subsequent development of left hydronephrosis. A retrograde ureteral catheter was recently placed. She returns today for catheter exchange. Patient was placed in the supine position. The ileal conduit was accessed. The existing catheter was removed over a guidewire and replaced with a similar 10 French 50 cm long locking pigtail catheter. Contrast was injected, confirming good position. IMPRESSION: Left retrograde ureteral catheter exchange via the ileal conduit.
The physician orders an ultrasound on a patient 25 weeks pregnant with twins to access fetal heart rate and fetal position. Select the code(s).
Using ultrasound guidance, the physician performed a percutaneous needle core biopsy on a suspicious lump on the patient’s right breast. This procedure was performed in the physician’s office. Code this encounter
A 42-year-old has a lesion on his pancreas. The physician passes the biopsy needle through the skin and removes tissue to be sent to pathology. Fluoroscopic guidance is used to obtain the biopsy. Code this encounter
A surgical specimen was removed from the proximal jejunum during a resection for adenocarcinoma and was submitted to surgical pathology for gross and microscopic examination. The correct code for this service is:
The physician performs the following tests on her automated equipment: HDL, total serum cholesterol, triglycerides and a quantitative glucose. The correct codes for these procedures are:
A patient presents to the ED with crushing chest pain radiating down the left arm and up under the chin. There are elevated S-T segments on EKG. The cardiologist sees and admits the patient to CCU. He orders three serial CPK enzymes levels with instructions that the tests are also to be done with iso-enzymes if the initial tests are elevated for that date of service. The CPK enzyme levels were elevated, the lab codes would be:
The patient presents with burning urination and frequency. The physician performs a UA dipstick, which shows elevated WBC. He orders a urine culture with identification for each isolate to determine which antibiotic to give to the patient for the infection. What are the appropriate lab codes?
Which of the following coding combinations is an example of unbundling?
A patient has an iliac crest bone marrow biopsy. The physician suspects the patient has myelofibrosis. The bone marrow specimen is sent to pathology for gross and microscopic exam. What is the appropriate code for the pathologist’s service?
A patient presents to her oncologist’s office for schedule chemotherapy. The patient is severely dehydrated. The physician decides to schedule the chemotherapy for another day and orders hydration therapy to be performed today instead of the chemotherapy. The therapy is ordered and administered for one hour and 10 minutes. Select the code(s
Left heart catheterization retrograde from the femoral artery with injection procedures for selective coronary angiography and selective left ventriculography, including imaging supervision and interpretation with report, are performed. The cardiologist performed all of the services at the hospital. The CPT® codes are:
A pediatrician is managing the care of a patient who is at home on a ventilator under the care of a home health agency. The patient has cystic fibrosis and is suffering from recurrent pneumonia. The MD did the initial plan of care for the home health agency and now is following this monitor vent management oversight on day 20. The provider has a total 45 minutes for this month how should he code?
A two-month-old comes in for a well check up and several shots (Rota, DTaP, PCV) with her pediatrician. He offers suggestions to the mom, completes the exam, and counsels her on the vaccinations. How should this be coded?
Mary, who has food allergies, came to her physician for her weekly allergen immune therapy that consists of two injections prepared and provided by the physician. The correct code is:
The patient presents to see the nurse for his scheduled vitamin B12 injection. The physician ordered the injection at the patient’s last visit. The physician is in the office seeing other patients. The nurse administers the 1000 mcg of vitamin B12 intramuscularly. She schedules the patient for his next appointment
The wound was debrided. What was done to the wound?
Which of the following anatomical sites have septums?
Lordosis is a disorder of which anatomical site?
What is the approach in PTCA?
A patient with a contralateral fracture has what?
Which of the following is a disorder of the facial nerve?
The newborn has been placed in NICU to treat herpetic vesicles on her torso and lower extremities. Tests have been ordered to rule out herpetic encephalitis, chorioretinitis, and sepsis, and prophylactic protocols will be put in place to prevent spread of the infection from rupturing lesions. Code the patient’s diagnosis
Following the MUGA scan, the physician documents that the patient has developed congestive heart failure associated with the trastuzumab she received as a treatment for her breast cancer. The trastuzumab antineoplastic therapy is being discontinued while he attempts to manage the heart failure pharmaceutically. Code the diagnosis
Mr. Jones is here today to receive an intercostal nerve block to mitigate the debilitating pain of his malignancy. His cancer has metastatized to his lungs
The patient came today to discuss Lapband surgery. He is engaged to be married next spring, and is ready to change his life. He is morbidly obese and his BMI calculates to 41. His diabetes is controlled with preprandial tablets of 120 mg Starlix. He has bilateral primary osteoarthritic changes in his knees. Overall, he is a good candidate for the procedure, and I have referred him to Dr. Mast, general surgeon.
The patient is seen today for radiation therapy for treatment of breast cancer following a lumpectomy that removed a lesion on the central portion of the right breast. Which of the following diagnosis codes would be listed first for this encounter?
A patient has an insulin pump of 100 units. The pump is filled. Which code reports the supply?
A 78-year-old patient, with known arrhythmia, presented to an outpatient clinic for the insertion of a cardiac event recorder. What is the proper HCPCS Level II code for this device?
The physician performed manipulation of a closed fracture of the distal radius on a 12-year-old male. He placed a short arm fiberglass cast. What is the HCPCS Level II code for the supply?
What is the full CPT® code description for 61535?
Which of the following place of service codes is reported for fracture care performed by an orthopedic physician in the emergency department?
In order to use the critical care codes, which of the following statements is TRUE?
Which of the following statements regarding the ICD-10-CM coding conventions is TRUE?
Which statement is true regarding the perinatal period?
A 36-year-old male presents to have multiple lesions destroyed. Three benign lesions on his face are destroyed and five actinic keratoses on his left arm are destroyed. Code for the procedures
Patient is having ongoing back and hip pain. The physician elects to perform a sacroiliac injection at an ambulatory surgery center. After sterile prep, the patient is placed prone and under fluoroscopic guidance; the needle is placed into the SI joint with a mixture of 20 mg of Celestone and Marcaine for pain relief. Code the procedure(s).
Which modifier should be append to a CPT®, for which the provider had a patient sign an ABN form because there is a possibility the service may be denied because the patient’s diagnosis might not meet medical necessity for the covered service?
Which of the following is an example of fraud?
Which of the following statements regarding advanced beneficiary notices (ABN) is TRUE?
Pre-Procedure Diagnosis: Basal cell carcinoma, left chin. Procedure: Wide local excision of 3.0 cm with 0.3 cm margin basal cell carcinoma of the left chin with a 4 cm closure. Procedure: The patient’s left chin was examined. The site of intended excision was marked out. The site was then prepped. The patient was then prepped and draped in the usual fashion. A 15 blade scalpel was then used to make an incision in the previously marked site. It was carried down to the subcuticular fat. The lesion was then sharply dissected off underlying tissue bed using a 15-blade scalpel. It was tagged for pathologic orientation. The hyfrecator was used for hemostasis. The wound edges were then undermined. The wound was then closed by advancing the tissue surrounding the lesion and closing in layers with 3-0 Vicryl for the deep layer, followed by 5-0 Prolene for the skin. The skin closure was in a running subcuticular fashion. Steri-Strips were then applied. What are the procedure and diagnosis codes?
The patient presented for medial meniscal tear left knee. Arthroscopy with partial medial menisectomy left knee and arthroscopic picking (drilling pick holes) of the lateral femoral condyle left knee was performed. Code the procedure and diagnosis codes.
The patient had been hoarse for a month. His surgeon scheduled a direct laryngoscopy with injection of his vocal cords. During the surgery it became necessary to use an operating microscope. How should these services be reported?
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?
The physician performs a cystoscopy, bilateral retrograde pyelograms and ureteroscopy on the left side at a hospital. DESCRIPTION: After satisfactory general anesthesia, and after routine preparation and draping in the lithotomy position. The urethra seemed to be free of lesions. There was no prostatic tissue. The bladder had two diverticula, one right end one left inferolateral wall, no lesions were noted, and the right was larger. Urine for cytology and FISH was sent. Residual urine was approximately 100 mL. Ureteral stent was seen in the left ureter. Right retrograde ureterogram revealed no lesions. The bladder was free of lesions. Ureteroscopy was carried out into the renal pelvis with no lesions noted. Right retrograde pyelogram then revealed grade II-III dilatation of the ureter, grade I dilatation of the calices on the left side, and no other lesions. It was decided not to replace the double-J stent. The patient tolerated the procedure well and was sent to the RR in good condition. How would you code the procedure?
The patient was taken to the procedure room and placed prone and the L4–L5 interspace was identified using fluoroscopy to determine the injection site. The patient was prepped in routine sterile fashion with Betadine and covered in sterile drape. 1% lidocaine was used to anesthetize the skin, subcutaneous tissue, and muscle. Once the proper anesthesia was obtained, a 3 inch, 20 gauge Tuohy needle was inserted and slowly advanced towards the L4-L5 interspace. Using a 6 cc glass syringe and the loss-of-resistance technique the epidural space was identified. After aspiration revealed no blood or cerebrospinal fluid return, the syringes were then changed and 80 mg/ml preservative-free Depo Medrol and 2 cc of 1% methylparaben free lidocaine were injected in slow incremental fashion. After aspiration, all needles were removed intact, the skin was cleaned and a Band-Aid was applied. Code this encounter
Physician was called to the floor to evaluate a 94-year-old that had sudden weakness, hypotension, and diaphoresis. Physician found the patient in mild distress and dyspenic. Her BP 101/60, pulse 85. Her heart was positive for a systolic murmur. EKG came back with ST elevation V2-V6. Labs were still pending. She was admitted to CCU for Acute Antero-lateral MI and hypotension. Physician spent total critical care time of 48 minutes. Select the appropriate CPT® code for this visit:
Patient is admitted in labor for delivery. She received a labor neuraxial epidural for a vaginal delivery. The baby goes into fetal distress and a cesarean section is performed. Following delivery the patient starts to hemorrhage. The physician decides, with family approval, to perform a hysterectomy. Code the anesthesia services.
Due to an elevated CEA level two years following a colon resection, the patient’s oncologist ordered a diagnostic liver ultrasound. Code this encounter.
Patient is undergoing in vitro fertilization to get pregnant. Following the retrieval of follicular fluid from the patient, the physician uses a microscope to examine the fluid to identify the ooctyes. What is the code for the laboratory service?
Indication: Patient has a hypertrophic scar on the posterior side of the left leg at the level of the knee. This has begun to restrict his mobility. Physical therapy trial was unsuccessful. Procedure: After the proper induction of anesthesia, the subcutaneous tissue of the patient’s left leg beneath the scar was infiltrated with crystalloid solution containing epinephrine to minimize blood loss. The scar was then excised down to viable dermis. Hemostasis was obtained with epinephrine soaked pads. Skin was harvested from the patient’s thigh in a split thickness fashion and was used to cover the 90 sq cm defect created by the surgery. The graft was secured with skin staples and then dressed with fine mesh gauze followed by medication-soaked gauze. The donor site was dressed with mesh followed by Adaptic, followed by a dry dressing and an Ace wrap.
The physician is called in to perform repairs for a 17-year-old girl involved in a motor vehicle accident. She sustained an 8.6 cm laceration to her forehead, a 5.5 cm laceration to her right cheek, a 4 cm laceration to her left cheek, a 4 cm laceration across her chin, and a 12.5 cm laceration to her chest. The wound on her chin required a layered closure. All other wounds required complex closure
A 15-year-old boy was burned in a fire and assessed to have received burns to 75 percent of his total body surface area. He was transferred to a burn center for definitive treatment. Once stable, he was brought to the OR. Procedure: Due to extent of the patient’s burns and lack of sufficient donor sites, his full-thickness burns will be excised and covered with porcine grafts, and a split-thickness skin biopsy will be harvested for preparation of autologous grafts to be applied in the coming weeks, when available. After induction of anesthesia, extensive debridement of the full-thickness burns was undertaken. Attention was first directed to the patient’s face, neck, and scalp. A total of 500 sq cm in this area received full-thickness burns. The eschar involving this area was excised down to viable tissue. Hemostasis was achieved using electrocautery. Attention was then turned to the trunk. A total of 950 sq cm in this area received full-thickness burns. The eschar involving this area was excised down to viable tissue. Hemostasis was achieved. Attention was then turned to the arms and legs. A total of 725 sq cm received full-thickness burns. The eschar involving this area was excised down to viable tissue. Hemostasis was achieved. Attention was then turned to the hands and feet. A total of 300 sq cm in this area received full-thickness burns. The eschar involving this area was excised down to viable tissue. All involved areas were then covered with porcine graft. Finally a split thickness skin graft of 0.015 inches in depth was harvested using a dermatome from a separate donor site. A total of 85 sq cm was recovered. What procedures codes would be reported service?
The left breast was prepped and draped in a sterile fashion. An incision from the 3 around to the 9 o’clock position on the areolar border on its inferior aspect was made in the skin and extended to the subcutaneous tissue. The breast mass was excised by sharp dissection. The mass was found to be approximately 1.5 - 2 cm in maximum dimension. Hemostasis was made adequate using electrocautery and the Argon beam coagulator. After this was accomplished, the skin margins were reapproximated with running inverted 3-0 Vicryl subcuticular suture. Select the procedure and diagnosis codes.
This 37-year-old paraplegic has developed a sacral decubitus ulcer. He is brought to the OR today for debridement of the pressure ulcer with a split-thickness skin graft to cover the defect. The patient was placed prone on the operative table after induction of adequate endotracheal anesthesia. The sacral area was prepped and draped sterilely, and the ulcer is inspected. The area is debrided extensively to healthy tissue. Involved bone, including part of the coccyx, was also removed. Once the area was clear of necrotic tissue, the site was prepared for a skin graft. A split-thickness skin graft was harvested from the thigh with a dermatome. Total graft size was 25 sq. cm. The graft was sutured in place using 6-0 Vicryl. The harvest site was closed primarily with skin staples. Dressings were applied. Needle counts were correct x 2. The patient tolerated the procedure well. Code the procedure(s).
The physician removes a tumor from the patient’s neck using the Mohs micrographic surgery technique. During the first stage, the physician takes four tissue blocks and reviews them under a microscope. The exam of the tissue blocks reveals a second stage is necessary to remove areas where the tumor is still present. The physician removes two tissue blocks. What are the appropriate CPT® codes for reporting the procedure?
Patient is seen in the hospital’s outpatient surgical area with a diagnosis of a displaced comminuted fracture of the lateral condyle, right elbow. An ORIF procedure was performed, which included the following techniques: An incision was made in the area of the lateral epicondyle. This was carried through subcutaneous tissue, and the fracture site was easily exposed. Inspection revealed the fragment to be rotated in two places about 90 degrees. It was possible to manually reduce this quite easily, and the manipulation resulted in an almost anatomic reduction. This was fixed with two pins driven across the humerus. The pins were cut off below skin level. The wound was closed with plain catgut subcutaneously and 5-0 nylon for the skin. Dressings and a long arm cast were applied. Which are the correct ICD-9-CM and CPT® codes assignment?
A 35-year-old female patient presents with acute onset of severe pain since October. Her workup has revealed evidence of disk herniation with loss of lordosis at the C5-C6. Intraoperative findings were consistent with two large fragments of free disk fragments in the foramen at C5-C6 on the right side. After general anesthesia, the patient was placed on the operative table in the supine position. All pressure points were cushioned and a transverse skin incision was fashioned under fluoroscopic guidance over the C5-C6 disc space. Dissection through the platysma eventually allowed for exposure of the anterior entrance to the vertebral body of C5 and C6 and retractors were inserted to maintain adequate exposure. The operating microscope was brought into the field. Caspar posts were placed and slight distraction allowed exposure. A complete discectomy was performed at C5-C6 by using endplate curets pituitary rongeurs and Kerrison rongeurs. The posterior longitudinal ligament was resected and beneath the posterior longitudinal ligament, two significant sized disc fragments were noted in the foramen at C5-C6. These were removed using pituitary and Decker instruments. The endplates were then decorticated so that they were parallel to each other and a midline keel was performed on AP and lateral fluoroscopy. A size #1 by 5 mm interbody Kineflex-C device was placed under fluoroscopic guidance. Satisfied with the positioning of the device, the decision was made to close. What is the correct code for this procedure?
A Grade I, high velocity open right femur shaft fracture was incurred when a 15-year-old female pedestrian was hit by a car. She was taken to the operating room within four hours of her injury for thorough irrigation and debridement, including excision of devitalized bone. The patient was then reprepped, redraped, and repositioned. Intramedullary rodding was then carried out with proximal and distal locking screws. What are the correct codes for this diagnosis and procedure?
This 45-year-old male presents to the operating room with a painful mass of the right upper arm. General anesthesia was induced. Soft tissue dissection was carried down thru the proximal aspect of the teres minor muscle. Upon further dissection a large mass was noted just distal of the IGHL(inferior glenohumeral ligament), which appeared to be benign in nature. With blunt dissection and electrocautery, the 4.5 cm mass was removed en bloc and sent to pathology. The wound was irrigated, and repair of the teres minor with subcutaneous tissue was then closed with triple-0 Vicryl. Skin was closed with double-0 Prolene in a subcuticular fashion. What is the correct CPT® code for this service?
Postoperative Diagnosis: 1. Impingement syndrome left shoulder. 2. AC synovitis left shoulder Procedure: Arthroscopy with subacromial decompression and AC resection left shoulder. The patient was placed supine on the operating table prepped and draped in usual sterile fashion. The scope was introduced from a posterior portal and the joint was inspected. The rotator cuff looked in good condition. The articular surfaces looked good. The bicep also was in good condition. We went subacromially and there was a fair amount of bursal inflammation encountered. We did a thorough bursectomy. A ligament chisel was used to take down the coracoacromial ligament. A high-speed bur was used to do a subacromial decompression going from lateral to medial. We took off about 2 cm of bone anteriorly. Next we opened the AC joint through an anterosuperior portal. We ground off about 10 mm of distal clavicle because there was a large subchondral cyst and we wanted to get this totally ground out, which we did. Then the wounds were irrigated out, Nylon suture was placed in our portals. The patient was placed in a bulky dressing and an arm sling and sent to the recovery room in stable condition. Code the procedure
A 47-year-old patient was previously treated with external fixation for a Grade III left tibia fracture. There is now nonunion of the left proximal tibia and he is admitted for open reduction of tibia with bone grafting. Approximately 30 grams of cancellous bone was harvested from the iliac crest. The fracture site was exposed and the area of nonunion was osteotomized, cleaned, and repositioned. Intrafragmentary compression was applied and three screws and the harvested bone graft were packed into the fracture site. What are the correct codes for this diagnosis and procedure?
Procedure: Dual chamber pacemaker defibrillator implantation. Indications: A 67-year-old white gentleman who has significant underlying ischemic cardiomyopathy with EF of 25 percent, prior infarcts, remote history of syncope and at high risk for malignant ventricular arrhythmias. He has had a recent T wave alternans test which was clearly abnormal. He has had episodes of resting bradycardia also noted. He also meets Madit II criteria for ICD implantation. Description of Procedure: After informed consent had been obtained, the patient was brought to the outpatient hospital lab in the fasting state. The left anterior chest was prepped and draped in a sterile fashion. Intravenous sedation and local anesthetic were given. After local anesthetic, a 5 cm incision was made at the left deltopectoral groove. With blunt dissection and cautery, this was carried down through the prepectoralis fascia. The cephalic vein was identified and ligated distally. Through the venotomy, a subclavian venogram was performed to provide a roadmap. The atrial and ventricular leads were then advanced into the vessel to the level of the right atrium under fluoroscopic guidance. The ventricular lead was maneuvered to the right ventricular outflow tract and then through the RV apex where it was actively fixed. Good sensing and pacing thresholds were demonstrated. The lead was anchored to the pre-pectoralis fascia with interrupted 2-0 Tycron sutures. 10 volt pacing did not result in diaphragmatic capture. The atrial lead was maneuvered to the anterolateral right atrial wall where it was actively fixed. Good sensing and pacing thresholds were demonstrated. The lead was anchored to the pre-pectoralis fascia with interrupted 2-0 Tycron sutures. 10 volt pacing did not result in diaphragmatic capture. A subcutaneous pocket was created with good hemostasis achieved. The pocket was subsequently irrigated with solution of Bacitracin. The generator was connected to the lead and then placed in the pocket with no tension on the lead. The deep fascial layer was closed with interrupted 2-0 Vicryl suture. The subcutaneous closure was made with running 3-0 Vicryl suture. Subcuticular closure was made with running 4-0 Vicryl suture. Steri-strips were applied. Ventricular fibrillation was induced with a T wave shock. This was successfully sensed and terminated with a 15 joule shock to sinus rhythm. High voltage impedence was 39 ohms. Dry dressing was placed over the wound. The patient returned to the floor in stable condition without apparent complications. Which of the following codes accurately describes the basic procedure summarized in this report?
This 25-year-old male presents with deviated nasal septum. After intubation, a left hemitransfixion incision was made with elevation of the mucoperichondrium. Cartilage from the bony septum was detached and the nasoseptum was realigned and removed in a piecemeal fashion from the obstructed perpendicular plate of the ethmoid. Thereafter, 4-0 chronic was used to approximate mucous membranes. Next, submucous resection of the middle and inferior turbinates was handled in the usual fashion by removing the anterior third of the bony turbinate and lateral mucosal followed by bipolar cauterization of the posterior enlarged tip of the inferior turbinate as well as outfracturing. A small amount of silver nitrate cautery was used to achieve hemostasis. A dressing consisted of a fold of Telfa with a ventilating tube for nasal airway on each side achieved good hemostasis, patient went to recovery in good condition. What is the correct code for this procedure?
At the patient’s bedside in the hospital, a PICC line is inserted. Using Xylocaine local anesthesia, aseptic technique and ultrasound guidance, a 21 gauge needle was used to aspirate the right cephalic vein of a 72-year-old patient. When blood was obtained, a 0.018 inch platinum tip guidewire was advanced to the central venous circulation. A 6 French dual lumen PICC was introduced through a 6 French peel-away sheath to the SVA RA junction and after removal of the sheath, the catheter was attached to the skin with a STAT-LOCK device and flushed with 500 units of Heparin in each lumen. A sterile dressing was applied and the patient was discharged in improved condition. Code the procedure(s).
A 62-year old female with three-vessel disease and supraventricular tachycardia, which has been refractory to other management. She previously had pacemaker placement and stenting of the coronary artery stenosis, which has failed to solve the problem. She will undergo CABG with autologous saphenous vein and a modified MAZE procedure to treat the tachycardia. The risks and benefits have been discussed and the patient wishes to proceed. She is brought to the cardiac OR and placed supine on the OR table. She is prepped and draped and adequate endotracheal anesthesia is assured. A median sternotomy incision is made and cardiopulmonary bypass is initiated. The endoscope is used to harvest an adequate length of saphenous vein from her left leg. This is uneventful and bleeding is easily controlled. The vein graft is prepared and cut to the appropriate lengths for anatomosis. Three bypasses are performed, one to the LAD, one to the circumflex and another distally on the circumflex. A modified maze procedure was then performed and the patient was weaned from bypass. Once the heart was once again beating on its own again, we attempted to induce an arrhythmia and this could not be done. At this point, the sternum was closed with wires and the skin reapproximated with staples. The patient tolerated the procedure without difficulty and was taken to the PACU. Choose the procedure code(s) for this service.
he patient is a three-year-old boy who attempted to swallow a half-dollar. The boy’s mother immediately brought the child to the ED, which was only a short distance from the house, and the thoracic team was called emergently. The patient was in acute respiratory distress when we arrived in the ED. A temporary tracheostomy was accomplished, allowing oxygen exchange. X-ray revealed the coin to be deeply wedged in the trachea. Several attempts were made to remove the coin in the ED with the use of forceps, without success. The patient was given a mild sedative and taken to the OR where a scope was used to successfully remove the coin. The trach was discontinued. The patient was admitted for overnight observation and discharged the next day in satisfactory condition.
Diagnosis: Right lung mass Indications: Patient with a mass in the right lung mass identified on routine X-ray presents for bronchoscopy and biopsy. Procedure: The patient was brought to the endoscopy suite and the mouth and throat were anesthetized. The bronchoscope was inserted and advanced through the larynx to the bronchus. The left side was examined first and no abnormalities were appreciated. The bronchoscope was then introduced into the right bronchus. Using fluoroscopic guidance, the tip of the bronchoscope was maneuvered into the area of the mass. A closed biopsy forceps was passed through the channel in the bronchoscope and then through the bronchial wall. A tissue sample was obtained. There were no other abnormalities appreciated in the right side and the bronchoscope was removed. The specimen was labeled and sent to pathology for testing. The patient tolerated the procedure well. Pathology indicates that the mass is cancer. What are the procedure and diagnosis codes?
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. 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
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
