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Exam 27: Coding and Surgical Procedures

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Question 431

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Preoperative diagnosis: Left hip pain and bilateral chest and back pain Postoperative diagnosis: Left hip pain and bilateral chest and back pain Procedures: Bilateral lumbar paravertebral sympathetic nerve block under ultrasound guidance. Left hip greater trochanter bursa injection. Procedure in detail: All questions were answered. His back was palpated to try to elicit areas of discomfort. This was quite difficult to do, since he said he hurt all over. Of note is that we had looked at his legs, and on his right leg he had an area of excoriation or erythema that was unusual for him, and he stated that his pain seemed to correlate with his edema and erythema of his legs. With this in mind, we turned our attention first to his left hip pain and asked him to move his left hip to where we could elicit a point of maximum tenderness. Point of maximum tenderness was elicited over what appeared to be the greater trochanter of the left hip area itself. We then injected what appeared to be the bursa of the left hip with 10 cc of 0.25% Marcaine with 20 mg of Depo-Medrol. He was then placed in a prone position with a pillow supporting his upper abdomen. In light of his symptoms down his legs, we felt that a lumbar paravertebral sympathetic nerve block was indicated at this time. We identified the spinous process of L2. The midpoint of the spinous process of L2 was marked. A line perpendicular to the spinous process of L2 was then drawn on his skin, and a point that was 1¾ inches from the midline was then marked. The skin at this point was anesthetized with 1.5% lidocaine using a 25-gauge B-bevel needle. This was then followed with a 22-gauge 3½-inch needle that was advanced under a slightly cephalic medial direction, approximately 85 degrees off midline. Under fluoroscopic guidance, the needle was advanced. On the first attempt on the left, we encountered the transverse process of L2. The needle was repositioned left of cephalic, and we were able to bypass the transverse process. The needle was advanced until we encountered the vertebral body of L2 under ultrasound guidance. We then obtained a lateral view and found that indeed we were at the level of the midbody of L2. With this needle felt to be adequately placed, we then injected 6 cc of 0.25% Marcaine with 20 mg of Depo-Medrol. The needle was left in place, and the stylet was replaced. We then turned our attention to the right-hand side because of the excoriation on his legs and the edema that he said he experiences with increased levels of his pain. The skin was once again marked 1¾ inches from the midline at the midlevel of the spinous process of L2. The skin was anesthetized with 1.5% lidocaine. This was then followed with a 22-gauge 3½-inch spinal needle that was advanced under fluoroscopic guidance. Of note, we made three or four passes in the attempt to approximate the needle next to the vertebral body of L2. Interesting to note is that in order to obtain the maximum view of the spinous process of L2, we were approximately 5 degrees to the right in terms of off midline. Once the 22-gauge 3½-inch spinal needle was placed on the right after several attempts, he did not complain of any paresthesias at this time. We then took a lateral view and found that our needle was not as deep as it should be. We then withdrew the needle, and on ultrasound guidance, using a lateral view, the needle was advanced until it was felt that we were at the appropriate depth. An AP view was then retaken, and we were found to be not at the body of L2 in terms of next to it. The needle was then removed and repositioned in a slightly medial fashion, and it was felt that we encountered bone. We then turned to the lateral view once again and found that we were at this time at the midbody of L2. This was felt to be adequately placed after three attempts. Then 6 cc of 0.25% Marcaine with 20 mg of Depo-Medrol was injected. The needle stylet was then replaced, and we then waited approximately 4 minutes for the Marcaine to set. We then removed the needles of both the right and the left sides, respectively, and pressure was applied at the skin to prevent any bleeding. He was then placed in the supine position and was discharged home in satisfactory condition. He was instructed to call if he had any changes in edema of his legs. Select the appropriate ICD-10-CM and CPT code(s) :

A) M25.552, R07.9, M54.5, 64520-50
B) M25.52, R07.9, M54.5, 64520
C) M25.552, R07.9, M54.5, 20610, 0216T-50
D) M25.552, R07.89, M54.5, 0213T

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Question 432

Multiple Choice

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Section: Kidney (left) : Adenocarcinoma MACROSCOPIC Specimen type: Radical nephrectomy Laterality: Left Tumor site: Upper pole Focality: Unifocal Tumor size: Greatest dimension is 7.2 cm. Macroscopic extent of tumor: Tumor extends into major veins. MICROSCOPIC Histologic type: Clear cell (conventional) renal carcinoma Histologic grade: Furhman Nuclear Grade 2 PATHOLOGIC STAGING (pTN) Primary tumor (pT) : pT3 Regional lymph nodes (pN) : Nx Number of lymph nodes examined: 0 Number of lymph nodes involved: 0 Margins: Renal vein margin positive Adrenal gland: Unevolved Venous (large vessel) invasion (V) (excluding renal vein and inferior vena cava) : Negative Lymphatic (small vessel) invasion (L) : Present Additional pathologic findings: Chronic glomerulonephritis present in noninvolved renal parenchyma Clinical history: A 76-year-old male with a left renal mass in the upper pole; hematuria Gross description section: Received in formalin, labeled "left kidney," is a 12.2- × 7.1- × 2.5-cm kidney with unremarkable perirenal fat present at the upper pole (suture oriented, per requisition) . A 2.3 cm in length segment of ureter exits from the hilum. The renal vein appears occluded. The cut sections demonstrate a 7.2- × 1.5- × 1.5-cm brown-orange circumscribed tumor with sharp borders present in the upper pole. Gerota's fascia appears uninvolved. The tumor extends into the renal vein; the venous margin appears positive for tumor. Microscopic section: Microscopic examination was performed. Select the appropriate ICD-10-CM and CPT code(s) :

A) C64.2, N03.9, 88307
B) C64.9, 88307-LT
C) C64.8, 88307
D) C64.9, N08, 88307-LT

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Question 433

Multiple Choice

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A 48-year-old female with a 20+ year smoking history is diagnosed with a pulmonary nodule growing in the left lower lobe of the lung. After discussion with her surgeon, the patient is brought to the OR for a laproscopic wedge resection of the nodule using VATS approach to obtain a frozen section. Following a pathology report of adenocarcinoma of the lung, a VATS lobectomy of the left lower lobe was performed. The patient tolerated the procedure and was sent to the surgical ICU in stable condition. Select the appropriate CPT and ICD-10-CM codes.

Carpal tunnel release was performed for a patient with carpal tunnel syndrome. She had been experiencing chronic and worsening pain in the right hand and had previously tried a series of injections that did not relieve the problem. An EMG showed compression of the median nerve, so she opted for surgery which was performed today. Select the appropriate CPT and ICD-10-CM codes.

Tammie Jones needs a dry pressure mattress because of her recurrent lumbar decubitus ulcer. Select the appropriate HCPCS code.

Clinical history: Carcinoma of the breast with skeletal metastasis. Study performed: Total Body Bone Scan. Impression: Abnormal total body bone scan with abnormalities noted in the ribs and spine and possibly within the skull. Select the appropriate CPT and ICD-10-CM codes.

Diagnostic esophagogastroduodenoscopy was performed for a patient with suspected ulcers. The endoscope was inserted in the pharynx and was passed all the way through to the jejunum, which revealed ulcers of the stomach, pylorus, and duodenum. The patient tolerated the procedure well and was sent home with prescriptions and a referral to a nutritionist. Select the appropriate CPT and ICD-10-CM codes.

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

A condition brought on due to an abnormal accumulation of acidic products of metabolism such as happens in uncontrolled diabetes mellitus is known as

A physician interprets and writes a report on a tier 1 molecular pathology procedure for BRCA1 and BRCA2 gene analysis for a 20-year-old female with a family history of breast cancer. Select the appropriate CPT and ICD-10-CM codes.

Carpal tunnel release was performed for a patient with carpal tunnel syndrome. She had been experiencing chronic and worsening pain in the right hand and had previously tried a series of injections that did not relieve the problem. An EMG showed compression of the median nerve, so she opted for surgery which was performed today. Select the appropriate CPT and ICD-10-CM codes.

One of the largest veins in the body is the:

A patient is sent to the radiology department with an indication of abdominal pain. A KUB is ordered. The coder inputs data that is then transferred to line 21 of the CMS-1500 form, showing ICD-10-CM code R10.11, and line 24 field C showing CPT 74018. Which of the following has the coder demonstrated?

A 66-year-old female with CHF, atrial fibrillation, and type II diabetes was admitted with right pleural effusion demonstrated on x-ray, as well as shortness of breath and dyspnea on exertion. A video-assisted thoracic surgery (VATS) pleurodesis was performed. A 10-mm port was placed and the effusion was drained by placing a sucker into the port site. An additional anterior port was then placed in similar fashion and the effusion was drained with a sucker. A 32 curved chest tube was placed and secured with nylon. The other port site was also closed. Select the appropriate CPT and ICD-10-CM codes.

A 28-year-old was in a car accident and is now in the ED due to 3 fingers on his left hand being completely amputated above the metacarpophalangeal joint during the crash. The ED physician calls in an orthopedic surgeon and the patient is taken to surgery. Under surgical microscope his index finger and middle finger were reconnected; however, his 3rd finger was not able to be reconnected due to extensive crush injuries to that finger, so that finger was surgically amputated. Select the appropriate CPT and ICD-10-CM codes.

Dr. Green works for a house-call physician service. She was called to evaluate a new patient, an 88-year-old bedridden woman who has developed a painful rash on her posterior left side of the trunk, extending from C6 to C7 around the right side and ending midline on the anterior trunk just below the sternum. The physician performs a detailed history and a detailed examination and medical decision making is of low complexity. She diagnoses the patient with shingles. Select the appropriate codes.

The patient was seen for I&D of simple carbuncle on the left thigh. Code this procedure with the appropriate ICD-10-CM and CPT code(s) :

Tom Smith, who is 45 years old, was recently diagnosed with a liver mass. The family physician ordered a liver biopsy to be performed. At the outpatient surgery area the patient was treated by Dr. Jane, who performed a percutaneous liver biopsy. Select the appropriate CPT and ICD-10-CM codes for the anesthesia for this procedure.

A patient is placed on a ventilator as a result of a closed head injury with loss of consciousness due to a car accident. Select the appropriate CPT and ICD-10-CM codes for physician management on the initial and three subsequent days while the patient is in the hospital.

A patient with a significant past medical history consisting of coronary artery disease and hypertension was found to have a tumor in the chest wall. Resection of left chest wall tumor was performed, including transection of three ribs and partial resection of left diaphragm, left lower lobe lung wedge resection, and left chest wall reconstruction with Gore-Tex mesh. The pathology report indicated mesothelioma in the chest wall and lung. Select the appropriate CPT and ICD-10-CM codes.