Blog

Integumentary SystemMrs. Jones is seen today for puncture aspiration of three cysts on the left breast and one on the right. The pathology report revealed cystic breast disease. Select the appropriate ICD-10-CM and CPT code(s):

Integumentary SystemPreoperative diagnosis: Morbid obesityPostoperative diagnoisis: Morbid obesityProcedure performed: Abdominal panniculectomyEstimated blood loss: Throughout the procedure, approximately 20 MlAnesthesia: General endotracheal anesthesiaIndications for procedure: This is a 49-year-old female who previously underwent gastric bypass surgery and has lost 120 pounds, leaving a large lower pannus of the abdomen. This pannus needs to be resected. The nonoperative versus operative management options were discussed with the patient. The operative risks included bleeding, infection, hematoma, chance for further surgery as well as pain, and a resulting scar. The patient accepted the risks and consented to surgery.Procedure in detail: The patient was placed under general endotracheal anesthesia. The patient was draped in the proper manner, and the lower abdominal pannus was identified. It was preoperatively marked prior to going to the OR. The lower incision was made from the superior iliac crest with the middle being the pubic tubercle. That lower incision was then made. The pass was then elevated at the level of the anterior abdominal fascia and was elevated superiorly to the level of the inferior umbilicus. Then incisions were made on the umbilicus to the superior iliac crest, and the skin and subcutaneous pannus was passed off table as a specimen. The wound was then made hemostatic with the use of electrocautery. JP drains were placed. The abdominal skin flap was then brought to the inferior skin flap and sutured in place with 2-0 Vicryl sutures at the dermal level. The drains were then secured, and then the skin was closed with running 3-0 Monocryl suture. The wound was further dressed with Steri-strips, gauze, and abdominal binder. The patient tolerated the procedure well. All needle and instrument counts at the end of the procedure were correct, and the patient was taken to PACU in good condition.Select the appropriate ICD-10-CM and CPT code(s):

DigestiveMrs. Jones presented with pain in the right upper quadrant. Upon a CT of the abdomen and an ultrasound of the gallbladder, a diagnosis of cholelithiasis and acute cholecystitis was confirmed, and the patient was taken to the operating room. The patient underwent a laparoscopic cholecystectomy with a normal intraoperative cholangiogram to remove the gallstones. Select the appropriate ICD-10-CM and CPT code(s):

Respiratory/CardiovascularPreoperative diagnosis: Left perihilar massPostoperative diagnosis: Left perihilar mass, mucosal abnormality in the posterior subsegment of the left upper lobeProcedure performed: Bronchoscopy, transbronchial lung biopsy and bronchial lung biopsy, brushing and washingAssistant: NoneAnesthesia: MACDescription of procedure: With the patient in the supine position, under monitored anesthesia care, the scope was introduced through the mouth, and the larynx and the laryngeal area were inspected. All of them were normal. The scope was then inserted through the trachea into the carina, which was sharp and clear. There was a moderate amount of thick-thin secretions that were suctioned through both right and left main bronchi. The scope was then directed into the right main bronchus, and then the right upper-lobe bronchus with its subsegments was inspected. All of them were normal. Right middle-lobe and right lower-lobe bronchi with their subsegments were also inspected and were normal. The scope was then directed into the left side, where the left main bronchus was normal. Left lower-lobe and middle-lobe bronchi with their subsegments were normal. The left upper-lobe bronchus, anterosuperior segment, showed an anterior subsegment to have a bulging in one of its subbronchi. Under fluoroscopy, biopsy forceps were inserted, and several pieces of lung tissue were obtained from the area of the left perihilar lesion. Then brushing was done in the same area. Washing was also done in the same area. Then, in a separate container, several pieces of bronchial tissue were taken from the area that was bulging, anterosuperior subsegment of the left upper-lobe bronchus. All specimens were submitted for cytology, pathology, and/or culture. The patient tolerated the procedure well, with no apparent complications. Chest x-ray is pending.Select the appropriate ICD-10-CM and CPT code(s):

Coding Guidelines/Compliance/Practice ManagementThe time associated with coding sequelae (late effects) is:

DigestiveA 45-year-old male with pancreatic cancer presents with a distended abdomen. The ultrasound reveals fluid in the peritoneal cavity. The patient undergoes a therapeutic paracentesis with ultrasound imaging guidance to drain the fluid. Select the appropriate ICD-10-CM and CPT code(s):

Coding Guidelines/Compliance/Practice ManagementWhich of the following is not considered a covered entity?

AnesthesiaA 43-year-old male came into the doctor’s office to have a hemorrhoidopexy by stapling for his second-degree hemorrhoids. He was very uneasy since he had never had this procedure before. Dr. Hanson administered an IV of Versed, for the anxiety. The procedure is not really painful, so there was no need for a full anesthetic or painkiller. Myrtle Pape, a certified registered nurse anesthetist (CRNA), sat with the patient throughout the procedure to ensure his safety and comfort level. The procedure was complete in one stage, taking 30 minutes.Select the appropriate ICD-10-CM and CPT code(s):

AnesthesiaPreoperative diagnosis: Left hip pain and bilateral chest and back painPostoperative diagnosis: Left hip pain and bilateral chest and back painProcedures: 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):

50).                                         results in feeble heartbeat; arrhythmias.