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               A final diagnosis for a patient in the ER is COPD with acute bronchitis due to echovirus. How is this diagnosis coded?

                A 59-year-old is suffering from foraminal spinal stenosis. Patient is to have a L4-L5 laminectomy on the right side. Under general anesthesia a knife dissection was made on the back and was taken down to the fascia. The fascia on the right side of the spine was stripped. The deep Taylor retractor was placed. Using an intraoperative X-ray, the physician traced out the foramen of L4-L5. There appeared to be some compression at this lamina into the foramen and significant stenosis. The provider removed the spinous process and lamina. Nerve roots canals are freed by removal of the facet. Compression is relieved by removing bony overgrowth around the foramen. What CPT® code is reported for this procedure?

A patient recently experienced muscle atrophy and noticed she did not have pain when she cut herself on a piece of glass. The provider decides to obtain a needle biopsy of the spinal cord under ultrasound guidance in the outpatient setting. The biopsy results come back as syringomyelia. What CPT® and ICD-10-CM codes are reported for the biopsy procedure?

                  Which one of the following is TRUE about the tympanic membrane?

                A patient is seen for hypertension. Her blood pressure remains at her goal with the prescribed medication.  When referring to the number and complexity of problems addressed, what type of problem is this considered?

What is the correct ICD-10-CM diagnosis code for a patient with a postoperative diagnosis of a malignant pancreatic mass?

Case 1 Preoperative Diagnosis: Aortic valve stenosis with coronary artery disease associated with congestive heart failure Postoperative Diagnosis: Same Procedure: Aortic valve replacement, coronary artery bypass graft with harvesting of the saphenous vein and the radial artery. Anesthesia: General endotracheal Incision: Median sternotomy Description of Procedure: The patient was brought to the operating room and placed in supine position. After the patient was prepared, median sternotomy incision was carried out and conduits were taken from the left arm as well as the right thigh. She was cannulated after the aorta and atrium were exposed and after full heparinization.   She went on cardiopulmonary bypass, and the aortic cross-clamp was applied. Cardioplegia was delivered through the coronary sinuses in a retrograde manner. The patient was cooled to 32 degrees. Iced slush was applied to the heart. The aortic valve was then exposed through the aortic root by transverse incision. The valve leaflets were removed, and the 23 St. Jude mechanical valve was secured into position by circumferential pledgeted sutures. At this point, aortotomy was closed.   Attention was turned to the coronary arteries. The first obtuse marginal artery was a very large target and the vein graft to this target indeed produced an excellent amount of flow. Proximal anastomosis was then carried out to the foot of the aorta. The radial artery was anastomosed to the left anterior descending artery target in an end-to-side manner. The proximal anastomosis was then carried out to the root of the aorta.   The patient came off cardiopulmonary bypass after aortic cross-clamp was released. She was adequately warmed. Protamine was given without adverse effect. Sternal closure was then done using wires. The subcutaneous layers were closed using Vicryl suture. The skin was approximated using staples. What CPT® codes are reported?

               A patient with deep vein thrombosis requires heparin to maintain therapeutic anticoagulation levels. He has regular PTTs drawn to monitor his level of anticoagulation. What CPT® code is reported?

               A 72-year-old female sustained a left radius fracture, resulting in volar angulation, radial shortening and loss of radioulnar inclination. A general anesthetic was administered. A standard dorsal central approach to the wrist was made. The capsule was opened in a T fashion and the malunion site was identified. A series of osteotomes was utilized to open the fracture site and the normal distal radial architecture was restored. The pie-plate was placed on the distal radius utilizing a combination of 2.0 and 1.8 screws and threaded pins for the distal segment and 2.7 screws proximally. Fragments were secured, and Norian SRS was packed into the defect and allowed to harden. With this completed, the wounds were copiously irrigated with normal saline. Soft tissue was closed over the plate and distal radius and secured with 2-0 Vicryl. What CPT® code is reported?

                A 26-year-old gravida 2 para 1 female has been spotting and has been on bed rest. She awoke this morning with severe cramping and bleeding. Her husband brought her to the hospital. After examination, it was determined she has an incomplete early spontaneous abortion. She is in the 12th week of her pregnancy. She was taken to the OR and a dilation and curettage (D&C) was performed. There were no complications from the procedure. She will follow-up with me in the office. She has had four antepartum visits during her pregnancy.