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Operative ReportPREOPERATIVE DIAGNOSIS: Diabetic foot ulceration. POSTOPERATIVE DIAGNOSIS: Diabetic foot ulceration. OPERATION PERFORMED: Debridement and split thickness autografting of left midfoot.ANESTHESIA: General endotracheal. INDICATIONS FOR PROCEDURE: This patient with multiple complications from type 2 diabetes developed skin ulcerations which were debrided with homograft last week. The homograft is taking quite nicely; the wounds appear to be fairly clean. He is ready for autografting. DESCRIPTION OF PROCEDURE: After informed consent the patient is brought to the operating room and placed in the supine position on the operating table. Anesthetic monitoring was instituted; general anesthesia was induced. The left lower extremity is prepped and draped in a sterile fashion. Staples were removed and the homograft was debrided from the surface of the wounds. One wound appeared to have healed; the remaining two appeared to be relatively clean. We debrided this sharply with good bleeding in all areas. Hemostasis was achieved with pressure, Bovie cautery, and warm saline soaked sponges. With good hemostasis a donor site was then obtained on the left anterior thigh, measuring less than 100 cm 2. The wounds were then grafted with a split-thickness autograft that was harvested with a patch of Brown dermatome set at 12,000 of an inch thick. This was meshed 1.5:1. The donor site was infiltrated with bupivacaine and dressed. The skin graft was then applied over the wound, measured approximately 60 cm2 in dimension on the left midfoot. This was secured into place with skin staples and was then dressed with Acticoat 18’s, Kerlix incorporating a catheter, and gel pad. The patient tolerated the procedure well. The right foot was redressed with skin lubricant sterile gauze and Ace wrap. Anesthesia was reversed. The patient was brought back to the ICU in satisfactory condition. What CPT® and ICD-10-CM codes are reported?

A 17-year-old female has a bone marrow biopsy for examination as a potential volunteer stem cell donor for her mother who has acute monocytic leukemia (AML). What diagnosis code(s) is/are used for the typing of the stem cell specimens?

A 65-year-old female has a 2.5 cm x 2.0 cm non-small cell lung cancer in her right upper lobe. The tumor is inoperable due to severe respiratory conditions. She is receiving stereotactic body radiation therapy today under image guidance. Beams arranged in 8 fields will deliver 25 Grays per fraction for 4 fractions. What CPT® and ICD-10-CM codes are reported?

A patient is seen for three extra visits during the third trimester of her pregnancy because of her history of pre-eclampsia during her previous pregnancy putting her at risk for a recurrence of the problem during this pregnancy. No problems develop, but the patient ended up delivering at 31 weeks. The three extra visits took place during week 30. What diagnosis code(s) is/are reported for these three extra visits?

Mrs. Smith is visiting her mother and is 150 miles away from home. She is in the 26th week of pregnancy. In the late afternoon she suddenly feels a gush of fluids followed by strong uterine contractions. She is rushed to the hospital but the baby is born before they arrive. In the ED she and the baby are examined and the retained placenta is delivered. The baby is in the neonatal nursery doing okay. Mrs. Smith has a 2nd degree perineal laceration secondary to precipitous delivery which was repaired by the ED physician. She will return home for her postpartum care. What ICD-10-CM and CPT® codes are reported by the ED physician?

Cytopathology is the study of:

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.

Four years post hepatic transplant, the patient is recently diagnosed with combined hepatocellular carcinoma and cholangiocarcinoma of the liver. What ICD-10-CM codes are reported?

The patient has a history of unstable angina, hypertension, and chronic systolic heart failure. He is seen in the ED after prolonged chest pain that was not relieved by medication. Cardiac enzymes are elevated, and EKG shows anterior infarct. A decision was made to perform a cardiac catheterization and coronary angiography. Left heart catheterization was performed in order to perform a left ventriculogram. He tolerated the procedure well and will be discharged. His final diagnosis is chronic systolic heart failure and hypertension. The two conditions are unrelated. What ICD-10-CM code(s) is/are reported?

The corpus luteum secretes progesterone. What is an effect of this secretion?