Module 04 Assignment – Surgical Coding Worksheet

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Dec 6, 2023

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HIM1257 Section 01 Ambulatory Coding (5.5 Weeks) - Online Plus - 2023 Fall Quarter Term 1 Module 04 Assignment – Surgical Coding Worksheet Feedback for student 10/29/23, 2:18 PM #1 61700, 69990 #4 58953 #5 55840 #6 67901-E1 #8 59409, 59426 #10 no modifier #12 57522 #13 49593 #17 42825 #23 50590-LT #24 no modifier #25 63045, 63048, 63048 ************************************************ 1. Question 1 0/1 Final Grade: 0 points out of 1 point possible Intracranial aneurysm repair by intracranial approach with microdissection using operating microscope, carotid circulation. Provide the CPT code(s): Your Answer 61697 2. Question 2

1/1 Final Grade: 1 point out of 1 point possible Code the following case study. One code is required. Preoperative Diagnosis: Backache, unspecified Procedure: Lumbal epidural steroid injection L5-S1 interspace Indications: The patient is a 41-year-old man with severe work-related back and leg pain, more left than right. The patient understands the reasons for the procedure and the risk associated with it. The patient is anxious and needed IV sedation and tolerated the pain associated with injection. Procedure Notes: For the procedure, the patient was sedated with 2 mg of Versed and 1,250 mg of Alfenta. The patient was monitored throughout the procedure and afterward with pulse oximeter and Dinamap. The pulse oximetry ranged in the lower and upper 90 range. The patient tolerated the IV well; therefore, the procedure went well. For the procedure, the patient was placed prone on the fluoroscopy table with a pillow under his abdomen. We identified the sacral hiatus. We prepared the skin with alcohol and DuraPrep and applied drapes and anesthetized the skin with xylocaine. Next, we used fluoroscopy to guide the 17-gauge needle into the spinal canal through the sacral hiatus. This was advanced under AP and lateral fluoroscopic guidance with loss of resistance. We verified proper depth and placement with myelography injection. The lumbar myelography injection was extradural in the lumbosacral area and consisted of 2 cc of Isovue 300. This showed we were in the spinal canal and highlighting the nerve roots at the lumbosacral region. Next, we placed the catheter to the L5-S1 interspace. Through the catheter we injected steroid solution that contained 80 mg of Depo-Medrol, 3 cc of 0.75% marcaine, and 4 cc of Omnipaque 300. This was injected under fluoroscopy, visualizing the nerve roots well throughout the lower lumbar area, more left than right. We cleared the catheter and needle of solution and removed them from the back. Permanent films were taken, and the patient was taken to the recovery room where he recovered in good condition. Interpretation of Permanent Films: The permanent films afterward verified the myelography and steroid solution were in the proper areas. On AP and lateral views, the solution highlighted the nerve roots at the lower lumbar area, but scar tissue is preventing the spread of medication throughout the entire region. Nerve roots do highlight in the lower lumbar spine. No evidence of dural puncture. CPT code: Your Answer 62323 3. Question 3 1/1 Final Grade: 1 point out of 1 point possible Orchiectomy for tumor removal, abdominal exploration. Provide the CPT code: Your Answer 54535 4. Question 4

0/1 Final Grade: 0 points out of 1 point possible A female patient with extensive tumors of the reproductive organs undergoes a total abdominal hysterectomy, bilateral salpingo-oophorectomy, omentectomy and radical dissection for debulking. Provide the CPT code: Your Answer 58575-50 5. Question 5 0/1 Final Grade: 0 points out of 1 point possible Retropubic radical prostatectomy. Provide the CPT code: Your Answer 55866 6. Question 6 0/1 Final Grade: 0 points out of 1 point possible Code the following case study. One code is required. Preoperative Diagnosis: Ptosis, left upper eyelid Postoperative Diagnosis: Ptosis, left upper eyelid Procedure: Frontalis ptosis, left upper eyelid Anesthesia: Local Procedure Notes: Topical Tetracaine was applied to both eyes. The left upper lid and brow were infiltrated with Xylocaine with epinephrine and Marcaine with Wydase. The patient was prepared and draped in the usual fashion for oculoplastic surgery. Incisions were made in the medial and lateral thirds of the lid, 3 mm above the lash line. Stat incisions were made at the medial and lateral thirds of the brow, approximately 5 mm above the brow and a single incision was made in the middle of the brow, approximately 1 cm higher than the previous two incisions. A 3-0 Prolene suture was passed from the lateral lid incision to the medial lid incision beneath the orbicularis, just above the tarsus. Suture was then passed beneath the brow and frontalis to emerge from the medial and lateral brow incisions respectively. Each end of the suture was then passed beneath the frontalis to emerge through the central brow incision. The suture was tied, and tension was adjusted so that the lid level was just above the papillary border. The brow incisions were closed with interrupted sutures of 6-0 Prolene, the eye was dressed with Ocumycin ointment. The patient tolerated the procedure well and left the OR in good condition. CPT code: Your Answer 67900-E1 7. Question 7 1/1 Final Grade: 1 point out of 1 point possible

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Code the following case study. One code is required. Preoperative Diagnosis: Chronic recurrent otitis media Postoperative Diagnosis: Chronic recurrent otitis media Operation: Bilateral tympanostomy; placement of permanent ventilating tube Anesthesia: General Procedure Notes: A standard myringotomy incision was made, and a copious amount of serous fluid was suctioned from the middle ear cleft. A Goode T-tube was placed without problems. The procedure was then repeated on the left side in the same manner . CPT code: Your Answer 69436-50 8. Question 8 0/1 Final Grade: 0 points out of 1 point possible Routine prenatal obstetric care with vaginal delivery, 9 prenatal visits (postpartum care done by another physician). Provide the CPT code(s): Your Answer 59400 9. Question 9 1/1 Final Grade: 1 point out of 1 point possible Bilateral Orchiopexy using inguinal approach. Provide the CPT code: Your Answer 54640-50 10. Question 10 0.5/1 Final Grade: 0.5 points out of 1 point possible Code the following case study. One code is required. Preoperative Diagnosis: History of colon polyps Postoperative Diagnosis: Polyp of colon Procedure: Colonoscopy with polypectomy Indications: The patient is a 46-year-old who had a polyp removed a little over a year ago and presents for a follow-up at this time. Findings: The patient was taken to the procedure room and placed in the supine position. The patient was initially given 50 mg of Demerol and 3 mg of Versed. Next, a rectal exam was performed, and the scope was introduced through the rectum. The scope could be passed up to an area of about 35 cm and a polyp was found. It was removed with a snare and then brought out with the biopsy forceps through that port. This specimen was sent on to the pathologist for further evaluation. Good hemostasis was found at the site of the polypectomy. The scope was then carefully withdrawn. The

patient tolerated the procedure reasonably well. There were no complications. The patient left the procedure room in stable condition. Follow-up: The patient will follow up in my office in seven to 14 days. The patient will be given a prescription for Anusol suppositories. CPT code: Your Answer 45385 - 52 11. Question 11 1/1 Final Grade: 1 point out of 1 point possible A simple Marshall-Marchetti-Krantz procedure (without the performance of a hysterectomy). Provide the CPT code: Your Answer 51840 12. Question 12 0/1 Final Grade: 0 points out of 1 point possible Code the following case study. One code is required. Preoperative Diagnosis: Moderate dysplasia of the cervix Postoperative Diagnosis: Moderate dysplasia of the cervix Procedure: LEEP Conization Anesthesia: General inhalation anesthesia per mask Procedure Notes: The patient was brought to the OR with IV fluids infusing and placed on the table in the supine position. General inhalation anesthesia per mask was administered after acquisition of an adequate anesthetic level, and the patient was placed in the lithotomy position. The perineum was draped. A laser speculum was placed in the vaginal vault. Using the 2 cm electrosurgical loop excision, the endocervical canal was cauterized with bipolar cautery. The procedure was then completed. The speculum was removed. The patient was taken out of the lithotomy position. Her anesthesia was reversed. She was awakened and taken to the recovery room in stable condition. Sponge, instrument, and needle counts were correct times three. The estimated blood loss was less than 25 cc. CPT code: Your Answer 57461 13. Question 13 0/1 Final Grade: 0 points out of 1 point possible Code the following case study. One code is required. Preoperative Diagnosis: Ventral Hernia Postoperative Diagnosis: Ventral Hernia Operation Performed : Laparoscopic repair of Ventral Hernia

Anesthesia: General Procedure Notes: The patient was taken to the operating room, placed in the supine position. The abdomen was prepped and draped in the usual sterile fashion. A Veress needle was then inserted in the left lateral abdominal wall. The abdomen was insufflated with CO2 gas. A 10-mm Surgiport was then placed. The laparoscopic camera was then inserted. Additional 5-mm Surgiports were placed under direct vision, one in the left lower quadrant of the abdomen, the other in the left upper quadrant of the abdomen. The 5-mm harmonic scalpel was used along with the dissecting forceps to take down the adhesions from within and around the hernia sac. There were a number of adhesions, primarily involving the omentum. These were all removed. Two hernia defects were noted, one just above the umbilicus, perhaps 3 to 4 em in diameter, and another toward the upper aspect of the midline incision, that had not been previously recognized. It was elected to place an 18 x 24-cm segment of Gore-Tex dual mesh. #1 Prolene was sewn at each of the corners of this as well as in between, at the midpoint of each of the sides. Suitable locations were chosen for tying the anchoring sutures. The patch then was rolled around a grasper and inserted into the abdominal cavity through the 10-mm port. The patch was then unrolled, and the orientation placed with the smooth side down against the bowel. An endoclose device was used to grasp each of the sutures and bring out through the previously placed incisions for the anchoring sutures. The patch was anchored at each of the six locations as noted previously. Then, an auto suture Protac was placed around the periphery of the patch. Additional staples were placed within the inner aspect of the patch using an Ethicon tacking stapler. The patch was noted to be quite taut and applied closely to the abdominal wall to prevent any movement of the patch. The abdomen was then desufflated and the ports withdrawn. Each of the skin incisions was closed with 4-0 clear PDS subcuticular suture and Steri-Strips. Tegaderm dressings were then applied. The patient tolerated the procedure well with no apparent difficulty. She was then taken to the postanesthesia recovery room for further postoperative care. CPT code: Your Answer 49591 14. Question 14 1/1 Final Grade: 1 point out of 1 point possible Cystoscopy with resection of a 0.9 cm bladder tumor. Provide the CPT code: Your Answer 52234 15. Question 15 1/1 Final Grade: 1 point out of 1 point possible Code the following case study. One code is required. Preoperative Diagnosis: Carpal tunnel compression, left, severe Postoperative Diagnosis: Carpal tunnel compression, left, severe

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Operation: Release, left carpal tunnel Procedure Notes: After successful axillary block was placed, the patient's left arm was prepared and draped in the usual sterile manner. Tourniquet was inflated. A curvilinear hypothenar incision was made, and the palmaris retracted radially. The carpal tunnel and the transverse carpal ligament were then opened and completely freed in the proximal directions. It was noted to be severely tight in the palm with flattening and swelling of the median nerve. The carpal tunnel was opened distally in the hand and noted to be clear, out to the transverse palmar crease. The wound was then closed with 4-0 Dexon in subcuticular tissues. Sterile bulky dressing was applied, and the patient was awakened and taken to the recovery room in satisfactory condition. CPT code: Your Answer 64721-LT 16. Question 16 1/1 Final Grade: 1 point out of 1 point possible Code the following case study. One code is required. Procedure: Diagnostic Colonoscopy History and Indications: The patient is a 30-year-old woman who has had complaints of abdominal pain, altered bowel habits, and a 2- to 3-g documented decline in her hemoglobin level. Her stools have been heme negative, but there is significant suspicion that she may have pathology in the colon. Technique: The patient was sedated with 1.5 mg Versed and received antibiotics prior to the procedure per the recommendations of the cardiology service. She is status post heart transplant with significant cardiac complications. In the endoscopy suite with appropriate monitoring of pulse, oxygenation, temperature, blood pressure, and other vital signs, a digital rectal examination was performed. Following the examination, the Pentax video colonoscope was inserted through the anus and advanced to the cecum. There was no evidence of malignancy. The scope was withdrawn. CPT code: Your Answer 45378 17. Question 17 0/1 Final Grade: 0 points out of 1 point possible Code the following case study. One code is required. Procedure: Tonsillectomy History and Indications: This 10-year-old patient was found to have recurrent tonsillitis, and a tonsillectomy was planned. Technique: The patient was placed in the supine position, and general endotracheal anesthesia was begun. The nasopharynx was inspected, revealing only a very small amount of adenoid, which was not removed. The tonsils were noted to be very large and obstructive and were removed by dissection and snare technique. The bleeders

were electrocoagulated. The inferior cuff was suture ligated with 2-0 plain catgut. The patient tolerated the procedure well and was brought to the recovery room in satisfactory condition. CPT code: Your Answer 42820 18. Question 18 1/1 Final Grade: 1 point out of 1 point possible Transurethral resection of prostate, complete. Provide the CPT code: Your Answer 52601 19. Question 19 1/1 Final Grade: 1 point out of 1 point possible Code the following case study. One code is required. Preoperative Diagnosis : Intrauterine pregnancy at 12 weeks, history of cervical incompetence Postoperative Diagnosis : Intrauterine pregnancy at 12 weeks, history of cervical incompetence Procedure: McDonald's cerclage placement Anesthesia: Epidural History: The patient is a 36-year-old gravida 3 para 2 with a last menstrual period (LMP) on January 28. Positive HCG was noted on March 1. Intrauterine pregnancy was determined to be at 12 weeks by time of LMP and at first trimester by ultrasound. She has a history of cervical incompetence in a previous pregnancy that was brought to term with a cerclage. She also has a history of diethylstilbestrol exposure and of cerclage placement times 2, D&C times 2, and umbilical herniorrhaphy. Findings and Technique: Preoperatively, her internal os was approximately 1 cm dilated. The posterior cervix was approximately 2 cm long, and the interior cervix was approximately 1 cm long. At the end of the procedure, the knot could be felt at the 12 o'clock position and the internal os was closed to digital examination. The patient was in the dorsal lithotomy position. She had internal and external perineal preps and was draped for the procedure. A Mersilene band on two needles was used with one needle placed in at the 6 o'clock position and brought out at 3 o’clock and replaced at the same position and brought out at 12 o'clock. The other needle was taken in at 3 o'clock and brought out at 9 o'clock, and then replaced and brought out at 12 o'clock. The Mersilene band then was tied at the 12 o'clock position until the internal os was closed. It was palpable at the end of the procedure, and the two ends were cut long. The patient received perioperative antibiotics, and her heart tones were Dopplerable before the procedure. The procedure was without complications, and the patient was taken to the recovery room in stable condition. CPT code:

Your Answer 59320 20. Question 20 1/1 Final Grade: 1 point out of 1 point possible Flexible sigmoidoscopy with decompression of volvulus. Provide the CPT code: Your Answer 45337 21. Question 21 1/1 Final Grade: 1 point out of 1 point possible Code the following case study. One code is required. Preoperative Diagnosis: Cholecystitis with cholelithiasis Postoperative Diagnosis: Cholecystitis with cholelithiasis Procedure: Laparoscopic cholecystectomy with operative cholangiogram Anesthesia: General Bleeding: None Complications: None Procedure Notes: The patient was brought to the OR, placed in the supine position and given anesthesia. The skin over the abdomen was prepped with DuraPrep and draped in a sterile fashion. A one cm incision was made above the umbilicus, and the Veress needle was introduced into the abdomen obtaining pneumoperitoneum. A 10-mm trocar was inserted, and the laparoscope introduced. The patient had significant cholecystitis. Direct exploration of the abdomen was normal. Other trocars were introduced into the subcostal space under direct vision. Lysis of adhesions was completed. Exposure of the gallbladder bed was obtained, and the cystic artery and cystic duct were isolated. The common duct was of normal size. The cystic duct was ligated distally and proximally and was opened. We inserted the biliary catheter and obtained a cholangiogram that showed a normal biliary tree. The catheter was removed, and the cystic duct double ligated with hemoclips and divided. The gallbladder was removed through the upper trocar and dissected with electrocautery. The area was irrigated with saline solution. The trocars were removed under vision and pneumoperitoneum decompressed. The skin was closed with subcuticular #4-0 vicryl, and a sterile dressing was applied. The patient tolerated the procedure well. CPT code: Your Answer 47563 22. Question 22 1/1 Final Grade: 1 point out of 1 point possible Code the following case study. One code is required. Preoperative Diagnosis: Chalazion, left lower lid Postoperative Diagnosis: Chalazion, left lower lid

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Operation: Excision of mass, left lower lid Procedure Notes: Under adequate topical anesthesia and block anesthesia, the eye was prepared and draped in the usual manner. Chalazion speculum was applied. The left lower lid was everted, and a vertical incision made. Excision of the mass was performed using curet. and a biopsy of the capsule of this 9-mm mass was made, as requested. Patient tolerated the procedure well and left the operating room in good condition after application of Cortisporin ointment and pressure patch. CPT code: Your Answer 67800-E2 23. Question 23 0.5/1 Final Grade: 0.5 points out of 1 point possible The patient receives extracorporeal shock wave lithotripsy (ESWL) to destroy a kidney stone in the left kidney. Provide the CPT code: Your Answer 50590 24. Question 24 0.5/1 Final Grade: 0.5 points out of 1 point possible Code the following case study. Two codes are needed. Preoperative Diagnosis: Bilateral vocal cord neoplasm Postoperative Diagnosis: Bilateral vocal cord neoplasm, with right post-procedural pharyngeal bleed Procedure: Laryngoscopy with bilateral vocal cord stripping with use of operating Microscope. Control of oral, pharyngeal hemorrhage, less than 20ccs Laryngoscopy with bilateral vocal cord stripping with use of operating Microscope. Control of oral, pharyngeal hemorrhage, less than 20ccs Indications: This 65-year-old woman presented to the ENT service with a 2-year history of hoarseness. Upon evaluation, she was noted to have bilateral vocal cord neoplasms. The patient also has a history of smoking. A decision for the above stated procedures was made for definitive diagnosis. Procedure Notes: The patient was brought to the operating suite, given a general anesthetic and properly prepared and draped. It was noted that her teeth were not in good repair, and that the lateral incisor was already loose on the right side. However, teeth guards were put not place. The Jako laryngoscope was carefully introduced into the oral cavity with attention not to injure the lips, gums, or teeth. The base of the tongue, vallecula, epiglottis, paraform sinuses and false and true vocal cords all were visualized. The laryngoscope was fixed in to place with microsuspension. The vocal cords were well visualized. There were polypoid- type neoplasms bilaterally. These were grasped anteriorly, stripped to the posterior bilaterally, and sent to pathology. Hemostasis was obtained with an adrenaline cotton ball and silver nitrate. After good hemostasis was obtained, the oral cavity was irrigated with a saline solution. When the patient exhibited

hemostasis, she was taken out of anesthetic and transferred to the recovery room in stable condition. CPT Code(s): Your Answer 31541-50; 42960 25. Question 25 0/1 Final Grade: 0 points out of 1 point possible The physician performs a posterior laminectomy, facetectomy, and foraminotomy on C3, C4, and C5. Provide the CPT code(s). Your Answer 63045