Code the following reports utilizing CPT codes, ICD-10-CM codes, and apply any applicable modifiers.
Assignment #1
Description: The right upper lobe wedge biopsy
shows a poorly differentiated non-small cell carcinoma with a solid
growth pattern and without definite glandular differentiation by
light microscopy.
GROSS DESCRIPTION:
A. Received fresh labeled with patient's name, designated 'right
upper lobe wedge', is an
8.0 x 3.5 x 3.0 cm wedge of lung which has an 11.5 cm staple line.
There is a 0.8 x
0.7 x 0.5 cm sessile tumor with surrounding pleural
puckering.
B. Received fresh, labeled with patient's name, designated "lymph
node', is a 1.7 cm possible lymph node with anthracotic
pigment.
C. Received fresh labeled with patient's name, designated 'right
upper lobe', is a 16.0 x
14.5 x 6.0 cm lobe of lung. The lung is inflated with formalin.
There is a 12.0 cm staple line on the lateral surface, inked blue.
There is a 1.3 x 1.1 x 0.8 cm subpleural firm ill-defined mass, 2.2
cm from the bronchial margin and 1.5 cm from the previously
described staple line. The overlying pleura is puckered.
D. Received fresh, labeled with patient's name, designated '4 lymph
nodes', is a 2.0 x 2.0 x 2.0 cm aggregate of lymphoid material with
anthracotic pigment and adipose tissue.
E. Received fresh, labeled with patient's name, designated
'subcarinal lymph node', is a
2.0 x 1.7 x 0.8 cm aggregate of lymphoid material with anthracotic
pigment .
FINAL DIAGNOSIS:
A. Right upper lobe wedge lung biopsy: Poorly differentiated
non-small cell carcinoma. Tumor Size: 0.8 cm. Arterial (large
vessel) invasion: Not seen. Small vessel (lymphatic) invasion: Not
seen. Pleural invasion: Not identified. Margins of excision:
Negative for malignancy.
B. Biopsy, 10R lymph node: Anthracotically pigmented lymphoid
tissue, negative for malignancy.
C. Right upper lobe, lung: Moderately differentiated non-small cell
carcinoma
(adenocarcinoma). Tumor Size: 1.3 cm. Arterial (large vessel)
invasion: Present. Small vessel (lymphatic) invasion: Not seen.
Pleural invasion: Not identified. Margins of excision: Negative for
malignancy.
D. Biopsy, 4R lymph nodes: Lymphoid tissue, negative for
malignancy.
E. Biopsy, subcarinal lymph node: Lymphoid tissue, negative for
malignancy.
COMMENTS: Pathologic examination reveals two
separate tumors in the right upper lobe. They appear histologically
distinct, suggesting they are separate primary tumors (pT1). The
right upper lobe wedge biopsy (part A) shows a poorly
differentiated non-small cell carcinoma with a solid growth pattern
and without definite glandular differentiation by light microscopy.
The right upper lobe carcinoma identified in the resection (part C)
is a moderately differentiated adenocarcinoma with obvious gland
formation.
Assignment #2
Description: Specimen labeled "sesamoid bone
left foot".
GROSS DESCRIPTION: Specimen labeled "sesamoid
bone left foot" is received in formalin and consists of three
irregular fragments of grey-brown, hard, bony tissue admixed with
multiple fragments of brown-tan, rubbery, fibrocollagenous, soft
tissue altogether measuring 3.1 x 1.5 x 0.9 cm. The specimen is
entirely submitted, after decalcification.
DIAGNOSIS: Acute Osteomyelitis, with foci of
marrow fibrosis.
Focal acute and chronic inflammation of fascia and soft tissue.
Arteriosclerosis, severely occlusive.
Assignment #3
Description: The patient is a 26-year-old
female, referred to Physical Therapy for low back pain. The patient
has a history of traumatic injury to low back.
HISTORY OF PRESENT ILLNESS: The patient is a
26-year-old female, referred to Physical Therapy for low back pain.
The patient has a history of traumatic injury to low back. The
patient stated initial injury occurred eight years ago, when she
fell at a ABC Store. The patient stated she received physical
therapy, one to two visits and received modality treatment only,
specifically electrical stimulation and heat pack per patient
recollection. The patient stated that she has had continuous
low-back pain at varying degrees for the past eight years since
that fall. The patient gave birth in August 2008 and since the
childbirth, has experienced low back pain. The patient also states
that she fell four to five days ago, while mopping her floor. The
patient stated that she landed on her tailbone and symptoms have
increased since that fall. The patient stated that her initial
physician examination with Dr. X was on 01/10/09, and has a
followup appointment on 02/10/09.
PAST MEDICAL HISTORY: The patient denies high
blood pressure, diabetes, heart disease, lung disease, thyroid,
kidney, or bladder dysfunctions. The patient stated that she quit
smoking prior to her past childbirth and is currently not pregnant.
The patient has had a C-section and also an appendectomy. The
patient was involved in a motor vehicle accident four to five years
ago and at that time, the patient did not require any physical
therapy nor did she report any complaints of increased back pain
following that accident.
MEDICATIONS: Patient currently states she is
taking:
1. Vicodin 500 mg two times a day.
2. Risperdal.
3. Zoloft.
4. Stool softeners.
5. Prenatal pills.
DIAGNOSTIC IMAGERY: The patient states she has not
had an MRI performed on her lumbar spine. The patient also states
that Dr. X took x-rays two weeks ago, and no fractures were found
at that time. Per physician note, dated 12/10/08, Dr. X dictated
that the x-ray showed an anterior grade 1 spondylolisthesis of L5
over S1, and requested Physical Therapy to evaluate and
treat.
SUBJECTIVE: The patient states that pain is
constant in nature with a baseline of 6-7/10 with pain increasing
to 10/10 during the night or in cold weather. The patient states
that pain is dramatically less, when the weather is warmer. The
patient also states that pain worsens as the day progresses, in
that she also hard time getting out of bed in the morning. The
patient states that she does not sleep at night well and sleeps
less than one hour at a time.
Aggravating factors include, sitting for periods greater than 20
minutes or lying supine on her back. Easing factors include side
lying position in she attempts to sleep.
OBJECTIVE: AGE: 26 years old. HEIGHT: 5 feet 2
inches. WEIGHT: The patient is an obese 26-year-old female.
ACTIVE RANGE OF MOTION: Lumbar spine, flexion,
lateral flexion and rotation all within functional limits without
complaints of pain or soreness while performing them during
evaluation.
PALPATION: The patient complained of bilateral SI
joint point tenderness. The patient also complained of left greater
trochanter hip point tenderness. The patient also complained of
bilateral paraspinal tenderness on cervical spine to lumbar
spine.
STRENGTH:
RIGHT LOWER EXTREMITY:
Knee extension 5/5, hip flexion 5/5, knee flexion 4/5, internal and
external hip rotation was 4/5. With manual muscle testing of knee
flexion, hip, internal and external rotation, the patient reports
an increase in right SI joint pain to 8/10.
LEFT LOWER EXTREMITY:
Hip flexion 5/5, knee extension 5/5, knee flexion 4/5, hip internal
and external rotation 4/5, with slight increase in pain level with
manual muscle testing and resistance. It must be noted that PT did
not apply as much resistance during manual muscle testing,
secondary to the 8/10 pain elicited during the right lower
extremity.
NEUROLOGICAL: The patient subjectively complains
of numbness with tingling in her bilateral extremities when she
sits longer than 25 minutes. However, they subside when she stands.
The patient did complain of this numbness and tingling during the
evaluation and the patient was seated for a period of 20 minutes.
Upon standing, the patient stated that the numbness and tingling
subsides almost immediately. The patient stated that Dr. X told her
that he believes that during her past childbirth when the epidural
was being administered that there was a possibility that a sensory
nerve may have been also affected during the epidural less causing
the numbness and tingling in her bilateral lower extremities. The
patient does not demonstrate any sensation deficits with gentle
pressure to the lumbar spine and during manual muscle
testing.
GAIT: The patient ambulated out of the examination
room, while carrying her baby in a car seat.
ASSESSMENT: The patient is a 26-year-old
overweight female, referred to Physical Therapy for low back pain.
The patient presents with lower extremity weakness, which may be
contributing to her lumbosacral pain, in that she has poor lumbar
stabilization with dynamic ADLs, transfers, and gait activity when
fatigued. At this time, the patient may benefit from skilled
physical therapy to address her decreased strength and core
stability in order to improve her ADL, transfer, and mobility
skills.
PROGNOSIS: The patient's prognosis for physical
therapy is good for dictated goals.
SHORT-TERM GOALS TO BE ACHIEVED IN TWO
WEEKS:
1. The patient will be able to sit for greater than 25 minutes
without complaints of paraesthesia or pain in her bilateral lower
extremities or bilateral SI joints.
2. The patient will increase bilateral hip internal and external
rotation to 4/5 with SI joint pain less than or equal to
5/10.
3. The patient will report 25% improvement in her functional and
ADL activities.
4. Pain will be less than 4/10 while performing __________ while at
PT session.
LONG-TERM GOALS TO BE ACCOMPLISHED IN ONE
MONTH:
1. The patient will be independent with home exercise
program.
2. Bilateral hamstring, bilateral hip internal and external
rotation strength to be 4+/5 with SI joint pain less than or equal
to 2/10, while performing manual muscle test.
3. The patient will report 60% improvement or greater in functional
transfers in general ADL activity.
4. The patient will be able to sit greater than or equal to 45
minutes without complaint of lumbosacral pain.
5. The patient will be able to sleep greater than 2 hours without
pain.
TREATMENT PLAN:
1. Therapeutic exercises to increase lower extremity strength and
assist with lumbar sacral stability.
2. Modalities as indicated for pain and inflammation relief.
Modalities to include ice, heat, electrical stimulation and
ultrasound as appropriate.
3. Instruction of home exercise program/patient education.
FREQUENCY AND DURATION: The patient is to be seen
by Physical Therapy two times a week x4 weeks.
I have discussed the findings of the initial evaluation with the
patient. The patient is in agreement to the plan of care as
outlined above. We will refer the patient back to the physician if
the current plan does not seem to decrease the patient's pain level
or increase her functional abilities.
Thank you for this referral. If you have any questions, comments,
or concerns, please feel free to contact our office.
1. Assignments 1. Answer :
Right upper lobe non small cell carcinoma :
With a solid growth pattern :
ICD code : C34.11.
CPT code : 10022 and 77012.
Modifier : NOS C349.
2. Assignment .2. Answer :
Acute osteomyelitis with foci of marrow fibrosis
ICD code : M 86.1.
Specimen labeled sesamoid bone left foot ICD code is S92.902A.
CPT code : 28315.
Modifier : "- 57"
3. Assignment 3. Answer :
Low back pain
ICD 10 CM code : " 54.5"
CPT code : 73721 for imaging studies
Modifier is 25.
Code the following reports utilizing CPT codes, ICD-10-CM codes, and apply any applicable modifiers. Assignment #1...
Code the following reports utilizing CPT codes, and apply any applicable modifiers. Assignment #1 Description: The right upper lobe wedge biopsy shows a poorly differentiated non-small cell carcinoma with a solid growth pattern and without definite glandular differentiation by light microscopy. GROSS DESCRIPTION: A. Received fresh labeled with patient's name, designated 'right upper lobe wedge', is an 8.0 x 3.5 x 3.0 cm wedge of lung which has an 11.5 cm staple line. There is a 0.8 x 0.7 x...
Code the following reports utilizing ICD-10-CM codes. Assignment #1 Description: The right upper lobe wedge biopsy shows a poorly differentiated non-small cell carcinoma with a solid growth pattern and without definite glandular differentiation by light microscopy. GROSS DESCRIPTION: A. Received fresh labeled with patient's name, designated 'right upper lobe wedge', is an 8.0 x 3.5 x 3.0 cm wedge of lung which has an 11.5 cm staple line. There is a 0.8 x 0.7 x 0.5 cm sessile tumor with...
Code the following reports utilizing CPT codes, apply any application modifiers 1. Description: The right upper lobe wedge biopsy shows a poorly differentiated non-small cell carcinoma with a solid growth pattern and without definite glandular differentiation by light microscopy. GROSS DESCRIPTION: A. Received fresh labeled with patient's name, designated 'right upper lobe wedge', is an 8.0 x 3.5 x 3.0 cm wedge of lung which has an 11.5 cm staple line. There is a 0.8 x 0.7 x 0.5 cm...
Code the following reports utilizing CPT codes, apply any application modifiers. 3. Description: The patient is a 26-year-old female, referred to Physical Therapy for low back pain. The patient has a history of traumatic injury to low back. HISTORY OF PRESENT ILLNESS: The patient is a 26-year-old female, referred to Physical Therapy for low back pain. The patient has a history of traumatic injury to low back. The patient stated initial injury occurred eight years ago, when she fell at...
Review Exercises: ICD-10-CM and ICD-10-PCS Review Exers Chapter 5 dure codes for the following Assign the correct ICD-10-CM diagnosis codes or ICD-10 PCS procedure cod exercises. 1 Small cell carcinoma of the left lower lobe of the lung with metastasis to the intrathoracic lymph nodes, brain, and right rib 2. Benign carcinoid tumor of the jejunum 3. Subacute monocytic leukemia in remission 4. Malignant melanoma of the left shoulder area 5. The patient is seen in the pain clinic for...
Code the following three operative reports assigning the appropriate CPT and ICD-10-CM codes and modifiers. Assignment #1 PROCEDURE PERFORMED: Cataract extraction with lens implantation, right eye. DESCRIPTION OF PROCEDURE: The patient was brought to the operating room. The patient was identified and the correct operative site was also identified. A retrobulbar block using 5 ml of 2% lidocaine without epinephrine was done after adequate anesthetic was assured, and the eye was massaged to reduce risk of bleeding. The patient was...
code the following three operative reports assigning the appropriate CPT and ICD-10-CM codes and modifiers. Assignment #1 PROCEDURE PERFORMED: Cataract extraction with lens implantation, right eye. DESCRIPTION OF PROCEDURE: The patient was brought to the operating room. The patient was identified and the correct operative site was also identified. A retrobulbar block using 5 ml of 2% lidocaine without epinephrine was done after adequate anesthetic was assured, and the eye was massaged to reduce risk of bleeding. The patient was...
code the following three operative reports assigning the appropriate CPT and ICD-10-CM codes and modifiers. PREOPERATIVE DIAGNOSIS: Bladder lesions with history of previous transitional cell bladder carcinoma. POSTOPERATIVE DIAGNOSIS: Bladder lesions with history of previous transitional cell bladder carcinoma, pathology pending. OPERATION PERFORMED: Cystoscopy, bladder biopsies, and fulguration. ANESTHESIA: General. INDICATION FOR OPERATION: This is a 73-year-old gentleman who was recently noted to have some erythematous, somewhat raised bladder lesions in the bladder mucosa at cystoscopy. He was treated for...
Code the following three operative reports assigning the appropriate ICD-10-CM codes and modifiers. Assignment #1 PROCEDURE PERFORMED: Cataract extraction with lens implantation, right eye. DESCRIPTION OF PROCEDURE: The patient was brought to the operating room. The patient was identified and the correct operative site was also identified. A retrobulbar block using 5 ml of 2% lidocaine without epinephrine was done after adequate anesthetic was assured, and the eye was massaged to reduce risk of bleeding. The patient was prepped and...
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