Instructions: Assign the CPT code(s) and appropriate modifier(s) to each case. Please be aware that when an answer consists of more than one code, there will be an answer blank for each code.
1. Via transabdominal approach, the physician performs imbrication by overlapping diaphragm tissue to ensure that the diaphragm is in the correct position and the eventration is corrected.
2. A patient is found to have a cystlike lesion per magnetic resonance imaging (MRI) of the mediastinum. This is to be removed. An incision is made by the physician from the shoulder blade to the spinal column of the thoracic area. Muscles are retracted, and the rib cage is exposed. After gaining access to the thoracic cavity, the physician identified the cyst and removed it. The specimen is sent to pathology. The wound is closed in layers.
3. A lacerated diaphragm tear measuring 2.5 cm is repaired with sutures.
4. A patient is being seen to confirm the diagnosis of sarcoidosis. An endoscopic examination of her mediastinum is done under general anesthesia. After making an incision in the area of the sternum, the scope is inserted. The trachea, bronchi, and lymph nodes are examined. A lymph node biopsy is taken. The scope is withdrawn, and the incision is closed with sutures
5. A patient had the signs and symptoms consistent with a perforated viscus. After discussion, the patient consented to suture repair of the gastric ulcer. The patient was placed in a supine position. After adequate anesthesia, attention was turned to the anterior abdominal wall. A midline incision was made. Gross contamination was visualized. This was suctioned out. The gastric ulcer was visualized, and copious irrigation with 3 l of warm saline was performed. All gross evidence of contamination was gone. Checking was done, hemostasis was throughout, and the skin incision was closed.
6. A patient presented with a lesion of the lip; due to the patient's history of smoking, it was determined to remove the lesion and send it to analysis to rule out carcinoma. After adequate anesthesia, a wedge incision was done of the lower lip to remove the lesion. The defect was closed with a small flap and sutures.
7. A patient with the diagnosis of carcinoma of the stomach presented for a hemigastrectomy. With the patient in the supine position and after adequate level of general anesthesia, the abdomen was prepped and draped in usual sterile fashion. An upper midline incision was made to access the abdominal cavity. The abdominal ligament was retracted to the right side of the incision. The stoma was mobilized. The duodenum was divided away from the stomach. The tumor was identified. The stomach tumor was transected with cautery, and a specimen was sent for evaluation by pathology. The distal margin of the remaining stomach was cleaned. Staples were used to close the curvature area of the stomach. The abdomen was closed with running Prolene for the fascia. The skin was closed with staples.
8. An 18-year-old patient has a history of chronic tonsillitis. Under general anesthesia, the physician separated the tonsils from the tonsil bed by blunt and sharp dissection followed by the snare. No gross bleeding was found. The adenoids were extracted by the adenotome followed by the sharp curette. Again, no gross bleeding was found. The patient had minimal blood loss
9. A 72-year-old male patient presented to the emergency department with a 14-hour history of acute right inguinal pain and obstructive symptoms. Examination found a tender nonreducible mass in the right groin. He consented to surgical intervention via exploration and correction of possible hernia. After adequate anesthesia, the patient had an oblique preperitoneal incision through the fascia. The peritoneal cavity was entered. A strangulated loop was found along with the femoral hernia. The lower edge of the inguinal ligament was grasped with clamps, and interrupted Prolenes were used to close the femoral defect using Coopers ligament repair. The defect was closed up to the edge of the external iliac vein. Once the repair was completed, the wound was irrigated with saline. The bowel was inspected and appeared to be totally revascularized, with no evidence of necrosis and no need for resection. The femoral hernia sac was reduced and resected using electrocautery. The abdominal wall was closed with interrupted polypropylene sutures for the anterior wall fascia. A Jackson-Pratt drain was brought out through a separate stab wound. The subcutaneous tissue was closed with interrupted 3-0 Vicryl, and the skin was closed with staples.
1. Via the transabdominal approach, the physician performs imbrication by overlapping diaphragm tissue to ensure that the diaphragm is in the correct position and the eventration is corrected.
We can apply the code 39545 for Imbrication of the diaphragm for eventration, transthoracic or transabdominal, paralytic or nonparalytic and the modifier is 59
2. A patient is found to have a cystlike lesion per magnetic resonance imaging (MRI) of the mediastinum. This is to be removed. An incision is made by the physician from the shoulder blade to the spinal column of the thoracic area. Muscles are retracted, and the rib cage is exposed. After gaining access to the thoracic cavity, the physician identified the cyst and removed it. The specimen is sent to pathology. The wound is closed in layers.
39200 - Resection of the mediastinal cyst and the modifier is 59
3. A lacerated diaphragm tear measuring 2.5 cm is repaired with sutures.
Here we can apply the code 39501 - Repair, laceration of the diaphragm, any approach and the modifier is 59
4. A patient is being seen to confirm the diagnosis of sarcoidosis. An endoscopic examination of her mediastinum is done under general anaesthesia. After making an incision in the area of the sternum, the scope is inserted. The trachea, bronchi, and lymph nodes are examined. A lymph node biopsy is taken. The scope is withdrawn, and the incision is closed with sutures
Here we can apply the code 39402 where Mediastinoscopy when performed with lymph node biopsy. and the modifier is 59
5. A patient had the signs and symptoms consistent with a perforated viscus. After discussion, the patient consented to suture repair of the gastric ulcer. The patient was placed in a supine position. After adequate anaesthesia, attention was turned to the anterior abdominal wall. A midline incision was made. Gross contamination was visualized. This was suctioned out. The gastric ulcer was visualized, and copious irrigation with 3 l of warm saline was performed. All gross evidence of contamination was gone. Checking was done, hemostasis was throughout, and the skin incision was closed.
Here we can apply 43500 Gastrotomy; with exploration and suture repair of ulcer and the modifier is 59
6. A patient presented with a lesion of the lip; due to the patient's history of smoking, it was determined to remove the lesion and send it to analysis to rule out carcinoma. After adequate anaesthesia, a wedge incision was done of the lower lip to remove the lesion. The defect was closed with a small flap and sutures.
Here we can apply 40510 - Excision of the lip; transverse wedge excision with primary closure and the modifier is 59
7. A patient with the diagnosis of carcinoma of the stomach presented for a hemigastrectomy. With the patient in the supine position and after an adequate level of general anaesthesia, the abdomen was prepped and draped in a usual sterile fashion. An upper midline incision was made to access the abdominal cavity. The abdominal ligament was retracted to the right side of the incision. The stoma was mobilized. The duodenum was divided away from the stomach. The tumour was identified. The stomach tumour was transected with cautery, and a specimen was sent for evaluation by pathology. The distal margin of the remaining stomach was cleaned. Staples were used to closing the curvature area of the stomach. The abdomen was closed with running Prolene for the fascia. The skin was closed with staples.
Here we can apply 43631 Gastrectomy, partial and the modifier is 59
8. An 18-year-old patient has a history of chronic tonsillitis. Under general anaesthesia, the physician separated the tonsils from the tonsil bed by blunt and sharp dissection followed by the snare. No gross bleeding was found. The adenoids were extracted by the adenectomy followed by the sharp curette. Again, no gross bleeding was found. The patient had minimal blood loss.
Here we can apply 42821 for tonsillectomy and adenoidectomy for age 18.and the modifier is 59
9. A 72-year-old male patient presented to the emergency department with a 14-hour history of acute right inguinal pain and obstructive symptoms. An examination found a tender nonreducible mass in the right groin. He consented to surgical intervention via exploration and correction of possible hernia. After adequate anaesthesia, the patient had an oblique preperitoneal incision through the fascia. The peritoneal cavity was entered. A strangulated loop was found along with the femoral hernia. The lower edge of the inguinal ligament was grasped with clamps and interrupted Prolenes were used to close the femoral defect using Coopers ligament repair. The defect was closed up to the edge of the external iliac vein. Once the repair was completed, the wound was irrigated with saline. The bowel was inspected and appeared to be totally revascularized, with no evidence of necrosis and no need for resection. The femoral hernia sac was reduced and resected using electrocautery. The abdominal wall was closed with interrupted polypropylene sutures for the anterior wall fascia. A Jackson-Pratt drain was brought out through a separate stab wound. The subcutaneous tissue was closed with interrupted 3-0 Vicryl, and the skin was closed with staples.
Here we can apply the code 49520, 49555 and the modifier is 59
Instructions: Assign the CPT code(s) and appropriate modifier(s) to each case. Please be aware that when an answer consi...
Assign the CPT surgery code(s) and the appropriate HCPCS level II and CPT modifier(s). PREOPERATIVE DIAGNOSIS: Cervical lymph node abscess. POSTOPERATIVE DIAGNOSIS: Same. PROCEDURE: Lymph node drainage ANESTHESIA: Local After the administration of adequate local anesthesia, the patient was prepped and draped in the usual sterile fashion. The enlarged left cervical lymph node was palpated. An incision was made over the node, and a whitish gray fluid was drained. A sample of the fluid from abscess was sent to the...
Instructions: Assign the CPT code(s) and appropriate modifier(s) to each case. Please be aware that when an answer consists of more than one code, there will be an answer blank for each code. Patient was prepped and draped; after adequate general endotracheal anesthesia, the body was somewhat flexed at the waist to provide adequate exposure after taping in preparation to separate the buttocks at the sacral crease. A probe was inserted into the inferior sinus, and only 3–4 cm of...
Assign the CPT surgery code(s) and the appropriate HCPCS level II and CPT modifier(s). The patient, a 25-year old female with a diagnosis of portal hypertension, presented to the surgical suite for a splenectomy. After informed consent was obtained, the patient was given a preoperative anesthesia injection. Then the patient was prepped and draped in the usual sterile fashion. With the patient under general anesthesia, a midline incision was made. After the spleen was identified, surrounding tissue was dissected free....
Assign the CPT surgery code(s) and the appropriate HCPCS level II and CPT modifier(s). With the patient under general anesthesia, an upper midline incision was made and dissected around the spleen. The ruptured segment of the spleen was identified at the distal portion, and this was resected. The wound was irrigated, and the incision was closed using sutures and a sterile dressing. Three-fourths of the spleen was left intact. DIAGNOSIS: Ruptured spleen due to Plasmodium vivax malaria.
Case 8-1 Assign an external cause code to indicate how the injury occurred. LOCATION: Inpatient, Hospital PATIENT: Tara Barron ATTENDING PHYSICIAN: Gary Sanchez, MD SURGEON: Gary Sanchez, MD PREOPERATIVE DIAGNOSIS: Stab wound, right upper abdominal quadrant. POSTOPERATIVE DIAGNOSIS: Same as Preoperative. PROCEDURE PERFORMED: Exploration of stab wound, right upper quadrant of abdomen, with closure of fascial defect. ANESTHESIA: General. PROCEDURE: The patient was brought to the operating room and placed under general anesthesia; we then removed the jar lid from...
Instructions: Assign the CPT code(s) and appropriate modifier(s) to each case. Please be aware that when an answer consists of more than one code, there will be an answer blank for each code. Patient underwent reconstruction of the entire forehead and supraorbital rims, requiring grafts, to correct a congenital skeletal deformity. After administration of general anesthesia, scalp and upper eyelid incisions were made to access the surgical site. The forehead bones were reshaped and repositioned, and bone allografts were inserted...
Assign the CPT surgery code(s) and the appropriate HCPCS level II and CPT modifier(s). PREOPERATIVE DIAGNOSIS: Rule out lymphoma. Enlarged lymph node of axillary area on the left. POSTOPERATIVE DIAGNOSIS: Same. ANESTHESIA: Local, using 0.5% Marcaine without epinephrine The patient was brought to the operating room, and after adequate prepping and draping of the left axillary area, a large several-centimeters-in-diameter lymph node was palpated medially and superiorly. The skin overlying this node was infiltrated with 0.5% Marcaine without epinephrine, and...
Assign the CPT code(s) and appropriate modifier(s) to each statement. Please be aware that when an answer consists of more than one code, there will be an answer blank for each code. The physician passed an endoscope through the patient's mouth and visualized the entire esophagus, stomach, duodenum, and jejunum. One lesion was removed using biopsy forceps. Another lesion was removed using a snare. ,
CHAPTER 8: MUSCULOSKELETAL SYSTEM Case 8-1 Assign an external cause code to indicate how the injury occurred. LOCATION: Inpatient, Hospital PATIENT: Tara Barron ATTENDING PHYSICIAN: Gary Sanchez, MD SURGEON: Gary Sanchez, MD PREOPERATIVE DIAGNOSIS: Stab wound, right upper abdominal quadrant. POSTOPERATIVE DIAGNOSIS: Same as Preoperative. PROCEDURE PERFORMED: Exploration of stab wound, right upper quadrant of abdomen, with closure of fascial defect. ANESTHESIA: General. PROCEDURE: The patient was brought to the operating room and placed under general anesthesia; we then removed...
Q: Need help with my assignment to code diagnoses(ICD-10-CM) and CPT for the following cases with explanation. Case-1 Patient Name: DOB: Age: 2Y Date of Surgery: 04/04/2014 Primary Care Physician: Cecil H Lashlee, M.D. Referring Physician(s): John F Bealer, M.D. PCP Operative Report Surgeon: John F Bealer, M.D. Assistant(s): None. Preoperative Diagnosis: Umbilical hernia. Postoperative Diagnosis: Umbilical hernia. Procedure: Umbilical herniorrhaphy. Anesthesia: General endotracheal anesthesia. Estimated Blood Loss: Less than 5 mL. Complications: There were no intraoperative complications. Counts: Correct....