Question 116
A 74-year-old arrived at the ED experiencing bright red rectal bleeding when using the toilet. She does not have any abdominal pain, no nausea or vomiting. She has been undergoing dialysis for years due to end-stage renal failure and has a diagnosis of myelodysplastic syndrome with a platelet count of just 3,000. Her hemoglobin level, which was 10 at her dialysis session the previous day, dropped to 7. Abdominal films are negative. An urgent esophagogastroduodenoscopy (EGD) was performed, and no active bleeding was found in the esophagus or the stomach.
However, the scope was passed into the upper duodenum which did reveal some oozing, and was controlled with cautery. Next, the patient was then positioned on her left side for a colonoscopy that extended from the colon to the ileum and into the lower duodenum, but no definitive sources of bleeding were found. Again, no outright bleeding sources were identified. A CRNA performed the anesthesia and documented PS III.
What CPT codes are reported for the CRNA?
However, the scope was passed into the upper duodenum which did reveal some oozing, and was controlled with cautery. Next, the patient was then positioned on her left side for a colonoscopy that extended from the colon to the ileum and into the lower duodenum, but no definitive sources of bleeding were found. Again, no outright bleeding sources were identified. A CRNA performed the anesthesia and documented PS III.
What CPT codes are reported for the CRNA?
Question 117
(A 6-month-old child was brought to the hospital with severe breathing difficulties. After testing, the child was diagnosed withtracheal stenosis present from birth. The pediatric surgeon performed atracheoplasty (surgical widening of the trachea). What CPT and ICD-10-CM codes are reported?)
Question 118
A 42-year-old male is diagnosed with a left renal mass. Patient is placed under general anesthesia and in prone position. A periumbilical incision is made and a trocar inserted. A laparoscope is inserted and advanced to the operative site. The left kidney is removed, along with part of the left ureter. What CPT code is reported for this procedure?
Question 119
Preoperative diagnosis: Right thigh benign congenital hairy nevus. *1
Postoperative diagnosis: Right thigh benign congenital hairy 0 nevus.
Operation performed: Excision of right thigh benign congenital>1
nevus, excision size with margins 4.5 cm and closure size 5 cm.
Anesthesia: General.0
Intraoperative antibiotics: Ancef.0
Indications: The patient is a 5-year-old girl who presented with her parents for evaluation of her right thigh congenital nevus. It has been followed by pediatrics and thought to have changed over the past year. Family requested excision. They understood the risks involved, which included but were not limited to risks of general anesthesia, infection, bleeding, wound dehiscence, and poor scar formation. They understood the scar would likely widen as the child grows because of the location of it and because of the age of the patient. They consented to proceed.
Description of procedure: The patient was seen preoperatively in > I the holding area, identified, and then brought to the operating room. Once adequate general anesthesia had been induced, the patient's right thigh was prepped and draped in standard surgical fashion. An elliptical excision measuring 6 x 1.8 cm had been marked. This was injected with Lidocaine with epinephrine, total of 6 cc of 1% with 1:100,000. After an adequate amount of time, a #15 blade was used to sharply excise this full thickness.
This was passed to pathology for review. The wound required limited undermining in the deep subcutaneous plane on both sides for approximately 1.5 cm in order to allow mobilization of the skin for closure. The skin was then closed in a layered fashion using 3-0 Vicryl on the dermis and then 4-0 Monocryl running subcuticular in the skin, the wound was cleaned and dressed with Dermabond and Steri-Strips.
The patient was then cleaned and turned over to anesthesia for S extubation.
She was extubated successfully in the operating room and taken S to the recovery room in stable condition. There were no complications.
What CPT and ICD-10-CM codes are reported?
Postoperative diagnosis: Right thigh benign congenital hairy 0 nevus.
Operation performed: Excision of right thigh benign congenital>1
nevus, excision size with margins 4.5 cm and closure size 5 cm.
Anesthesia: General.0
Intraoperative antibiotics: Ancef.0
Indications: The patient is a 5-year-old girl who presented with her parents for evaluation of her right thigh congenital nevus. It has been followed by pediatrics and thought to have changed over the past year. Family requested excision. They understood the risks involved, which included but were not limited to risks of general anesthesia, infection, bleeding, wound dehiscence, and poor scar formation. They understood the scar would likely widen as the child grows because of the location of it and because of the age of the patient. They consented to proceed.
Description of procedure: The patient was seen preoperatively in > I the holding area, identified, and then brought to the operating room. Once adequate general anesthesia had been induced, the patient's right thigh was prepped and draped in standard surgical fashion. An elliptical excision measuring 6 x 1.8 cm had been marked. This was injected with Lidocaine with epinephrine, total of 6 cc of 1% with 1:100,000. After an adequate amount of time, a #15 blade was used to sharply excise this full thickness.
This was passed to pathology for review. The wound required limited undermining in the deep subcutaneous plane on both sides for approximately 1.5 cm in order to allow mobilization of the skin for closure. The skin was then closed in a layered fashion using 3-0 Vicryl on the dermis and then 4-0 Monocryl running subcuticular in the skin, the wound was cleaned and dressed with Dermabond and Steri-Strips.
The patient was then cleaned and turned over to anesthesia for S extubation.
She was extubated successfully in the operating room and taken S to the recovery room in stable condition. There were no complications.
What CPT and ICD-10-CM codes are reported?
Question 120
What ICD-10-CM coding is reported for a patient who has hypertension and CKD stage 2?
