|21. A 67-year-old male patient with a history of carcinoma of the sigmoid colon is referred for a diagnostic colorectal cancer screening. The patient completed all treatment for his cancer in 2004. The physician performed a diagnostic flex sigmoidoscopy exam to screen for recurrent colon cancer and examine the anatomic site. During the exam, the physician found three polyps in the rectosigmoid junction. They were removed by hot biopsy forceps. The path report indicated the polyps were benign. Code the encounter.
A. 45333, V10.05, 211.3 B. 45331, V12.72, 211.3
C. 45338, V10.05 D. 45339, 211.3, V12.72
22. Postoperative Diagnosis: Calculi of the gallbladder Procedure: Removal of gallbladder Indications: The patient is a 40-year-old woman who has a six month history of RUQ pain, which ultrasound revealed to be multiple gallstones. She presents for removal of her gallbladder. Procedure: The patient was brought to the OR and prepped and draped in a normal sterile fashion. After adequate general endotracheal anesthesia was obtained, a trocar was placed and CO2 was insufflated into the abdomen until an adequate pneumoperitoneum was achieved. A camera was placed at the umbilicus and the gallbladder and liver bed were visualized. The gallbladder was enlarged and thickened, and there was evidence of chronic inflammatory changes. Two additional ports were placed and graspers were used to free the gallbladder from the liver bed with a combination of sharp dissection and electrocautery. Several attempts were made before it was decided that additional exposure was needed and I converted to an open approach. The trocars were removed and a midline incision was made. At this time, it was clear that there were multiple adhesions in the area, and once these were carefully taken down, we were able to grasp the gallbladder. The cystic duct was carefully ligated and the gallbladder carefully removed from the field. The area was copiously irrigated, and a needle biopsy of the liver was taken. Then the skin was reapproximated in layers. Sponges and needle counts were correct, and the patient was taken to the recovery room in good condition.
A. 47600-22 B. 47600-22, 47001
C. 47562, 47600-22, 47001 D. 47562-22, 47000
23. A patient with rectal bleeding undergoes a proctosigmoidoscopy. During the proctosigmoidoscopy, the physician identifies internal hemorrhoids. The proctoscope was withdrawn, and the anus was prepped and draped. A field block with Marcaine 0.25% was then placed. Anoscope was inserted. There was a prolapsing hemorrhoid in the anterior midline. This was rubber band ligated by applying two bands. In the posterior midline, there was another hemorrhoid that was banded in the same manner. Code the procedures.
A. 46221, 45300-51, 46600-51 B. 46221, 45300-51
C. 46945, 45300 D. 46934, 45300-51, 46600-51
24. A patient diagnosed with GERD presents to the same day surgery department for an upper GI endoscopy. The procedure is done in order to treat the GERD by delivering thermal energy to the muscle of the gastric cardia and lower esophageal sphincter. Anesthesia was administered and as the physician begins the procedure, the patient’s blood pressure drops to a dangerously low level. The physician decides not to finish the procedure due to the risk it may cause the patient. What are the codes for this procedure and diagnosis?
A. 43257-73, 530.7, 458.8 B. 43499, 530.81, 458.9
C. 43257-74, 530.81, 458.29 D. 43257-53, 530.81, 458.29, V64.1
25. Preoperative diagnosis: History of prior colon polyps Postoperative diagnosis: Colon polyps, diverticulosis, hemorrhoids Procedure: A rectal exam was performed and revealed small external hemorrhoids. The video colonoscope was passed without difficulty from anus to cecum. The colon was well prepped. The instrument was slowly withdrawn with good views obtained throughout. There was a 3 mm polyp in the proximal ascending colon. This polyp was removed with hot biopsy forceps and retrieved. There was a 4 mm rectal polyp located 10 cm from the anus in the proximal rectum. The polyp was removed by hot biopsy forceps. There was also moderate diverticulosis extending from the hepatic flexure to the distal sigmoid colon. Code the CPT® procedure(s).
A. 45384 B. 45384, 45384-51
C. 45380, 45384 D. 45383
26. A patient with esophageal cancer is brought to the OR for subtotal esophagectomy. A thoracotomy incision is made and the esophagus is identified. The tumor is carefully dissected free of the surrounding structures. No invasion of the aorta or IVC is identified. The cervical esophagus is controlled with pursestring sutures and then transected above the sternal notch. The esophagus is then dissected free of the stomach and the entire specimen is removed from the chest cavity and sent to pathology. The stomach is then pulled into the chest cavity and anastomosed to the remaining cervical esophageal stump. The anastomosis is tested for patency and no leaks are found. Hemostasis is assured. The chest is examined for any signs of additional disease but is grossly free of cancer. The chest is closed in layers and a chest tube is place through a separate stab incision. The patient tolerated the procedure well and was taken to the PACU in stable condition.
A. 43101 B. 43117
C. 43107 D. 43112
27. Patient with RUQ pain and nausea suspected of having a stone or other obstruction in the biliary tract is brought in for ERCP under radiologic guidance. Procedure: The patient was brought to the hospital outpatient endoscopy suite and placed supine on the table. The mouth and throat were anesthetized. Under radiologic guidance, the scope was inserted through the oropharynx, esophagus, stomach and into the small intestine. The ampulla of Vater was cannulated and filled with contrast. It was clear that there was an obstruction in the common bile duct. The endoscope was advanced retrograde to the point of the obstruction, which was found to be a stone that was removed with a stone basket. The rest of the biliary tract was visualized and no other obstructions or anomalies were found. The scope was removed without difficulty. The patient tolerated the procedure well.
A. 43260, 74328-26 B. 43264, 74328-26
C. 43265 D. 43269, 74329
28. Preoperative Diagnosis: Lower left inguinal pain Postoperative Diagnosis: Inguinal hernia Procedure: This 30-year-old patient presented with lower left inguinal pain and on examination was found to have a left inguinal hernia. The decision to perform a left inguinal hernia repair was made. The procedure was performed in the outpatient hospital surgery center. Risks and benefits of the surgery were discussed with the patient and the patient decided to proceed with the surgery. A skin incision was placed at the umbilicus where the left rectus fascia was incised anteriorly. The rectus muscle was retracted laterally. Balloon dissector was passed below the muscle and above the peritoneum. Insufflation and deinsufflation were done with the balloon removed. The structural balloon was placed in the preperitoneal space and insufflated to 10 mm Hg carbon dioxide. The other trocars were placed in the lower midline times two. The hernia sac was easily identified and was well-defined. It was dissected off the cord anteromedially. It was an indirect sac. It was taken back down and reduced into the peritoneal cavity. Mesh was then tailored and placed overlying the defect, covering the femoral, indirect, and direct spaces, tacked into place. After this was completed, there was good hemostasis. The cord, structures, and vas were left intact. The trocars were removed. The wounds were closed with 0 Vicryl for the fascia, 4-0 for the skin. Steri-Strips were applied. The patient was awakened and carried to the recovery room in good condition, having tolerated the procedure well. What are the correct procedure and diagnostic codes?
A. 49505-LT, 550.90 B. 49505-LT, 49568, 550.90
C. 49507-LT, 550.92 D. 49501-LT, 49568, 550.92
29. Preoperative Diagnosis: Chronic tonsillitis. Chronic adenoiditis. Postoperative Diagnosis: Same. Procedure: Tonsillectomy and adenoidectomy. Patient is a 24-year old male who was taken to the operating room and put under IV sedation by the anesthesia department. An initial curettage of adenoids was done and packing was placed. The left tonsil was then identified and dissected out extracapsular and removed with scissors. Hemostasis was maintained by packing the left tonsil. Next, the right tonsil was identified and incision was made. Dissection was done extracapsular and the right tonsil was then removed. Both the right and left tonsil were sent as specimens as well as adenoid tissue. What are the procedure and diagnosis codes.
A. 42826, 42831-59, 474.01 B. 42826, 42831-51-59, 42809, 474.02
C. 42821-50, 42809-59, 474.00, 474.01 D. 42821, 474.02
30. Diagnostic upper GI endoscopy of the esophagus, stomach, and duodenum was performed after esophageal balloon dilation (less than 30 mm diameter) was done at the same operative session. Code the procedure(s).
A. 43235 B. 43249
C. 43226, 43200 D. 43220, 43235
31. A patient with ongoing symptoms of weight loss, constipation, and blood in stool verified with occult testing underwent a rectal approach colonoscopy with snare removal of three colonic polyps. The pathology report, which was returned to the physician the same day of the procedure, revealed benign colon polyps. How should you report this?
a. 44393, 211.3
b. 45385 x 3, 783.21, 564.00, 792.1, 211.3
c. 45378, 45385 x 3, 211.3
d. 45385, 211.3
32. A patient was fully prepped for a diagnostic colonoscopy; however, an object then shifted into the descending colon just below the splenic flexure. The physician was unable to advance the scope beyond the splenic flexure. How would you report this diagnostic colonoscopy?
d. None of the above
33. Jennifer, a 3-year-old patient, swallowed a marble that became lodged in her esophagus. An esophagotomy via thoracic approach was completed for removal of the foreign body. The patient tolerated the procedure well and was returned to the recovery room in good condition. How should you code this procedure?
34. An otherwise healthy 22-year-old patient was scheduled for repair of an incarcerated bilateral recurrent inguinal hernia. The patient was taken into a same-day OR, where she was prepped, positioned, and draped in the usual fashion. The anesthesiologist administered general anesthesia and indicated the patient was ready for the surgery to begin. The surgeon created the incision and started the procedure. At this point, the patient went into shock due to the surgery and the procedure was halted. The patient was stabilized and returned to the recovery room. How should the surgeon report this procedure?
a. 49507-74, 998.0, 550.10, V64.1
b. 49521-53, 550.13, 998.0, V64.1
c. 00830-P1, 49521-51, 550.10, 998.0, V64.1
d. 49521-47, 550.13, 998.0, V64.1
35. How would the following case be coded?
Preoperative diagnosis: Lesion, buccal submucosa, right lower lip
Postoperative diagnosis: Same
Procedure performed: Excision of lesion, buccal submucosa, right lower lip
Procedure: The patient was placed in the supine position. A measured 7×8 mm hard lesion is felt under the submucosa of the right lower lip. After application of 1% Xylocaine with 1:1000 epinephrine, the lesion was completely excised. The lesion does not extend into the muscle layer. The 8-cm wound was closed with complex mattress sutures to the submucosal level and dressed in typical sterile fashion. The patient tolerated the procedure well and returned to the recovery area in satisfactory condition.
a. 40816, 210.4
b. 40814, 40831-51, 210.4
c. 40814, 528.9
d. 40814, 210.4
36. A patient underwent an EGD with transendoscopic ultrasound-guided transmural fine needle aspiration. How should you code this procedure?
a. 43242, 76942-26
c. 43235, 43238-59
d. 43235, 43242-51, 76942-26
37. A patient underwent a laparoscopic repair of a paraesophageal hernia with fundoplasty with implantation of mesh. During the procedure, a laparoscopic esophageal lengthening was completed. Which codes capture this procedure?
a. 43327, 43282-59
b. 43333, 43283-51
c. 43281, 43282-59, 43283-51
d. 43282, 43283
38. A patient underwent an enterectomy in the small intestine with four resections and anastomoses. How should you report this type of procedure?
b. 44120 x 4
d. 44120, 44121 x 3
39. Veronica, a 55-year-old patient, has left upper quadrant pain with a negative ultrasound. Veronica’s physician explains the need for a diagnostic and possible surgical procedure to determine the cause of this pain. She agrees to the procedure, completes overnight fast and prep, signs a consent for surgery, and is then taken to a procedure room. After nasal spray of 2% Xylocaine is administered, the tube is introduced through one nostril, down the back of the throat, and positioned into the stomach as the patient swallows. The diagnostic duodenal intubation and aspiration is completed. However, the physician decides to reposition the tube under fluoroscopic guidance and obtain multiple duodenal fluid specimens during the same operative session. The patient tolerates the procedure well and is moved to the recovery suite. How would you report the physician services?
b. 43756, 43757-52
d. 43755, 43756-59, 43757-59
40. A patient has an adjustable gastric restrictive device component removed and replaced via a laparoscopic procedure. How should you code this procedure?
b. 43772, 43773-51