|23. Procedure: Dual chamber pacemaker defibrillator implantation. Indications: A 67-year-old white gentleman who has significant underlying ischemic cardiomyopathy with EF of 25 percent, prior infarcts, remote history of syncope and at high risk for malignant ventricular arrhythmias. He has had a recent T wave alternans test which was clearly abnormal. He has had episodes of resting bradycardia also noted. He also meets Madit II criteria for ICD implantation. Description of Procedure: After informed consent had been obtained, the patient was brought to the outpatient hospital lab in the fasting state. The left anterior chest was prepped and draped in a sterile fashion. Intravenous sedation and local anesthetic were given. After local anesthetic, a 5 cm incision was made at the left deltopectoral groove. With blunt dissection and cautery, this was carried down through the prepectoralis fascia. The cephalic vein was identified and ligated distally. Through the venotomy, a subclavian venogram was performed to provide a roadmap. The atrial and ventricular leads were then advanced into the vessel to the level of the right atrium under fluoroscopic guidance. The ventricular lead was maneuvered to the right ventricular outflow tract and then through the RV apex where it was actively fixed. Good sensing and pacing thresholds were demonstrated. The lead was anchored to the pre-pectoralis fascia with interrupted 2-0 Tycron sutures. 10 volt pacing did not result in diaphragmatic capture. The atrial lead was maneuvered to the anterolateral right atrial wall where it was actively fixed. Good sensing and pacing thresholds were demonstrated. The lead was anchored to the pre-pectoralis fascia with interrupted 2-0 Tycron sutures. 10 volt pacing did not result in diaphragmatic capture. A subcutaneous pocket was created with good hemostasis achieved. The pocket was subsequently irrigated with solution of Bacitracin. The generator was connected to the lead and then placed in the pocket with no tension on the lead. The deep fascial layer was closed with interrupted 2-0 Vicryl suture. The subcutaneous closure was made with running 3-0 Vicryl suture. Subcuticular closure was made with running 4-0 Vicryl suture. Steri-strips were applied. Ventricular fibrillation was induced with a T wave shock. This was successfully sensed and terminated with a 15 joule shock to sinus rhythm. High voltage impedence was 39 ohms. Dry dressing was placed over the wound. The patient returned to the floor in stable condition without apparent complications. Which of the following codes accurately describes the basic procedure summarized in this report?
A. 33207, 71090 B. 33208, 71090-26
C. 33240, 33208, 71090 D. 33249, 71090-26
24. A patient is brought from an MVA to the ER with multiple fractured ribs, labored breathing, and complaints of chest pain and palpitations. In the ER the thoracic surgeon performs a tube thoracostomy with some relief of the patient’s most severe symptoms. Several tests are run and radiographs taken. What is the correct code?
A. 32100 B. 32421
C. 32422 D. 32551
25. A sinus endoscopy with tissue removal from the sphenoid sinus was performed. The correct CPT® code is:
A. 31287 B. 31288
C. 31235 D. 31050
26. This 25-year-old male presents with deviated nasal septum. After intubation, a left hemitransfixion incision was made with elevation of the mucoperichondrium. Cartilage from the bony septum was detached and the nasoseptum was realigned and removed in a piecemeal fashion from the obstructed perpendicular plate of the ethmoid. Thereafter, 4-0 chronic was used to approximate mucous membranes. Next, submucous resection of the middle and inferior turbinates was handled in the usual fashion by removing the anterior third of the bony turbinate and lateral mucosal followed by bipolar cauterization of the posterior enlarged tip of the inferior turbinate as well as outfracturing. A small amount of silver nitrate cautery was used to achieve hemostasis. A dressing consisted of a fold of Telfa with a ventilating tube for nasal airway on each side achieved good hemostasis, patient went to recovery in good condition. What is the correct code for this procedure?
A. 30520 B. 30420
C. 30620 D. 30450
27. At the patient’s bedside in the hospital, a PICC line is inserted. Using Xylocaine local anesthesia, aseptic technique and ultrasound guidance, a 21 gauge needle was used to aspirate the right cephalic vein of a 72-year-old patient. When blood was obtained, a 0.018 inch platinum tip guidewire was advanced to the central venous circulation. A 6 French dual lumen PICC was introduced through a 6 French peel-away sheath to the SVA RA junction and after removal of the sheath, the catheter was attached to the skin with a STAT-LOCK device and flushed with 500 units of Heparin in each lumen. A sterile dressing was applied and the patient was discharged in improved condition. Code the procedure(s).
A. 36565 B. 36556, 76942-26
C. 36561, 76942-26 D. 36569, 76942-26
28. The patient had been hoarse for a month. His surgeon scheduled a direct laryngoscopy with injection of his vocal cords. During the surgery it became necessary to use an operating microscope. How should these services be reported?
A. 31571 B. 31561
C. 31571, 69990 D. 31545
29. A 62-year old female with three-vessel disease and supraventricular tachycardia, which has been refractory to other management. She previously had pacemaker placement and stenting of the coronary artery stenosis, which has failed to solve the problem. She will undergo CABG with autologous saphenous vein and a modified MAZE procedure to treat the tachycardia. The risks and benefits have been discussed and the patient wishes to proceed. She is brought to the cardiac OR and placed supine on the OR table. She is prepped and draped and adequate endotracheal anesthesia is assured. A median sternotomy incision is made and cardiopulmonary bypass is initiated. The endoscope is used to harvest an adequate length of saphenous vein from her left leg. This is uneventful and bleeding is easily controlled. The vein graft is prepared and cut to the appropriate lengths for anatomosis. Three bypasses are performed, one to the LAD, one to the circumflex and another distally on the circumflex. A modified maze procedure was then performed and the patient was weaned from bypass. Once the heart was once again beating on its own again, we attempted to induce an arrhythmia and this could not be done. At this point, the sternum was closed with wires and the skin reapproximated with staples. The patient tolerated the procedure without difficulty and was taken to the PACU. Choose the procedure code(s) for this service.
A. 33519, 33508, 33254-51 B. 33512, 33508, 33999-51
C. 33512, 33508, 33254-51 D. 33512, 33508-51, 33254-51
30. The patient is a three-year-old boy who attempted to swallow a half-dollar. The boy’s mother immediately brought the child to the ED, which was only a short distance from the house, and the thoracic team was called emergently. The patient was in acute respiratory distress when we arrived in the ED. A temporary tracheostomy was accomplished, allowing oxygen exchange. X-ray revealed the coin to be deeply wedged in the trachea. Several attempts were made to remove the coin in the ED with the use of forceps, without success. The patient was given a mild sedative and taken to the OR where a scope was used to successfully remove the coin. The trach was discontinued. The patient was admitted for overnight observation and discharged the next day in satisfactory condition.
A. 31530, 31603-51, 934.0 B. 31635, 31603-59, 934.0, E912, E849.0
C. 31603, 31530-59, 934.0, E912, E849.0 D. 31635, 934.0
31. The patient had trouble breathing for three days. Her urgent care physician referred her to an ENT physician. The ENT performed a diagnostic maxillary sinusoscopy. How should the sinusoscopy be reported?
A. 31237 B. 31256
C. 31233 D. 31256-LT
32. Diagnosis: Right lung mass Indications: Patient with a mass in the right lung mass identified on routine X-ray presents for bronchoscopy and biopsy. Procedure: The patient was brought to the endoscopy suite and the mouth and throat were anesthetized. The bronchoscope was inserted and advanced through the larynx to the bronchus. The left side was examined first and no abnormalities were appreciated. The bronchoscope was then introduced into the right bronchus. Using fluoroscopic guidance, the tip of the bronchoscope was maneuvered into the area of the mass. A closed biopsy forceps was passed through the channel in the bronchoscope and then through the bronchial wall. A tissue sample was obtained. There were no other abnormalities appreciated in the right side and the bronchoscope was removed. The specimen was labeled and sent to pathology for testing. The patient tolerated the procedure well. Pathology indicates that the mass is cancer. What are the procedure and diagnosis codes?
A. 31628, 786.6 B. 31628, 162.9
C. 31628, 31622-51, 162.9 D. 31625, 786.6
20. Dr. Walters performed a subsequent thoracentesis of the pleural cavity for aspiration with needle fluoroscopic guidance. Which codes should Dr. Walters report for his professional services?
a. 32422, 77012-26
b. 32421, 77002-26
c. 32421, 77012-26
d. 32421-26, 77002-TC
33. Alicia is 20 months old and suffering from chronic inflammation of the trachea, which is causing difficulty in breathing. Dr. Marion inserted a planned incisional tracheal tube for Alicia. This procedure was completed under general endotracheal anesthesia. The patient tolerated the procedure well and was returned to the recovery room in stable condition. How should Dr. Marion report this procedure?
34. Dr. Manning, a thoracic surgeon, was asked to consult with Nancy, a 66-year-old female with atherosclerotic heart disease. The patient, who requested the visit, is well known to Dr. Manning, who performed thoracic surgery on her two years ago. She was seen in his office Monday morning for a consultative visit with mild complaints of fatigue and shortness of breath. Dr. Manning dictated a comprehensive history, comprehensive examination, and high-complexity decision-making. During this consultation, Dr. Manning made the decision to reoperate on Nancy. He sent a written report back to her cardiologist, Dr. Shaw, regarding the need for another surgery to take place the following day. Monday evening, Nancy was admitted to the hospital to start the prep for the planned bypass surgery Tuesday morning. Tuesday’s operative report
Preoperative diagnosis: Atherosclerotic heart disease
Postoperative diagnosis: Same
Procedure: The patient was brought to the operating room and placed in the supine position. With the patient under general intubation anesthesia, the anterior chest, abdomen, and legs were prepped and draped in the usual fashion. Review of a postoperative angiography showed severe, recurrent, two-vessel disease with normal ventricular function.
A segment of the femoropopliteal artery was harvested using endoscopic vein-harvesting technique and prepared for grafting. The patient was heparinized and placed on cardiopulmonary bypass. The patient was cooled as necessary for the remainder of the procedure and an aortic cross-clamp was placed. The harvested vein was anastomosed to the aorta and brought down to the circumflex and anastomosed into place. An artery was anastomosed to the left subclavian artery and brought down to the left anterior descending and anastomosed into place. The aortic cross-clamp was removed after 55 minutes with spontaneous cardioversion to a normal sinus rhythm. The patient was warmed and weaned from the bypass without difficulties after 104 minutes. The patient achieved homeostasis. The chest was drained and closed in layers in the usual fashion. The leg was closed in the usual fashion. Sterile dressings were applied and the patient returned to intensive care recovery in satisfactory condition. How should Dr. Manning report his services for Monday and Tuesday in this case?
a. Monday: 99255-57; Tuesday: 33511, 33517, 35600
b. Monday: 99215-57; Tuesday: 33533, 33517-51, 35572-80, 33530-51
c. Monday: 99255-57; Tuesday: 33533, 33510, 33572, 33530
d. Monday: 99215-57; Tuesday: 33533, 33517, 35572, 33530
35. A patient had a temporary transvenous pacemaker system inserted with electrodes placed in the right atrial and ventricular chambers. How should you report this service?
c. 33213, 33208-51
d. 33211, 33208-51
36. Marvin, a 51-year-old patient, required a conversion of a single-chamber pacemaker system to a dual-chamber system. The previously placed electrode was removed transvenously. The skin pocket was opened and the pulse generator removed. The skin pocket was then relocated and a dual system was placed with transvenous electrodes in both the right atrial and ventricular chambers. The system was tested and the new skin pocket was then closed. The patient tolerated the procedure well. How should you report these services?
a. 33208, 33234-51, 33233-51, 33222 -51, 33214-51
b. 33208, 33214-51, 33223-51
c. 33208, 33234-51, 33233-51, 33222-51
d. 33214, 33222-51
37. A patient required a battery change for a single-chamber pacing cardioverter-defibrillator system. The battery was taken out in a subcutaneous fashion and a new battery placed. The cardioverter-defibrillator was then reattached to the electrodes, which were intact and tested, and the skin pocket was then closed. How should these services be reported?
a. 33244, 33241-51, 33240
b. 33241, 33240-51
c. 33236, 33202-51, 33206-51
d. 33241, 33240-51, 33233-51
38. Dr. Lim completed an external ECG with 48-hour continuous rhythm testing during which analysis was performed for Mr. Brown. The report was reviewed and interpretation completed for evaluation of change to the pacemaker system. The report conclusion stated predominant rhythm of atrial fibrillation with non controlled left ventricular rate. Dr. Lim scheduled Mr. Brown for placement of a biventricular pacemaker, which will be connected to his current pacemaker system. How should Dr. Lim report her services for the cardiovascular monitoring?
b. 33244, 93224-59
d. 33208, 33225-51, 93225-59
39. A patient had an endarterectomy during the same surgical session for a repair to a coronary arteriovenous chamber fistula. The fistula repair did not require cardiopulmonary bypass to complete the procedure. How should these services be reported?
a. 33572, 33501
b. 33500, 33572-59
d. 33507, 33501-59
40. A patient suffering from chronic inflammation of the maxillary sinus underwent a surgical endoscopic transnasal balloon dilation procedure to restore normal sinus function. During this procedure, maxillary antrostomy with removal of tissue was completed. How should you report these procedures?
b. 31267, 31295-59
c. 31295, 31256-59, 31267-59
41. A patient underwent a recurrent destruction of the laryngeal nerve for therapeutic purposes. How would you report this procedure?
c. 31595, 64681-59
d. 64614, 31599-59