View MT 004268
MT 004268
Operative Report
Preoperative Diagnosis: History of colon polyps
Postoperative Diagnosis: Sigmoid diverticulosis
Procedure: Diagnostic colonoscopy
Anesthesia: IV sedation
Technique: The patient was brought to the endoscopy suite and placed in the lateral decubitus position.
Digital rectal examination was then performed.
The colonoscope was then inserted under videoscopic visualization with minimal insufflation. The scope went beyond the splenic flexure. The sigmoid colon did reveal some diverticulosis. Further advancement of the colonoscope was unable to be accomplished and did not reach the cecum due to retained stool in the transverse colon. It was decided not to advance the scope further due to poor prep. The colonoscope was then removed and the patient was given instruction to go back after one week for repeat colonoscopy.
How is the surgeon's service reported?
A. 45330A 40-year-old woman with progressive sensorineural hearing loss in the right ear since the age of 13 has not benefited from her hearing aid. She has normal hearing in the left ear. A cochlear implant is placed in the right ear. Anesthesia is provided by a CRNA with medical direction by an anesthesiologist who is concurrently directing five CRNAs. PS is 3.
What anesthesia CPT(R) and ICD-10-CM codes are reported by the anesthesiologist?
A. 00300-QX-P3, H90.5A patient has a liver mass and presents for a percutaneous needle biopsy of the liver with CT guidance.
Four core specimens are taken to rule out benign hepatic adenoma.
What CPT(R) and ICD-10-CM codes are reported?
A. 47000, 10009, 77012, D13.4, R16.0The documentation states:
He was then sterilely prepped and draped along the flank and abdomen in the usual sterile fashion. I first made a skin incision off the tip of the twelfth rib, extending medially along the banger's lines of the skin.
This was approximately 3.5 cm in length. Once this incision was carried sharply, electrocautery was used to gain access through the external oblique, internal oblique, and transverse abdominis musculature and fascia.
What surgical approach was used for this procedure?
A. PercutaneousA 52-year-old woman has been experiencing discomfort and itching in the vulvar area for several months.
She has a history of abnormal Pap smears and a recent biopsy revealed vulvar intraepithelial neoplasia (VIN III). Decision has been made to perform a vulvectomy. Procedure: Under general anesthesia, the surgeon made an incision in the vulvar area and removed the vulva (more than 80%), including the affected skin and deep subcutaneous tissue.
What CPT(R) and ICD-10-CM codes are reported?
A. 56620, N90.1The patient has a ruptured aneurysm in the popliteal artery. The provider makes an incision below the knee and dissects down to and around the popliteal artery. After clamping the distal and proximal ends of the artery, the provider excises the defect, sutures the remaining ends of the artery together, and places a patch graft to fill the gap.
What is the correct CPT(R) code for the aneurysm repair?
A. 35081A patient presents to the ER with a large sacral pressure ulcer measuring 7 cm. The provider excised the ulcer with 3 mm margins, removed muscle and segmental bone, and performed a layered skin flap closure.
What CPT(R) and ICD-10-CM coding is reported?
A. 15933, L89.153The human shoulder is made of which three bones?
A. Olecranon, radius, ulnaA patient with a history of chronic venous embolism in the inferior vena cava has a radiographic study to visualize any abnormalities. In outpatient surgery the physician accesses the subclavian vein and the catheter is advanced to the inferior vena cava for injection and imaging. The supervision and interpretation of the images is performed by the physician.
What codes are reported for this procedure?
A. 36000, 75825-26A 27-year-old male has condyloma in the ventrum of the penis. In the operating suite, general anesthesia was administered. The lesions were individually lasered with a power to 10-15. Once this was completed, the eschar was removed from the base of the condyloma and the area was free of lesions.
What CPT code is reported for this procedure?
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