Hi! Effectively, I need the ICD-10-CM & CPT completed for the following 18 utems listed below:
Terms in this set (18)
PREOPERATIVE DIAGNOSIS
Chronic pyelonephritis.
POSTOPERATIVE DIAGNOSIS
Veiscoureteral reflux.
PRIMARY PROCEDURE
URETHROCYSTOGRAPHY.
BRIEF HISTORY
This 25-year-old male has had a history of long-standing urinary tract
infection with multiple recurrences. Urine cultures were positive for
Escherichia coli.
PROCEDURE
Consent forms were signed, and the patient was taken to the radiology
procedure suite. He was placed on the combination table and adjusted
to allow for the films to be centered at the level of the upper border
of the pubic symphysis. He was given mild sedation, prepped, and
draped. A catheter was inserted into the urinary meatus through the
urethra into the bladder. The bladder was then distended with the
contrast material until the patient felt the urge to micturate.
Voiding was then recorded on videotape. Vesicoureteral reflux was
noted. The patient tolerated the procedure well and was taken to a
recovery room. After he was fully awake, he was advised to have the
abnormality surgically corrected.
Hint: Code for radiological supervision and interpretation.
ICD-10-CM:
CPT:
PREOPERATIVE DIAGNOSIS
Hallux valgus.
POSTOPERATIVE DIAGNOSIS
Same.
PRIMARY PROCEDURE
REPAIR OF HALLUX VALGUS, KELLER.
BRIEF HISTORY
This 59-year-old construction worker has been seen over the past 6
weeks complaining of a painful prominence at the base of his left
great toe. He has worn pads over and around the bunion, but the pain
is getting worse. Because of his job, metal-toe footwear is required.
He has developed calluses over the area. The patient denies having
diabetes or a family history of abnormally shaped metatarsal bones.
PROCEDURE
The skin of the left foot was examined and was free from infection.
The patient signed the consent form and opted for general anesthesia.
Following sedation, the patient was placed in a supine position on the
table. A tourniquet was applied to allow little or no bleeding of the
surgical site. The skin of the foot was then thoroughly cleansed with
Betadine solution. Sterile towels covered all of the leg other than
the surgical site. A 5 cm lengthwise incision was made over the
bunion. The bone was exposed just to the inner side of the tendon. The
tendon was carefully pulled to one side so that the base of the
phalanx bone could be completely severed using an electric rotating
saw. Great care was taken while sawing to prevent damage to the tendon
on the underside of the toe. Once the base of the phalanx was removed,
the exostosis on the side of the metatarsal bone was shaved off with a
chisel and mallet to narrow the end of the bone. The ligamentous
tissue that overlies the bone on the inner edge of the foot was
sutured. The incision site was then sutured, and a firm gauze pad was
placed between the big toe and the 2nd toe to keep them parallel. The
tourniquet was released. Minimal blood loss was noted. The foot was
dressed with sterile gauze and taped securely. The patient was then
taken to the recovery room in good condition.
ICD-10-CM:
CPT:
PREOPERATIVE DIAGNOSIS
Infertility.
POSTOPERATIVE DIAGNOSIS
Infertility associated with peritubal adhesions.
PRIMARY PROCEDURE
HYSTEROSALPINGOGRAPHY.
BRIEF HISTORY
This 27-year-old woman and her husband of 6 years have been attempting
to conceive a child for the last 2 years to no avail. After a
consultation with a fertility specialist, they have agreed to a
hysterosalpingography before attempting any other measures.
PROCEDURE
The patient confirmed that she was 7 days prior menses. She read and
signed the consent form. Following irrigation of the vaginal canal,
complete emptying of the bladder, and perineal cleansing, she was
placed on the cystoscopic-radiographic table, draped, sedated, and
adjusted in the cystoscopic position, with her knees flexed over the
leg rests. Following inspection of the preliminary film and with a
vaginal speculum in position, a uterine cannula was inserted through
the cervical canal. The attached rubber plug was fitted firmly against
the external cervical os. Counter pressure was applied with a
tenaculum to prevent reflux of the contrast medium, and the speculum
was withdrawn. An opaque medium was introduced via the cannula into
the uterine cavity, where it flowed through the fallopian tubes and
spilled into the peritoneal cavity. Bilateral peritubal adhesions were
noted. The patient tolerated the procedure well and will be discharged
to her husband following complete recovery from the sedation.
Hint: Code for radiological supervision and interpretation as well as
for the injection portion.
ICD-10-CM:
CPT:
ICD-10-CM:
CPT:
CHIEF COMPLAINT
Sinus tachycardia.
BRIEF HISTORY
This anxious 45-year-old male presents with breathlessness,
lightheadedness, and a feeling that his heart is beating too fast.
PRIMARY PROCEDURE
TWELVE-LEAD ELECTROCARDIOGRAM EVALUATION, INCLUDES TRACING.
FINDINGS
The P waves were 130/min. The atrial depolarization is consistent with
origin at the junction of the high right atrium and superior vena
cava. Carotid sinus massage temporarily slowed the heart rate, but it
returned to a tachycardic level as soon as the carotid sinus pressure
was removed.
ASSESSMENT
Sinus tachycardia.
PLAN
A cardiology consultation was recommended to further evaluate his
cardiac status.
ICD-10-CM:
CPT:
BRIEF HISTORY
The patient is a 45-year-old female. While attempting to release the
blades from an electric knife after carving a turkey, her hand slipped
and cut the middle finger on her left hand. She immediately applied
pressure but was unable to stop the bleeding. The patient had her last
tetanus shot 3 years ago prior to minor surgery.
PROCEDURE
After signing the consent form, she was taken to the procedure room,
placed supine on the bed with her left forearm and hand extended o the
movable armrest. The wound was noted to be 2 cm in length. a 35 mL
syringe with a 19-gauge needle was used to irrigate the wound with
saline. The wound was then anesthetized with 1% lidocaine using the
aspiration technique first to prevent intravascular injection of the
drug. Adison’s forceps were used with gentle pressure to decrease
trauma when handling the skin edges. A simple repair of the supeficial
wound was made using 5-0 nylon and a locked-running suture pattern.
The suture was secured with Steri-Strips. The patient was instructed
to keep the wound dry for at least 24-48 hours and to report any
redness or swelling around the wound.
Note: External Cause code(s) apply.
ICD-10-CM:
CPT:
ICD-10-CM:
DIAGNOSIS
Osteoarthritis of diarthrodial joint, right knee.
PRIMARY PROCEDURE
CELL COUNT, BODY FLUID.
FINDINGS
Arthrocentesis was performed prior to obtain synovial fluid, specimen
#1, right knee noninflammatory articular osteoarthritis. Synovial
fluid is clear, viscous, and amber-colored with a white blood cell
count of 1900/mL and a predominance of mononuclear cells. The
viscosity was assessed by expressing fluid from the syringe 1 drop at
a time with a stringing effect and a long tail behind each drop. The
fluid was not hemorrhagic. These results are consistent with
noninflammatory articular osetoarthritis.
ICD-10-CM:
CPT:
DIAGNOSIS
Rotator cuff syndrome.
BRIEF HISTORY
This 22-year-old female is a member of the tennis team at the college
she is attending. She was seen 2 weeks ago and diagnosed with rotator
cuff syndrome affecting the suprasupinatus muscle of the right
shoulder. Since her visit, she has not played any sports and has been
using a sling to rest the shoulder muscle. She has been taking an
over-the-counter NSAID and applying moist heat with the minimal
symptomatic relief. Because conservative management has not resolved
the symptoms, she is seen today for a trigger point injection of the
supraspinatus muscle.
PROCEDURE
The patient was seated on the examination table, bent forward, with a
patient gown open in the back. The injection site was prepped. A
solution of 1 mL of triamcinolone, 40 mg/mL, and 2 mL of lidocaine
hydrochloride 2% was injected into the supraspinatus muscle. There was
minimal bleeding, and sterile gauze was secured with a bandage over
the site. The patient tolerated the procedure well and was assured the
pain should subside within the next 24-48 hours. She was also asked to
return if she had any redness or swelling at the injection site.
ICD-10-CM:
CPT:
BRIEF HISTORY
This pleasant 55-year-old male presented to his family doctor with
symptoms of a loss of sexual drive and a reduction in the size of his
testes. He appears to have an abnormal bronze skin color. Laboratory
findings included mildly abnormal liver tests (AST, alkaline
phosphatase), elevated plasma iron level with greater than 50%
saturation of the transferrin, and an elevated serum ferritin. The
livery biopsy showed extensive iron deposition in hepatocytes and in
bile ducts. The hepatic iron index was greater than 1.9. Studies
confirm hemochromatosis, and venesection was strongly recommended. The
venesection procedure was explained to the patient. He understands
that he will require weekly phlebotomy for about 1 or 2 years. After
that, it will be performed at intervals as required to maintain levels
within the normal range. He agreed and signed the consent form.
PROCEDURE
The patient was here today for his 1st treatment. He states he does
not have any questions at this time and was ready to begin treatments.
Using sterile technique, his first phlebotomy session with 500 mL of
blood (about 250 mg of iron) was performed. Following the procedure,
the site was negative for abnormal bleeding or hematoma. Sterile gauze
secured with tape was placed over the puncture site. Since there were
no complications or abnormalities, the patient was discharged and
driven home by his very supportive wife.
ICD-10-CM:
CPT:
PREOPERATIVE DIAGNOSIS
Prostate hypertrophy.
POSTOPERATIVE DIAGNOSIS
Benign prostatic hypertrophy with urinary retention.
PRIMARY PROCEDURE
PROSTATIC GLAND RESECTION, TRANSURETHRAL, ELECTROSURGERY.
BRIEF HISTORY
The 55-year-old male presented with increased urinary urgency and
frequency, especially at night, a weak urinary stream, and a feeling
that the bladder could not be emptied completely. He does not
experience any incontinence. There was slight burning on urination and
the color was abnormal. He has been experiencing frequent impotence. A
rectal examination revealed an enlargement of the prostate.
PROCEDURE
Consent forms were signed. The patient was taken to the operating room
and given general anesthesia. He was then prepped, draped, and placed
in the lithotomy position. The resectoscope was passed through the
opening at the tip of the penis and into the inside of the urethra.
The edge of the resectoscope was used to cut away the urethra wall to
reach the interior of the prostate gland. The loop of tungsten wire
was heated using electric current, passed through the scope, and used
to cut away part of the enlarged prostate gland. The pieces of tissue
were washed out through the resectoscope, and all bleeding vessels
were cauterized. The resectoscope was slid gently out, and a catheter
was gently pushed inside the urethra into the bladder for temporary
facilitation of urination and bladder irrigation. The patient appeared
to tolerate the procedure well and was taken to the recovery room.
ICD-10-CM:
CPT:
ICD-10-CM:
PREOPERATIVE DIAGNOSIS
Chronic hepatitis.
POSTOPERATIVE DIAGNOSIS
Chronic viral hepatitis C.
PRIMARY PROCEDURE
NEEDLE BIOPSY OF LIVER, PERCUTANEOUS.
BRIEF HISTORY
This 29-year-old male admits to multiple heterosexual sex partners and
recreational intravenous drug use with shared needles for the past 10
years. He thinks he has been diagnosed with hepatitis in the past, but
was unsure of when or what type. He presented with symptoms of poor
appetite, fatigue, low-grade fever, and some upper abdominal
discomfort. Noted were jaundice, enlarged spleen, spider-like blood
vessels in the skin, and fluid retention. A liver biopsy was
recommended to obtain hepatic tissue for diagnosis and treatment.
Preoperative testing was completed, and there were no contraindictions
for the procedure.
PROCEDURE
The patient signed the consent form and was taken to the operating
room. He was placed on the table in a supine position with a pillow
under his left side and his right arm over his head. The site was
prepped, draped, and infiltrated with a local anesthetic. A small
incision was made between the 6th and 7th intercostal space on the
right side. The patient was instructed to hold his breath while the
needle was inserted, and a sample of liver tissue was withdrawn. The
needle was removed and pressure was held over the site. Minimal
bleeding was noted, and sterile gauze was secured over the incision.
The sample was taken to the laboratory for an immediate cytohistologic
study over the incision. The sample was taken to the laboratory for an
immediate cystohistologic study to determine adequacy of the specimen.
The patient tolerated the procedure well and was discharged in 4 hours
after being observed for an unremarkable recovery.
ICD-10-CM:
CPT:
PREOPERATIVE DIAGNOSIS
Open Colles fracture, left wrist.
POSTOPERATIVE DIAGNOSIS
Same.
PRIMARY PROCEDURE
OPEN REDUCTION INTERNAL FIXATION LEFT DISTAL RADIUS FRACTURE WITH
DEBRIDEMENT OF OPEN FRACTURE SITE.
BRIEF HISTORY
This 59-year-old female presents with an open Colles fracture of the
left wrist due to an automobile accident. The patient was a passenger
in the vehicle that was struck by another vehicle. The air bag
deployed which caused the fracture. It was determined that closed
treatment was insufficient for fracture treatment.
PROCEDURE
After the attainment of adequate general anesthesia, the left upper
extremity was prepped and draped. A skin marker was used to identify
the appropriate location using the position on the forearm for the
radius pins. The fracture and open wound were addressed. The wound
required significant debridement of the skin and subcutaneous tissue
prior to proceeding with the repair of the fracture. After adequate
debridement, the fracture was reduced to the appropriate anatomic
position. Excellent stable fixation was obtained. Rotational alignment
appeared to be satisfactory. The wound was irrigated, sutured closed,
and dressed with Xeroflo, cast padding, and Ace wrap. The patient
tolerated the procedure well and arrive in the recovery room in good
condition.
Note: External Cause code(s) apply.
ICD-10-CM:
CPT:
ICD-10-CM:
CPT:
PREOPERATIVE DIAGNOSIS
Otalgia of left ear due to persistent middle ear effusion.
POSTOPERATIVE DIAGNOSIS
Chronic otitis media with effusion.
PRIMARY PROCEDURE
MYRINGOTOMY.
BRIEF HISTORY
The patient is a 3-year-old male with a history of chronic otitis
media. He has been treated in the past with amoxicillin over a 3-month
period. Bacterial cultures were positive for Haemophilus influenzae,
and he was treated with amoxicillin and sulfonamide for 10 days. The
mother and father claim their son does not appear to be improving and,
after a thorough explanation of the procedure, have agreed to sign the
consent forms.
PROCEDURE
The patient was given mild sedation in the preoperative area with the
mother and father present. The patient was then taken to the operating
room and given general anesthesia. The left ear was prepped and
draped. A small incision was made around the eardrum, and care was
taken not to injure the small bones of the middle ear. Most of the
fluid was removed by suction. A small sample was sent to the
laboratory for culture. At the same time, a small tube was left in
place to continue drainage. The tube will be removed in approximately
1-3 weeks. The patient tolerated the procedure well and will be sent
to the recovery room where his mother and father will be present when
he awakens.
ICD-10-CM:
CPT:
PREOPERATIVE DIAGNOSIS
Hemorrhoids.
POSTOPERATIVE DIAGNOSIS
Thrombosed internal hemorrhoids, 1st degree.
PRIMARY PROCEDURE
SIMPLE HEMORRHOIDECTOMY.
PROCEDURE
After discussing the procedure with the patient, the consent was
signed. He was then taken to the operating room and placed in a prone
position. He was anesthetized, then prepped and draped in a sterile
fashion. A large internal hemorrhoid, which was significantly
thrombosed, was palpated. The hemorrhoid was injected with 30 mL of
Marcaine that infiltrated the tissue around the hemorrhoid. After
allowing adequate time for the anesthesia to take effect, the
hemorrhoid was grasped with a clamp while another clamp was placed at
the base of the hemorrhoid. The hemorrhoid was excised above the
clamp, and a running stitch going in the opposite direction was looped
over the clamp. The clamp was then removed, and the stitch was
tightened. Another set of sutures was run down the length of the
excised hemorrhoid. Bleeding was controlled with cautery and sutures.
The area was dressed and packed with gauze. The patient tolerated the
procedure well and was discharged to the postanesthesia care unit.
ICD-10-CM:
CPT:
PREOPERATIVE DIAGNOSIS
Ascites and pleural effusion.
POSTOPERATIVE DIAGNOSIS
Same.
PRIMARY PROCEDURE
PARACENTESIS THORACENTESIS.
PROCEDURE
A paracentesis of the abdomen was performed using a 24-gauge needle
and 200 mL of straw-colored fluid was withdrawn. Pressure was applied
for 5 minutes to the puncture site. No complications were encountered.
A 22-gauge needle was then used to perform a right thoracentesis in
the left lateral decubitus, and 75 mL of serosanguineous fluid was
withdrawn. Pressure was applied for 5 minutes to the puncture site
with no significant blood loss. Good bilateral breath sounds were
auscultated following the procedure. Both fluid samples were sent for
cell count, acid-fast stain, and glucose and protein levels. A culture
and sensitivity was also ordered on both samples. Nonmalignant ascites
and exudative effusion confirmed by laboratory studies.
ICD-10-CM:
CPT:
ICD-10-CM:
CPT:
PREOPERATIVE DIAGNOSIS
Proteinuria.
POSTOPERATIVE DIAGNOSIS
Same.
PRIMARY PROCEDURE
CT-GUIDED RIGHT KIDNEY BIOPSY.
PROCEDURE
Patient was informed of the risks and benefits and potential
alternatives for the procedure. The consent was signed. The patient
was placed in a prone position on the CT table and initial images were
obtained to find the best path of biopsy. The lower pole of the right
kidney was selected as the clearest path. The overlying skin was
prepped and draped in a sterile fashion, following local anesthesia.
An 18-gauge coaxial system was positioned to the right of the renal
capsule of the lower pole for needle extraction. Three passes were
made. These samples were put in divided doses of preservative and sent
for analysis. No complications were noted at this time. The patient
was then transferred to ambulatory care for observation.
ICD-10-CM:
CPT:
PREOPERATIVE DIAGNOSIS
Obstructive sleep apnea with deviated septum.
POSTOPERATIVE DIAGNOSIS
Same with turbinate hypertrophy.
PRIMARY PROCEDURE
SEPTOPLASTY WITH BILATERAL TURBINECTOMY.
BRIEF HISTORY
This 35-year-old female was experiencing increasing problems with
sleep apnea. She also has a prior history of nasal trauma. Examination
shows significant septal deviation. We will correct her nasal airway
and determine if there are any additional problems.
PROCEDURE
After appropriate consent was obtained, the patient was taken to the
operating room and placed in the supine position on the table. General
anesthesia was introduced. Then the patient was turned and draped for
nasal surgery. The patient’s nose was packed with cotton pledgets and
soaked with 4% cocaine. Xylocaine with epinephrine was infilatrated
into the septum. It was then infiltrated into the interior turbinates
bilaterally. Using a right incision, the mucoperichondrium and
mucoperiosteal flaps were elevated. The deviated portion of the bony
septum was then removed. Hemostasis was achieved with suction and
cautery. Attention was then turned to the inferior turbinates. These
were examined bilaterally and found to be significantly hypertrophic,
and the decision was made to remove them. The anterior mucosa was
treated with a radiofrequency-submucosal excision of the inferior
turbinates bilaterally. Splints were placed on both sides of the nasal
septum and secured with nylon suture. The nose was then packed
bilaterally. The patient tolerated the procedure well. The patient was
extubated and taken to the postanesthesia care unit in good condition.
Hint: More than one modifier applies.
ICD-10-CM:
CPT:
ICD-10-CM:
CPT:
ICD-10-CM:
PREOPERATIVE DIAGNOSIS
Abdominal pain, LLQ.
POSTOPERATIVE DIAGNOSIS
Diverticulitis, large intestine. External hemorrhoids.
PRIMARY PROCEDURE
FLEXIBLE SIGMOIDOSCOPY.
PROCEDURE
The patient was taken to the endoscopy suite where preparation was
done for a flexible sigmoidoscopy. The sigmoidoscope was inserted into
the rectum and advanced into the sigmoid colon. The intestine showed
signs of inflamed diverticula. The scope was then carefully withdrawn
to visually inspect for polyps. The results were negative. Although an
incidental finding of external hemorrhoids was made, it must be noted
that this finding has no clinical significance with the patient’s
abdominal pain. Further studies will be discussed with the patient
following an appropriate recovery time.
ICD-10-CM:
CPT:
ICD-10-CM:
PREOPERATIVE DIAGNOSIS
Subarachnoic hemorrhage.
POSTOPERATIVE DIAGNOSIS
Subarachnoid hemorrhage. Nontraumatic.
PRIMARY PROCEDURE
LUMBAR SPINAL PUNCTURE.
ANESTHESIA
Local anesthesia.
BRIEF HISTORY
The patient was asymptomatic until this morning when he woke up with a
severe headache and a brief fainting spell. His wife called 911, and
he was brought to the emergency department.
PROCEDURE
Due to the patient’s drowsy state, he and his wife were advised of
complications, both agreed to the procedure, and both signed the
consent. The patient was placed on his right side, curled with knees
down in toward the chest and his neck maximally flexed. The area was
cleaned, prepped, and draped. The L4-L5 was identified. The area was
cleaned, prepped, and draped. Lidocaine was injected into the skin and
deeper subcutaneous tissue. The spinal needle with stylette was
passed, bevel upwards, and as the first drop of CSF was seen in the
needle hub, the manometer was immediately attached to the needle via
connecting tubing. The patient’s legs and hips were extended. Since
the opening pressure remained markedly elevated, the 3-way stopcock
was closed, and only the CSF in the manometer was collected. All
tubing was disconnected, and the stylette was reinserted. The patient
was placed in a prone position and will be observed following protocol
by post-op nursing. A neurosurgical consultation was requested.
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