9.66. This 45-year-old patient has been followed for left ear… 9.66. This 45-ye

9.66. This 45-year-old patient has been followed for left ear… 9.66. This 45-year-old patient has been followed for left ear conductive hearing loss. It was decided to proceed with surgery to correct the condition. The postoperative diagnosis is left ear otosclerosis. During the procedure, a markedly thickened stapes footplate was observed; however, the eustachian tube was intact, and there was normal mobility of the malleus and incus. The left ear stapedectomy with drillout of the footplate proceeded uneventfully. During recovery, the patient experienced atrial fibrillation. This was felt to be due to the surgery because the EKG was normal during the preoperative evaluation. The patient was admitted to the hospital from the outpatient surgical area, and a consultation was requested from the cardiologist.With the exception of E/M codes, what are the correct diagnosis and procedure codes for physician reporting?a. H80.92, I97.89, I48.91, 69661-LTb. H80.92, 69661-LTc. H80.92, I48.91, 69661-LTd. H80.92, 69660-LT 9.70. The following documentation is from the health record of a 10-year-old boy.Preoperative Diagnosis: Status post palatoplasty, history of bilateral incomplete cleft palate with recurrent tonsillitisPostoperative Diagnosis: SameOperation: Second-stage palatoplasty with attachment of pharyngeal flap and incidental tonsillectomyIndications: A 10-year-old patient scheduled for revision of palatoplasty with incidental tonsillectomy requested by pediatrician due to repeated infectionsDescription of Procedure: The patient was prepped and draped in normal sterile fashion. A midline incision was made through the soft palate, exposing the posterior pharyngeal wall. A flap was then taken by incising the mucosa, submucosa, and underlying muscle, and securely sutured to the soft palate.Bilateral tonsillectomy was then performed by grasping with a tonsil clamp and capsule dissection. Bleeders were controlled with electrocautery and gauze packing. Sponge and instrument counts were taken and correct, and the patient was transferred to the recovery room in good condition. Follow-up in the office in three days.Which of the following ICD-10-CM and CPT code sets will be reported?a. Q35.3, 42225, 42825b. Q35.3, J35.01, 42225c. Q35.3, J35.01, 42225, 42825-51d. Z40.8, Q35.3, J35.01, 42200, 42826-51 9.46. This is the documentation from the record of a patient presenting with a mass in the right breast.Chief Complaint: Mass in the right breastPast Medical History: No serious illnesses. She has had a tubal ligation. She has had an appendectomy. She has had an exploratory laparotomy.Systemic Review: She does have headaches. She has had abdominal pain and has to get up at night to urinate. Her menses are usually every 28 days and past seven days. She has four children who are living and well. She has had three miscarriages.Family History: There is cancer, epilepsy, diabetes, and heart attacks in the family.Social History: She does not smoke and takes a rare social drink. She is a housewife, married and lives with her family.History of Present Illness: This 31-year-old white female is admitted with the chief complaint of a nodule in her right breast and a lump in her left axilla. She has had this lump for several months but it is getting larger, was tender for a while, but is no longer tender. She had a mammogram which suggests a benign process in the right breast but there are concerns about the lesion in the axilla.Physical Examination:Blood Pressure 108/78; Pulse 68; Respirations 16HEENT: Head and neck are normal. Eyes?pupils are round, regular and equal. Reactive to light and accommodation. EOM are normal. Sclera?white. Conjunctiva?pink. Oral cavity is within normal limits. Tympanic membranes are clear bilaterally.Neck: No venous distention; no palpable thyroid.Chest: Clear to A&P. Breath sounds are normal and no rales are heard.Cardiac: The apex beat is in the fifth interspace, midclavicular line. Normal sinus rhythm is present and no murmurs are heard.Abdomen: Soft. No masses, tenderness, or palpable organs. Peristalsis is present and normal.Breasts: There is a nodule about 1.5 to 2 cm at the lower border of the areola in the right breast. There is a fairly large lymph node in the left axilla.Extremities: No edema. No deformity.Pelvic: Not done as she had one last week with a PAP and these were all ok.Diagnosis: Lesion of the right breast; nodule in the left axilla.Laboratory: The urine was negative; HGB was 13.8; HCT 39.8; WBC was 4,900 and 46 polys.Operative RecordPreoperative Diagnosis: Nodule of the right breast; lymphadenitis left axilla.Postoperative Diagnosis: SameOperation Performed: Excision of nodule of the right breast and excision of three or four lymph nodes in the left axilla.Findings: The patient was found to have at least one large lymph node and two or three small lymph nodes deep in the left axilla and these were all excised. She had a nodule, sort of like an oval nodule, at the areolar skin junction of the right breast. This was about 2 cm × 1 cm.Operative NoteUnder satisfactory general anesthesia, the patient is in the supine position and both breasts and left axilla were prepared with Hibiclens and draped with sterile drapes. A semi-lunar incision was made at the skin, areolar junction of the right breast. Subcutaneous tissue was divided, bleeding points were picked up with hemostats and ligated with 4-0 sutures. The nodule was excised by sharp dissection and bleeding points were again ligated with 4-0 Vicryl. The breast tissue was closed with interrupted 2-0 Vicryl sutures in a figure-of-eight manner. The skin and subcutaneous tissue were closed with continuous 4-0 sutures. The wound was cleansed with Hibiclens and a sterile Opsite dressing and sterile pressure dressings were applied. Incision was made at just about the apex of the axilla on the left side and the subcutaneous tissues were divided; bleeding points were picked up with hemostats and ligated with 4-0 sutures. Superficial lymph nodes were picked up with Allis forceps and dissected free and after we got these all dissected and free and the bleeding controlled we found another larger lymph node, much deeper, and this we excised by sharp dissection and bleeding points carefully ligated. Following this the deep tissues were closed with interrupted 2-0 Vicryl sutures. Subcutaneous tissues were closed with continuous 4-0 sutures. Sterile dressings were applied. The patient withstood the procedures well and returned to PACU in good condition.Pathological Findings: Sections labeled as specimen “A” consist of portions of fibrofatty breast tissue containing duct ectasia, small cyst formation, and aprocrine metaplasia. Sections labeled as “B” reveal the large ovoid structure and the small fragment of homogenous gray-tan tissue to consist of lymph nodes. The large lymph node shows some evidence of follicular hyperplasia with abundant mitotic and phagocytic activity. Lymphocytes are also noted in the surrounding fibrous capsule. The small lymph nodes contain general lymphoid-like tissue.Pathological Diagnoses: 1. RT Breast Nodule: Mild fibrocystic disease2. LT Axillary Nodule: Lymph nodes containing hyperplasia. The large lymph node has signs of toxoplasmosis but this cannot be determined without further testing.What codes are reported for this physician service?a. N60.11, I88.9, 19120-RT, 38525-LT, 38500-59-LTb. N60.21, B38.9, 19120-RT, 38525-LT, 38500-59-LTc. N60.21, I88.9, 19100-RT, 38525-LTd. N60.11, I88.9, 19101-RT, 38525-LT, 38500-59-LT 9.54. The following documentation is from the health record of a patient admitted for a right total hip.Preoperative Diagnosis: Right hip osteonecrosis, Ficat stage IVPostoperative Diagnosis: Right hip osteonecrosis, Ficat stage IVProcedure Performed: Right total hip arthroplastyBlood Loss: 350 ccComplications: NoneImplants Used: 1. DePuy Articul/EZE femoral head 28 mm 1.5, lot #11699392. DePuy large AML femoral component, 150 mm long, 45-mm offset, lot #YDZCV10003. DePuy hole eliminator, lot #YH9DH10004. DePuy pinnacle acetabular liner 28 mm, lot #X69AR10005. DePuy cancellous bone screw 25 mm long, lot #X2BEN10006. DePuy acetabular cup 36 mm, lot #X60CK1000Indications for Operation: The patient is a 54-year-old male who is presented with long-standing right hip pain secondary to osteonecrosis. Nonsurgical treatment was unsuccessful. After risks, benefits, and alternatives of the surgery were explained to the patient, informed consent was obtained for this procedure.Details of Procedure: Patient was taken back to the operating room and placed on the operating table in a supine position. After induction of general anesthesia, the patient was placed in the left lateral decubitus position and the left lower extremity was prepped and draped in usual sterile manner. Lateral incision was made over the greater trochanter. This incision was approximately 15 cm long. It was carried down through subcutaneous tissue to the iliotibial band, which was incised longitudinally. The gluteus medius was identified and split in line with its fibers down to the level of the greater trochanter. The gluteus medius was then split. This ran along with greater trochanter and was lifted anteriorly off the greater trochanter in line with vastus lateralis as well. These structures were dissected off of the greater trochanter. The gluteus minimus was exposed and its tendon was transected longitudinally as well. Capsule was delineated just lying underneath the gluteus adducted and placed in a sterile bag as it was dislocated. The neck was cut with an oscillating saw. Retractors were placed inferiorly, posteriorly along the acetabulum, as well as superiorly. The acetabulum was then debrided off the remaining capsular and labral tissue as well as ligamentaries. The acetabulum was then reamed starting with a 49-mm reamer and reamed sequentially in 1-mm increments to 55; 56 was trailed and it was deemed to be appropriate. Version was checked at each sequential reaming. The 56-mm acetabular component was then inserted and hammered into place. Trial liner was placed. The limb was then placed in the bag and the medial aspect of the greater trochanter was cut with the use of a box cutter. The femoral canal was then reamed sequentially and increments to a 13.5. The lateral side cutter was then used to cut out the cancellous bone from the calcar. A small broach was replaced with 13.5 large broach. The head component was placed and was trailed. The hip was deemed to be too tight. Intraoperative x-ray was obtained and demonstrated the femoral neck cut to be insufficient. The hip was dislocated. The trial head and neck were removed and the femur was then reamed further distally. The calcar planar was used to take down the femoral neck cut. The broach was placed prior to calcar planning often reaming the femoral canal sufficiently, the 13.5 large broach did in fact sink further end of the canal and after the hip was reduced it was deemed to be both stable and not in too much tension. The hip was then dislocated. The broach was removed as well as the trial liner. The true liner was then placed as well as the femoral stem component. Femoral head was placed and the hip was located. Tension was deemed to be adequate. The hip was tested and position of instability was deemed to be stable. The wound was copiously irrigated to sterile saline. The minimus was repaired with interrupted #0 VICRYL sutures. The medius was reapproximated with running #0 VICRYL sutures as well as drill holes placed into greater troch and #5 Tycron sutures. The IT band was repaired with interrupted #0 VICRYL sutures and subcutaneous tissue was repaired with interrupted #2-0 VICRYL sutures. The skin was closed with staples. Sterile dressings were applied. The patient was extubated and recovered in a holding area uneventfully.Code the orthopedic surgeon’s code sets.ICD-10-CM and CPT Code(s): ___________________________________________  9.74. The following documentation is from the health record of a boy with a fracture.Office Visits3/31 Office Visit (Primary Care Physician)S: Peter was playing basketball today, fell, and hurt his wrist.O: Tenderness and swelling of the wrist, especially the volar aspect. There is a slight abrasion over the swelling. The x-ray shows a fracture of the ulnar styloid and possibly the distal radius. There is some question of dorsal displacement of the epiphysis. Short arm cast is applied for comfort measures.A: Fracture of the ulnar styloidP: I am going to have the orthopedist look at the x-ray and obtain a consult to determine if reduction is necessary. Return to clinic in two days for ortho appt, sooner if problems.4/1 Office Visit (Primary Care Physician)S: Peter has pain inside his cast.O: We thought this was pressure, so I split the cast and it really didn’t relieve the pain much at all. I asked him what was hurting about it, and he said it was hurting further up his arm. Then he told me that at the time he had the injury he noticed a great big bulge there. He thought it was the bone poking through, pushed on it, and it sort of went down by itself. His x-ray clearly shows there is no bony injury at that area, but that he has the fracture down by the epiphyseal plate. This is probably a torn muscle.A: Torn muscle left arm with fractureP: Keep the appointment with ortho tomorrow. In the meantime, symptomatic care, and we left the cast split because it is probably going to have to be removed for adequate exam tomorrow anyway.4/2 Office Visit (Primary Care Physician)S: Peter injured the left wrist playing basketball. He is right-hand dominant. He is currently in a short arm cast, which had been split previously because it was a bit too snug. With the cast he has wrist in extension at least 15 degrees despite the fact that he has the epiphyseal plate fracture with slight posterior displacement of the distal fragment of about 4 mm. He has seen the orthopod in consultation, who felt that this did not require further reduction.O: He has intact CMS today. Cast is removed, and he is placed in a short arm cast with anterior flexion of about 10 degrees with very slight ulnar deviation. The position of the distal epiphysis of the radius appears to be about the same as it was on the original x-rays taken one week ago. This position alignment should be quite satisfactory.A: Distal radial fracture, Colles’ type, with ulnar styloid fractureP: We will continue with the short arm cast for a duration of six weeks. He is to return to see me in two weeks for repeat x-ray through the cast and follow up sooner if any problems.Which of the following is the correct ICD-10-CM and CPT code set to report these visits with the primary care physician? Do not assign external cause codes.a. 3/31: S52.612A, 25600, A45804/1: S52.612D, 990244/2: S52.532A, S52.612D, 99024, A4580b. 3/31: S52.612A, 29075, A45804/1: S46.912D, S52.612D, 992134/2: S52.532A, S52.612D, 25600, A4580c. 3/31: S52.612A, 25605, A45804/1: S46.912D, S52.612D, 992134/2: S52.532A, S52.612D, 29075, A4580d. 3/31: S52.612A, 29075, A45804/1: S46.912D, S52.612D, 992134/2: S52.532A, S52.612D, 25605, A4580 9.76. The following documentation is from the health record of a female patient.Discharge SummaryAdmission Date: 03/12/XXDischarge Date: 03/23/XXDischarge Diagnoses: 1. Term intrauterine pregnancy, delivered, single liveborn2. Maternal obesity3. Iron deficiency anemia4. Retained placenta5. EndometritisProcedures Performed: Right paramedian episiotomy, low outlet forceps vaginal delivery, repair of right paramedian episiotomy with repair of partial fourth-degree extension, manual removal of placenta 3/13/XX. Dilatation and suction curettage 3/22/XX.Hospital Course: This patient presented at 39 weeks’ gestation with rupture of membranes of clear fluid. She was not in active labor, her cervix was unfavorable for induction. She was initially managed expectantly, and oxytocin was used to facilitate labor. She progressed throughout the active phase of labor without complications. The fetal evaluations were reassuring throughout the labor process.The fetal head presented on the perineum in the OA position; because of maternal exhaustion and inability to allow further descent because there was a single nuchal cord released, low outlet forceps were placed after right paramedian episiotomy was performed, and the fetal head was delivered without difficulty. Upon delivery, there was a partial fourth-degree extension just through the anal mucosa. There was retained placenta and manual extraction was required. The episiotomy was repaired by using 000 Vicryl suture, closing the rectal mucosa.The postpartum course was complicated by the patient developing endometritis. The patient was placed on IV antibiotics and showed some sign of improvement with a dropping white blood cell count; however, her temperature continued to spike. An initial ultrasound revealed some intrauterine products that appeared to be retained placenta. The following day, however, she passed these retained products without difficulty, and her bleeding subsided. Her temperature, however, continued to develop intermittent fever, the antibiotics were switched to the IV, and she again showed a good clinical response with decreased uterine tenderness. Because of the fever continuing, however, a follow-up ultrasound was performed, and no placental products were appreciated. However, there were some clots and unidentifiable tissues still remaining in the intrauterine cavity. Thus, a dilatation and curettage was performed on 3/22/XX, and some amniotic membranes were removed, which appeared to be infected. There were no placental products noted in the curettage.After removal of the amniotic membrane, her temperature defervesced, and she remained afebrile throughout the remainder of the hospitalization. On discharge, she was tolerating a regular diet, ambulatory without complaints, very scant vaginal spotting, and on oral antibiotics.It should be noted that because of the excessive blood loss she was given two units of transfused blood to maintain hemoglobin levels from 8 to 9. She was asymptomatic with this hemoglobin, and thus was placed on iron and Colace therapy throughout the remainder of her hospitalization.Discharge Medications: Include iron sulfate, Colace, and AugmentinWhich of the following is the correct ICD-10-CM and CPT code set, presuming this physician provided the antepartum and postpartum care?a. O72.2, O99.214, O75.81, E66.9, O86.12, O70.3, O69.81X0, O90.81, Z37.0, Z3A.39, 59400, 59160b. O73.0, O99.214, E66.9, O86.12, O70.3, O69.81X0, O90.81, Z37.0, Z3A.39, 59400, 59300-51, 58120c. O72.2, O99.214, E66.9, O86.12, Z37.0, Z3A.39, 59400, 59300, 59160d. O73.0, O99.214, E66.9, O86.12, O70.3, O90.81, Z37.0, Z3A.39, 59400, 58120  Health Science Science Nursing HIT MISC Share QuestionEmailCopy link Comments (0)

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