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PRE OP DIAGNOSIS: Left Breast Abnormal MMG or Palpable Mass; Other Disorders of Breast PROCEDURE: Automated Stereotactic Biopsy Left Breast FINDINGS: Lesion is located in the lateral region, just at o... r below the level of the nipple on the 90 degree lateral view. There is a subglandular implant in place. I discussed the procedure with the patient today including risks, benefits and alternatives. Specifically discussed was the fact that the implant would be displaced out of the way during this biopsy procedure. Possibility of injury to the implant was discussed with the patient. Patient has signed the consent form and wishes to proceed with the biopsy. The patient was placed prone on the stereotactic table; the left breast was then imaged from the inferior approach. The lesion of interest is in the anterior portion of the breast away from the implant which was displaced back toward the chest wall. After imaging was obtained and stereotactic guidance used to target coordinates for the biopsy, the left breast was prepped with Betadine. 1% lidocaine was injected subcutaneously for local anesthetic. Additional lidocaine with epinephrine was then injected through the indwelling needle. The SenoRx needle was then placed into the area of interest. Under stereotactic guidance we obtained 9 core biopsy samples using vacuum and cutting technique. The specimen radiograph confirmed representative sample of calcification was removed. The tissue marking clip was deployed into the biopsy cavity successfully. This was confirmed by final stereotactic digital image and confirmed by post core biopsy mammogram left breast. The clip is visualized projecting over the lateral anterior left breast in satisfactory position. No obvious calcium is visible on the final post core biopsy image in the area of interest. The patient tolerated the procedure well. There were no apparent complications. The biopsy site was dressed with Steri-Strips, bandage and ice pack in the usual manner. The patient did receive written and verbal post-biopsy instructions. The patient left our department in good condition. IMPRESSION: 1. SUCCESSFUL STEREOTACTIC CORE BIOPSY OF LEFT BREAST CALCIFICATIONS. 2. SUCCESSFUL DEPLOYMENT OF THE TISSUE MARKING CLIP INTO THE BIOPSY CAVITY 3. PATIENT LEFT OUR DEPARTMENT IN GOOD CONDITION TODAY WITH POST-BIOPSY INSTRUCTIONS. 4. PATHOLOGY REPORT IS PENDING; AN ADDENDUM WILL BE ISSUED AFTER WE RECEIVE THE PATHOLOGY REPORT. What is (are) the CPT® code(s)? A. 19081 B. 19283 C. 19081, 19283 D. 19100, 19283 - ✔✔To start narrowing your choices was the biopsy performed percutaneously or by an open incision? The operative note documents that a "SenoRx needle" was used to obtain the biopsy, which is percutaneous. Because there was a biopsy and a placement of a localization device (clip), you eliminate multiple choice B. Code 19283 is reported only for the placement of the localization device. Stereotactic image was used to perform the needle biopsy and placement of the clip. This eliminates multiple choice D, because code 19100 is for needle biopsy without imaging guidance. Code 19081 is the only code reported for the operative note because its code description reports both the biopsy and the placement of the clip under stereotactic imaging, eliminating multiple choice C. Answer A Question 2 53 year-old male is in the dermatologist's office for removal of 2 lesions located on his lower lip and nose. Lesions were identified and marked. The lower lip lesion of 4mm in size was shaved to the level of the superficial dermis. Utilizing a 3-mm punch, a biopsy was taken of the left supratip nasal area. What are the CPT® codes for these procedures? A. 11100, 11101 B. 11310, 11100-59 C. 17000, 17003 D. 11440, 11100-59 - ✔✔The first procedure performed was the lesion on the lower lip removed by the shaving technique. Reported with code 11310. The punch biopsy is performed on the lesion located on the nose. Reported with code 11100. Modifier 59 indicates that the biopsy was totally separate performed on another lesion, otherwise it is bundled with 11310. Answer B 76 year-old has dermatochalasis on bilateral upper eyelids. A blepharoplasty will be performed on the eyelids. A lower incision line was marked at approximately 5 mm above the lid margin along the crease. Then using a pinch test with forceps the amount of skin to be resected was determined and marked. An elliptical incision was performed on the left eyelid and the skin was excised. In a similar fashion the same procedure was performed on the right eye. The wounds were closed with sutures. The correct CPT® code(s) is/are? A. 15822, 15823-51 B. 15823-50 C. 15822-50 D. 15820-LT, 15820-RT - ✔✔Patient is having a blepharoplasty done on the upper eyelids, eliminating multiple choice answer D. There is no indication in the scenario that excessive skin weighing down the lid had to be excised, eliminating multiple choice answers A and B. Modifier 50 is appended to indicate the procedure was performed on both eyelids. Answer C 42 year-old male has a frozen left shoulder. An arthroscope was inserted in the posterior portal in the glenohumeral joint. The articular cartilage was normal except for some minimal grade III-IV changes, about 5% of the humerus just adjacent to the rotator cuff insertion of the supraspinatus. The biceps was inflamed, not torn at all. The superior labrum was not torn at all, the labrum was completely intact. The rotator cuff was completely intact. An anterior portal was established high in the rotator interval. The rotator interval was very thick and contracted. Adhesions were destroyed with electrocautery and the Bovie. The superior glenohumeral ligament, the middle glenohumeral ligament and the tendinous portion of the subscapularis were released. The arthroscope was placed anteriorly, adhesions were destroyed and the shaver was used to debride some of the posterior capsule and the posterior capsule was released in its posterosuperior and then posteroinferior aspect. What CPT® code(s) is (are) reported? A. 23450-LT B. 23466-LT C. 29805-LT, 29806-51-LT D. 29825-LT - ✔✔To narrow down your choices decide if the procedure is an open procedure or performed with an arthroscope? It was performed with an arthroscope, eliminating multiple choice answers A and B. The diagnostic arthroscopy (29805) is a separate procedure, and according to CPT® Surgery Guidelines: The codes designated as "separate procedure" should not be reported in addition to the code for the total procedure or service of which it is considered an integral component. Meaning code 29806 already includes the diagnostic arthroscopy code, so you only report code 29806. Code 29806 represents suturing of the capsule (capsulorrhaphy); however, this was not the procedure performed. The procedure performed was a lysis of adhesions for a frozen shoulder (29825) noted in multiple choice answer D. After adequate anesthesia was obtained the patient was turned prone in a kneeling position on the spinal table. A lower midline lumbar incision was made and the soft tissues divided down to the spinous processes. The soft tissues were stripped away from the lamina down to the facets and discectomies and laminectomies were then carried out at L3-4, L4-5 and L5-S1. Interbody fusions were set up for the lower three levels using the Danek allografts and augmented with structural autogenous bone from the iliac crest. The posterior instrumentation of a 5.5 mm diameter titanium rod was then cut to the appropriate length and bent to confirm to the normal lordotic curve. It was then slid immediately onto the bone screws and at each level compression was carried out as each of the two bolts were tightened so that the interbody fusions would be snug and as tight as possible. Select the appropriate CPT® codes for this visit? A. 22612, 22614 x 2, 22842, 20938, 20930 B. 22533, 22534 x 2, 22842 C. 22630, 22632 x 2, 22842, 20938, 20930 D. 22554, 22632 x 2, 22842 - ✔✔To start narrowing the correct arthrodesis code to report, you first need to determine the surgical approach. The scenario tells us that the patient was placed in prone position (lying face down) on the table and a lumbar incision was made indicating a posterior approach, eliminating multiple choices B and D. The next bit of information to look for is the technique that was used for the arthrodesis, which was the interbody fusion technique guiding you to code 22630. Answer C PREOPERATIVE DIAGNOSIS: Displaced impacted Colles fracture, left distal radius and ulna. POSTOPERATIVE DIAGNOSIS: Displaced impacted Colles fracture, left distal radius and ulna. OPERATIVE PROCEDURE: Reduction with application of an external fixation system, left wrist fracture FINDINGS: The patient is a 46 year-old right-hand-dominant female who fell off stairs 4 to 5 days ago sustaining an impacted distal radius fracture with possible intraarticular component and an associated ulnar styloid fracture. Today in surgery, fracture was reduced anatomically and an external fixation system was applied. PROCEDURE: Under satisfactory general anesthesia, the fracture was manipulated and C-arm images were checked. The left upper extremity was prepped and draped in the usual sterile orthopedic fashion. Two small incisions were made over the second metacarpal and after removing soft tissues including tendinous structures out of the way, drawing was carried out and blunt-tipped pins were placed for the EBI external fixator. The frame was next placed and the site for the proximal pins was chosen. Small incision was made. Subcutaneous tissues were carried out of the way. The pin guide was placed and 2 holes were drilled and blunt-tipped pins placed. Fixator was assembled. C-arm images were checked. Fracture reduction appeared to be anatomic. Suturing was carried out where needed with 4-0 Vicryl interrupted subcutaneous and 4-0 nylon interrupted sutures. Sterile dressings were applied. Vascular supply was noted to be satisfactory. Final frame tightening was carried out. What CPT® code(s) is/are reported? A. 25600-LT, 20692-51 B. 25605- LT, 20690-51 C. 25606-LT D. 25607-LT - ✔✔In the body of the note after the Procedure heading it states, "the fracture was manipulated", eliminating multiple choice answer A. Was the fracture treatment opened or closed? There is no indication in the operative note that the patient was surgically opened at the fracture site to treat it, eliminating multiple choice answer D. The key words to choose the correct code between B and C are external fixation system and external fixator; where pins are connected to bone and to an external fixator to help the fracture heal. The fixator was a uniplane system as only one external fixator was applied in one plane (20690). Answer B 79 year-old male with symptomatic bradycardia and syncope is taken to the Operating Suite where an insertion of a DDD pacemaker will be performed. After the anesthesiologist provided moderate sedation, the cardiologist performed a left subclavian venipuncture was carried out. A guide wire was passed through the needle, and the needle was withdrawn. A second subclavian venipuncture was performed, a second guide wire was passed and the second needle was withdrawn. An oblique incision in the deltopectoral area incorporating the wire exit sites. A subcutaneous pocket was created with the cautery on the pectoralis fascia. An introducer dilator was passed over the first wire and the wire and dilator were withdrawn. A ventricular lead was passed through the introducer, and the introducer was broken away in the routine fashion. A second introducer dilator was passed over the second guide wire and the wire and dilator were withdrawn. An atrial lead was passed through the introducer and the introducer was broken away in the routine fashion. Each of the leads were sutured down to the chest wall with two 2-0 silk sutures each, connected the leads to the generator, curled the leads, and the generator was placed in the pocket. We assured hemostasis. We assured good position with the fluoroscopy. What CPT® code(s) is (are) reported by the cardiologist? A. 33208 B. 33212 C. 33226 D. 33235, 71090-26 - ✔✔The patient is having an insertion of a pace maker, eliminating multiple choice answers C and D. A subcutaneous pocket was created for the pacemaker generator and the leads connected to the generator were placed in the atrium and ventricle leading you to multiple choice answer A. Flouroscopy is included and should not be reported separately. Answer A Patient has lung cancer in his upper right and middle lobes. Patient is in the operating suite to have a video-assisted thorascopy surgery (VATS). A 10-mm-zero-degree thoracoscope is inserted in the right pleural cavity through a port site placed in the ninth and seventh intercostal spaces. Lung was deflated. The tumor is in the right pleural. Both lobes were removed thorascopically. Port site closed. A chest tube was placed to suction and patient was sent to recovery in stable condition. Which CPT® code is reported for this procedure? A. 32482 B. 32484 C. 32670 D. 32671 - ✔✔The removal of the lobes are performed thoracoscopically not by an open approach, eliminating multiple choices A and B. The entire right lung is not removed, only two lobes (upper and middle) in the right lung are removed, eliminating mulitple choice D. Answer C The patient is a 58 year-old white male, one month status post pneumonectomy. He had a post pneumonectomy empyema treated with a tunneled cuffed pleural catheter which has been draining the cavity for one month with clear drainage. He has had no evidence of a block or pleural fistula. Therefore a planned return to surgery results in the removal of the catheter. The correct CPT® code is: A. 32440-78 B. 32035-58 C. 32036-79 D. 32552-58 - ✔✔You can start narrowing your choices by the modifiers. Appendix A in the CPT® codebook lists the numeric modifiers. The key phrase to choose the correct modifier is "planned return", which is found in the descriptive for modifier 58. The patient is returning to surgery to remove the pleural catheter, eliminating multiple choice B. Answer D This 67 year-old man presented with a history of progressive shortness of breath. He has had a diagnosis of a secundum atrioseptal defect for several years, and has had atrial fibrillation intermittently over this period of time. He was in atrial fibrillation when he came to the operating room, and with the patient cannulated and on bypass, The right atrium was then opened. A large 3 x 5 cm defect was noted at fossa ovalis, and this also included a second hole in the same general area. Both of these holes were closed with a single pericardial patch. What CPT® and ICD-10-CM codes are reported? A. 33675, Q21.0 B. 33647, Q21.1, R06.02 C. 33645, Q21.2, R06.02 D. 33641, Q21.1 - ✔✔The patient had an atrial septal defect, eliminating multiple choice answers A and C. The surgery was only performed on the atrial septum, eliminating multiple choice answer B. According to ICD-10-CM Coding Guidelines (Section I.B.5): Signs and symptoms that are associated routinely with a disease process should not be assigned as additional codes, unless otherwise instructed by the classification. Shortness of breath (R06.02) is a symptom of an atrial septum defect and would not be coded. Answer D An 82 year-old female had a CAT scan which revealed evidence of a proximal small bowel obstruction. She was taken to the Operating Room where an elliptical abdominal incision was made, excising the skin and subcutaneous tissue. There were extensive adhesions along the entire length of the small bowel: the omentum and bowel were stuck up to the anterior abdominal wall. Time consuming, tedious and spending an extra hour to lysis the adhesions to free up the entire length of the gastrointestinal tract from the ligament to Treitz to the ileocolic anastomosis. The correct CPT® code is: A. 44005 B. 44180-22 C. 44005-22 D. 44180-59 - ✔✔This surgical procedure was not performed by a laparoscope, it was an open surgery, eliminating multiple choice answers B and D. It is documented that the adhesions were "extensive," "time consuming," and "spending an extra hour" to free up the attachments to the gastrointestinal tract. These are key words in indicating modifier 22 should be appended to the procedure code. Appendix A lists the modifiers. Answer C 55 year-old patient was admitted with massive gastric dilation. The endoscope was inserted with a catheter placement. The endoscope is passed through the cricopharyngeal muscle area without difficulty. Esophagus is normal, some chronic reflux changes at the esophagogastric junction noted. Stomach significant distention with what appears to be multiple encapsulated tablets in the stomach at least 20 to 30 of these are noted. Some of these are partially dissolved. Endoscope could not be engaged due to high grade narrowing in the pyloric channel, the duodenum was not examined. It seems to be a high grade outlet obstruction with a superimposed volvulus. A repeat examination is not planned at this time. What code should be used for this procedure? A. 43246-52 B. 43241-52 C. 43235 D. 43191 - ✔✔An esophagogastroduodenoscopy (also known as an upper GI endoscopy or EGD) is performed, not an esophagoscopy which is only an inspection of the esoph [Show More]

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