Surgery, Coding

Front 1

Blank is a term used in anesthesiology and many related medical fields to describe a level of sedation where most people are relaxed and comfortable, but are capable of responding to verbal commands.

Back 1

Moderate sedation

Front 2

Blankl numbs the pain without affecting muscle power, which means a woman cannot longer feel the contractions but is still able to push when directed to do so by her doctor.
can be used to treat certain types of chronic pain that have not responded to any other type of localized or general treatment.

Back 2

epidural

Front 3

Blank is a surgical procedure used to diagnose and often treat disorders, diseases, or problems due to injury of a joint.

Back 3

Arthroscopy

Front 4

Blank are performed to learn more about the patient’s condition and not to definitively treat the patient’s condition

Back 4

Diagnostic procedures

Front 5

A 58-year-old male patient had a diagnostic right wrist arthroscopy with a synovial biopsy 14 days ago because he was having difficulty moving his right wrist. He is in today because of acute right wrist pain. The physician explained it is not unusual to have pain after an arthroscopy for the first 3–4 weeks.

Back 5

The patient’s visit does not involve a complication of the diagnostic procedure; therefore, it is documented and coded as a routine follow-up visit in the post-op period. No claim will be submitted to the third-party payer. Follow-up visits in the postoperative period normally included in the surgical package are coded from the “Medicine Numeric Section.” You will cover Special Services, Procedures, and Reports in an upcoming unit. For now, read the code description for 99024.

Front 6

PROCEDURE: Right wrist diagnostic arthroscopy with synovial biopsy

Back 6

29840
Arthroscopy, wrist, diagnostic, with or without synovial biopsy (separate procedure)

Front 7

Blank involves the enlargement of body organs. Many different factors may cause such enlargement. While some causes are benign, others are more serious. Heart enlargement, liver enlargement, and spleen enlargement — called cardiomegaly, hepatomegaly, and splenomegaly, respectively — represent three examples of abnormal organ enlargement. Autoimmune disorders often cause blank as well.

Back 7

Organomegaly

Front 8

Blank is a medical term that translates to enlarged, and blank would refer to the enlargement of various areas of the body; these areas could include muscles, skin, appendages or organs. In this condition, at the most basic level, cell enlargement occurs.

Back 8

Hypertrophic, hypertrophy

Front 9

This should be considered as distinct from growth through cells dividing and creating new cells, which is frequently called blank

Back 9

Hyperplasia

Front 10

Blank is a clinical procedure used to destroy cancerous tumors in the liver, lungs, kidneys or elsewhere in the body when surgery would be too dangerous. It involves inserting a metal needle into the center of a tumor and introducing a very specific range of electrical current. Electrical signals cause surrounding tissue to oscillate and heat up until they are destroyed. Specialized blank procedures are also utilized to stabilize erratic heartbeats, ease chronic nerve pain, and treat varicose veins.

Back 10

Radiofrequency ablation

Front 11

Blank is a medical technique used to remove tissue from the body through radio-wave frequencies. It is used to treat many different medical problems. Among its many applications are cardiac blank, endometrial blank, surface blank, and liver tumor removal.

Back 11

Ablation

Front 12

Blank also known as blank, is a technique which involves the use of extremely low temperatures to destroy abnormal cells

Back 12

Cryotherapy, cryosurgery

Front 13

A 45-year-old female had bilateral Radiofrequency Ablation for the removal of two benign renal tumors performed two days ago. She went in to see the physician because she had blood in her urine. The physician explained it is not unusual to have some blood in the urine for 3-5 days after surgery.

Back 13

Index: Ablation, Renal Mass, Radiofrequency, 50592-50

Front 14

Three different systems inside the body can be listened to during blank: the heart, the lungs, and the bowels. Blank can reveal signs of ill health including irregular heartbeats, fluid in the lungs, or bowel obstructions. An attentive listener can often identify very specific conditions by sound alone, listening for tell-tale signs such as a particular type of crackle in the lungs which suggests pneumonia, or the wheezing characteristic of asthma.

Back 14

Auscultation

Front 15

Blank is an infection of the bone. It is commonly caused by an infection, usually bacterial in nature, which starts in another part of the body and spreads by the blood. It can be acute, meaning it has a rapid onset, or chronic, meaning it is persistent and long-lasting.

Back 15

Osteomyelitis

Front 16

Blank is a wound that is a specific type of injury that has opened the skin

Back 16

Incised

Front 17

Since the soft tissue infection around the implant (intramedullary, screws and cerclage) and osteomyelitis in the fibula bone is a complication of the primary surgery, the physician is allowed to bill for the two follow-up surgical procedures as an unplanned return trip to the operating room for related procedures. This is known as

Back 17

Therapeutic procedure

Front 18

CPT Code:
Interpretation: soft tissue infection around the implant and early stages of osteomyelitis of the tibia. Surgery is scheduled immediately for the patient to remove the implant and to incise the fibula bone to remove the osteomyelitis

Back 18

Removal
Implantation 20670-20680
20680
deep (eg, buried wire, pin, screw, metal band, nail, rod or plate

and
Incision, Fibula 27607 (Incision (eg, osteomyelitis, or bone abscess), leg or ankle)
PROCEDURES: Removal of an implant. Incision into fibula bone.20680-78, 27607-78-51

Front 19

A 30-year-old male patient diagnosed with severe, diffuse (Spread) polyposis (polyps) underwent a transorbital (passing through or performed by way of the eye socket)unilateral sinusectomy of the left sinus. The patient now returns 15 days later for a follow up visit. The patient has pain, itching, and swelling around the incision site.
Primary ICD-9-CM Code

Back 19

V67.09
Follow-up codes are used to explain continuing surveillance following completed treatment of a disease, condition, or injury. They imply the condition has been fully treated and no longer exists.The patient was seen for a follow up visit following surgery. To locate this code, turn in the “Index to Diseases” to the main term follow-up and the sub-term specified surgery NEC. The code listed is V67.09; follow-up examination following other surgery

Front 20

The patient has a history of a respiratory system disease; History codes (V10–19) may be used as secondary codes if the historical condition or family history has an impact on current care or influences

Back 20

To locate this code, turn in the “Index to Diseases” to the main term history (personal) of and the sub-terms disease, respiratory system, and specified NEC. The code listed is V12.69; personal history of other diseases of the respiratory system.

Front 21

A 30-year-old male patient diagnosed with severe, diffuse (Spread) polyposis (polyps) underwent a transorbital (passing through or performed by way of the eye socket)unilateral sinusectomy of the left sinus. The patient now returns 15 days later for a follow up visit. The patient has pain, itching, and swelling around the incision site.; fine the primary CPT Code

Back 21

The code 99024 can be located under the main term special services and the sub-term post-op visit. This code can also be located under the main term post-op visit. This code was chosen because the patient is still within the 90-day global period and the physician cannot charge for a regular E/M service during this time.

Front 22

Physician performs more than one service/procedure on the same date, same session for the same patient; use Modifier

Back 22

51

Front 23

Modifier Codes are used with E/M codes or surgical codes in the surgical time frame to convey special information:

Back 23

Modifier 23: Unusual Anesthesia

Modifier 24: Unrelated Evaluation and Management Service by the Same Physician During a Postoperative Period

Modifier 25: Significant, Separately Identifiable Evaluation and Management Services by the Same Physician on the Same Day of the Procedure or Other Service

Modifier 57: Decision for Surgery

Modifier 58: Staged or Related Procedure or Service by the Same Physician During the Postoperative Period

Modifier 59: Distinct Procedure

Front 24

CPT Codeing:
A 40-year-old female is scheduled for an EGD with biopsies. Biopsies were obtained from the esophagus and the lining of the stomach.

Back 24

1. CPT: Esophagogastroduodenoscopies
2. Endoscopy
3. Gastrointestinal
3. Upper; biopsy
4. 43239
or Biopsy
Gastrointestinal, Upper
Endoscopy 43239

Front 25

Complete the diagnosis coding for this patient: blood in stool

Back 25

Hematemesis: 578.81

Front 26

A 40-year-old female is scheduled for an EGD with biopsies. Biopsies were obtained from the esophagus and the lining of the stomach.

Back 26

Biopsy
Colon
Endoscopy 44389, 45380, 45391-45392
45380
with biopsy, single or multiple

Front 27

Blank is a thin flexible plastic tube that is inserted into a patient’s vein and remains there for repeated access to the vein.

Back 27

A vascular catheter, or venous catheter

Front 28

An arrhythmia is a disorder of the heart rate (pulse) or heart rhythm, such as beating too fast (blank), too slow (blank), or irregularly.

Back 28

tachycardia, bradycardia

Front 29

blank is an ancient medical practice that is still in use currently. It involves creating burns on the tissue to either close wounds or stop bleeding, or to remove part of the body. We’re most likely to think of medical doctors using this practice long ago to apply hot metal after amputation. This practice would close wounds and stop bleeding because the heat would make the blood clot. A related term, cautery , can mean placing a brand on a human, which was a practice that was also common, for punishment, as decoration in certain cultures, or to mark humans as property.

Back 29

Cauterization

Front 30

Surgical Destruction
Procedure: The debridement was performed removing necrotized skin, and sub-cutaneous tissue. Debridement continued down through muscle fascia, muscle to the bone removing stones, dirt and other debris. This procedure will need to be repeated in a day or two before attention will be given to the fracture site. The patient was taken to the recovery room in good condition.

Back 30

1. Debriedment/skin/with open fracture and/or dislocation
2. 11010-11012
3. 11012
4. Modifiers 58?
5. Which side of the body
6. Procedure: Debridement skin, muscle and bone, open fracture left tibia shaft. 11012-LT

Front 31

A 15-year-old female patient came into the office today for removal of two viral warts on her right hand. The patient’s right hand was prepped and the warts were destroyed by cryosurgery. Patient will return to the office in 10 days for a follow-up visit

Back 31

1. Warts, Flats, Destruction, 17110-17111
2. which side, any modifiers
3. right side
4. 17110-RT

Front 32

DIAGNOSIS: Viral warts, right hand.

Back 32

Wart, (viral),
078.10

Front 33

Skin laysers consist of

Back 33

Epidermis
Dermis
Hypodermis
Subcutaneous

Front 34

A blank cell is a skin cell at the base of the epidermis, the uppermost layer of the skin. These cells, along with most of the cells in the skin, are among a type of cells known as blank.

Back 34

basal keratinocytes

Front 35

an epithelium characterised by its most superficial layer consisting of flat, scale-like cells called

Back 35

Squamous Cells

Front 36

Procedures: Excision of malignant lesion on upper back, complex wound closure
This 38-year-old male patient who had a previous biopsy of the lesion on his back. A confirmed pathology report revealed primary carcinoma. He is here today in the ambulatory surgery center to have a 3.8 cm lesion excised. The removal was quite extensive, going through skin, subcutaneous tissue, muscle fascia and muscle. After the excision of the lesion we performed a complex wound closure (4.3 cm). Patient was taken to the recovery room in good condition.

Back 36

1. Excised
2. Repair
3. Modifier
4. Procedures: Excision of malignant lesion on upper back, complex wound closure. 5. 11604, 13101-51

Front 37

Code this procedure as if you are coding for the hospital ambulatory surgery center. What are the ICD-9 procedure codes?
Procedures: Excision of malignant lesion on upper back, complex wound closure

Back 37

ICD-9:
1. Excision, skin
86.3
2. Closure, wound, w/adhesive
3. 86.59

Front 38

36-year-old female patient is here today to for the destruction via cryosurgery on 16 pre-malignant lesions (actinic keratoses) on her face and neck.

Back 38

Destruction, Lesion, Premalignant, 17000
Answer 17004

Front 39

A 12-year-old boy comes into the pediatrician’s office today because he fell from a tree. After the examination the physician does not find any fractures; however, he does have a simple open wound measuring 8.3 cm on his right forearm. His surgical tray has lidocaine, syringe, and suture kit. The physician numbs the area and sutures the open wound.

Back 39

Your Answer:12004-RT (Repair/Wound/Simple, 12001-12021), (Right side)

Front 40

A male patient comes in for outpatient surgery today. The physician will perform a fine needle aspirate on his liver using ultrasonic guidance.

Back 40

Fine Needle Aspiration10021–10022.
10022
with imaging guidance
Procedure: Fine needle aspirate on the liver using ultrasonic guidance, 10022

Front 41

Excision of a 2.8 cm benign lesion from back and excision of a 3.2 cm benign lesion from neck.

Back 41

CPT: Excision, Lesion, Skin, Benign; read the headings for neck and back. Then multiple procedures.
11424, 11403-51

Front 42

Patient returns to the office because of a deep postoperative wound infection of the right leg. The physician reopens the wound and drains the infection

Back 42

Incision and Drainage ,
Wound Infection
Skin 10180

Front 43

Patient returns to the office because of a deep postoperative wound infection of the right leg. The physician reopens the wound and drains the infection. Next the physician performs a secondary closure of a complicated surgical wound.
(look under 10180)

Back 43

Locate and read the descriptions of codes 12020, 12021, 13160 carefully:

13160

Front 44

Patient returns to the office because of a deep postoperative wound infection of the right leg. The physician reopens the wound and drains the infection. Next the physician performs a secondary closure of a complicated surgical wound.
Finally

Back 44

Incision and drainage with secondary closure of a complicated surgical wound. 10180, 13160-51

Front 45

The patient was taken into the operating room where debridement of skin, subcutaneous tissue, muscle fascia was performed without fascial closure. The mesh (from the hernia repair) was also removed due to the abdominal wall infection. The patient will need another debridement and skin grafts to close the wound in a few days.
Debridement only

Back 45

Debridment/Skin/Infected/
11000-11006
See 11005

Front 46

operating room where debridement of skin, subcutaneous tissue, muscle fascia was performed without fascial closure. The mesh (from the hernia repair) was also removed due to the abdominal wall infection. The patient will need another debridement and skin grafts to close the wound in a few days.
Removal of mesh

Back 46

Removal/Mesh/Abdominal Wall/11008

Front 47

The patient was taken into the operating room where debridement of skin, subcutaneous tissue, muscle fascia was performed without fascial closure. The mesh (from the hernia repair) was also removed due to the abdominal wall infection. The patient will need another debridement and skin grafts to close the wound in a few days.

Back 47

Procedure: Debridement of skin, subcutaneous tissue, muscle fascia of abdominal wall without fascial closure and removal of infect hernia repair mesh. 11005-78, +11008-78

Front 48

DIAGNOSES: Postoperative wound infection due to Staphylococcal aureus. Necrosis (gangrene) of subcutaneous tissue.

Back 48

DIAGNOSES: Postoperative wound infection due to Staphylococcal aureus; ICD Infection, Postoperative wound, 998.59; Methicillin, Susceptible, Staphylococcus Aurus, 041.11; Gangrene, cutaneous, spreading, 785.4
998.59, 041.11, 785.4

Front 49

A 30-year-old male patient went to a plastic surgeon to have a benign lesion removed/excised from his back. The physician prepped the area and removed a 3.8 cm benign neoplasm from the patient’s back. Due to the length and depth of the excision the plastic surgeon performed an intermediate wound repair.
Excision only

Back 49

11404
excised 3.1 to 4.0 cm

Front 50

A 30-year-old male patient went to a plastic surgeon to have a benign lesion removed/excised from his back. The physician prepped the area and removed a 3.8 cm benign neoplasm from the patient’s back. Due to the length and depth of the excision the plastic surgeon performed an intermediate wound repair.
Repair only

Back 50

Repair/Wound/Intermediate
12031-12057
12032
2.6 to 7.5 cm

Front 51

A 30-year-old male patient went to a plastic surgeon to have a benign lesion removed/excised from his back. The physician prepped the area and removed a 3.8 cm benign neoplasm from the patient’s back. Due to the length and depth of the excision the plastic surgeon performed an intermediate wound repair

Back 51

Benign lesion excised from back with intermediate wound repair. 11404, 12032-51

Front 52

Mike, a 22-year-old, came into the emergency room with multiple open wounds with foreign bodies due to an unarmed fight at a local nightclub. The ER physician examined, debrided the wounds on his scalp (2.5 cm), back (3.5 cm), right forearm (3.5 cm), the right hand (2 cm) and the left hand (1.5 cm). The physician then performed complex wound closures on the scalp, back and right forearm. The right and left hands required intermediate closures.
Repair

Back 52

Repair
Skin
Wound
Complex 13100–13160
Repair
Skin
Wound
Intermediate 12031–12057

Front 53

DIAGNOSES: Postoperative wound infection due to Staphylococcal aureus; Necrosis (gangrene) of subcutaneous tissue

Back 53

ICD
Infection, Wound, Postoperative, 998.59;

Methicillin, Susceptible,
Staphylococcus Aurus, 041.11;

Gangrene, cutaneous, spreading, 785.4

Front 54

Mike, a 22-year-old, came into the emergency room with multiple open wounds with foreign bodies due to an unarmed fight at a local nightclub. The ER physician examined, debrided the wounds on his scalp (2.5 cm), back (3.5 cm), right forearm (3.5 cm), the right hand (2 cm) and the left hand (1.5 cm). The physician then performed complex wound closures on the scalp, back and right forearm. The right and left hands required intermediate closures.
Repair codes only, Complex:

Back 54

Repair
Skin
Wound
Complex 13100–13160

Front 55

Mike, a 22-year-old, came into the emergency room with multiple open wounds with foreign bodies due to an unarmed fight at a local nightclub. The ER physician examined, debrided the wounds on his scalp (2.5 cm), back (3.5 cm), right forearm (3.5 cm), the right hand (2 cm) and the left hand (1.5 cm). The physician then performed complex wound closures on the scalp, back and right forearm. The right and left hands required intermediate closures.
Repair codes only, Intermediate

Back 55

Repair
Skin
Wound
Intermediate 12031–12057

Front 56

Mike, a 22-year-old, came into the emergency room with multiple open wounds with foreign bodies due to an unarmed fight at a local nightclub. The ER physician examined, debrided the wounds on his scalp (2.5 cm), back (3.5 cm), right forearm (3.5 cm), the right hand (2 cm) and the left hand (1.5 cm). The physician then performed complex wound closures on the scalp, back and right forearm. The right and left hands required intermediate closures. Identify the sites

Back 56

Mike, a 22-year-old, came into the emergency room with multiple open wounds with foreign bodies due to an unarmed fight at a local nightclub. The ER physician examined, debrided the wounds on his scalp (2.5 cm), back (3.5 cm), right forearm (3.5 cm), the right hand (2 cm) and the left hand (1.5 cm). The physician then performed complex wound closures on the scalp, back and right forearm. The right and left hands required intermediate closures.

Front 57

Mike, a 22-year-old, came into the emergency room with multiple open wounds with foreign bodies due to an unarmed fight at a local nightclub. The ER physician examined, debrided the wounds on his scalp (2.5 cm), back (3.5 cm), right forearm (3.5 cm), the right hand (2 cm) and the left hand (1.5 cm). The physician then performed complex wound closures on the scalp, back and right forearm. The right and left hands required intermediate closures. Identify the sites
Complex CPT

Back 57

Back, 3.5, 13101
Scalp, 2.5, Right Forearm, 3.5, = 6 cm, 13121
CPT 13101, 13121

Front 58

Mike, a 22-year-old, came into the emergency room with multiple open wounds with foreign bodies due to an unarmed fight at a local nightclub. The ER physician examined, debrided the wounds on his scalp (2.5 cm), back (3.5 cm), right forearm (3.5 cm), the right hand (2 cm) and the left hand (1.5 cm). The physician then performed complex wound closures on the scalp, back and right forearm. The right and left hands required intermediate closures.
Identify the intermediate repair codes.

Back 58

• Right hand 2 cm
• Left hand 1.5 cm
CPT, Repair, Skin, Wounds, Intermediate, 12031-12057
12041/RH, 2.5cm/LH, 1.5cm/4cm/12042
12042

Front 59

The space technically is outside of the peritoneum, between the abdomen and the back. It sometimes is referred to as the retroperitoneum or extraperitoneum because of its location. This space is not specifically delineated by any abdominal structure, rather organs are said to be in the retroperitoneum if they are lined by peritoneum only on their anterior side.

Back 59

retroperitoneal

Front 60

TBSA

Back 60

Total Body Surface Area

Front 61

1Patient comes into the physician’s office to have 25 skin tags removed from the neck.

Back 61

1. Alphabetical Index → main term removal → sub-term skin tags 11200-11201
2. Numeric Section → code 11200 removal of skin tags, multiple fibrocutaneous tags any area; up to and including 15 lesions
3. Numeric Section → code 11201 each additional 10 lesions, or part thereof (List separately in addition to code for primary procedure)
4. Notice code 11201 is an add-on code; therefore modifier -51 would not be appended to this code
Correct Answer:11200, 11201

Front 62

2. A 30-year-old male patient goes to the emergency room because of a chain saw injury to his right thigh. The patient needs extensive debridement of skin, subcutaneous tissue and muscle. The physician then performed a complex wound closure (12.5 cm) on the right thigh.

Back 62

1. Alphabetical Index → main term repair → sub-term wound complex 13100-13160
2. Numeric Section → code 13121 repair, complex scalp, arms, and/or legs; 2.6 cm to 7.5 cm
3. Numeric Section → code 13122 each additional 5 cm or less (List separately in addition to code for primary procedure)
4. Notice code 13122 is an add-on code, therefore modifier -51 is not necessary
5. Alphabetical Index → main term debridement → sub-term skin subcutaneous tissue 11042-11044
6. Numeric Section → code 11043 debridement; skin, subcutaneous tissue and muscle
7. Appendix A → Modifiers → 51 multiple procedures
8. Modifier -51 is appended to code 11043 to indicate multiple procedures were performed on the same day during the same surgical session
Correct Answer:13121, 13122, 11043-51

Front 63

Patient goes to their physician’s office to have a malignant mole (1.5 cm) excised from the face.

Back 63

Correct Answer:11642

Front 64

A 48-year-old female patient was admitted to the hospital to have a left radical mastectomy including pectoral muscles and axillary lymph. The physician will insert a breast prosthesis immediately following

Back 64

Correct Answer:19305-LT, 19340-51-LT

Front 65

4. A 48-year-old female patient was admitted to the hospital to have a left radical mastectomy including pectoral muscles and axillary lymph. The physician will insert a breast prosthesis immediately following.

Back 65

Correct Answer:19305-LT, 19340-51-LT

Front 66

5. A patient went into the physician’s office today to have an incision and drainage with removal of a foreign body (splinters) from the bottom of the right foot

Back 66

Correct Answer:10120

Front 67

5. A patient went into the physician’s office today to have an incision and drainage (infection/pus/tissue that needs to be drained) with removal of a foreign body (splinters) from the bottom of the right foot. (Hint: One CPT code is associated with this report.)

Back 67

Correct Answer:10120 (Incision and Drainage, Foreign Body, Skin, 10120-10121)
10120

Front 68

48-year-old female patient was admitted to the hospital to have a left radical mastectomy including pectoral muscles and axillary lymph. The physician will insert a breast prosthesis immediately following

Back 68

Correct Answer:19305-LT, 19340-51-LT (Removal, Breast, Radical, 19305, 19340)
19340 is not an add on code, therefore add the additional procedure. Finally, these are both procedures on the left side.
19305-LT, 19340-51-LT

Front 69

3. Patient goes to their physician’s office to have a malignant mole (1.5 cm) excised from the face. (Hint: One CPT code is associated with this report.)

Back 69

Correct Answer:11642 (Excision, Skin, Malignant, 11640, 1.5, 11642)

Front 70

Correct Answer:11642 (Excision, Skin, Malignant, 11640, 1.5, 11642)

Back 70

Correct Answer:11642 (Excision, Skin, Malignant, 11640, 1.5, 11642)