Question 1

Jones, an established patient, is seen by the rheumatologist for repeated pain in her left knee due to osteoarthritis. Today she presents with pain and swelling. The rheumatologist performs an arthrocentesis of the left knee followed by injection of Dexa-Methasone sodium phosphate, 5 mg. No E/M service is performed. Select the appropriate ICD-10-CM and CPT code(s):

Accepted Answer

The correct ICD-10-CM code for osteoarthritis of the left knee is M17.12. The correct CPT code for an arthrocentesis of a major joint (like the knee) with injection is 20610. The code J1100 is for each milligram of Dexamethasone sodium phosphate, and since 5 mg was used, "5u" indicates the units. No E/M service was performed, so no E/M code is included.

Question 2

Jones is a patient with recurrent stage IV colon carcinoma of the sigmoid colon. He had previously undergone a laparoscopic low anterior resection (LAR). He was brought to the operating room today and under general anesthesia underwent a laparoscopic lysis of adhesions. The small bowel loops were found to be adherent to the anterior abdominal wall and also near the colostomy. These adhesions were lysed. There was one loop of small bowel that was adherent to the anterior abdominal wall of the RLQ, and this adhesion was not disturbed. Select the appropriate ICD-10-CM and CPT code(s):

Accepted Answer

K66.0 is the ICD-10-CM code for adhesions, which were addressed during the laparoscopic lysis of adhesions. C18.7 is the code for malignant neoplasm of the sigmoid colon, which is relevant due to the patient's history of colon carcinoma. 44180 is the CPT code for laparoscopy, surgical, enterolysis (freeing of intestinal adhesion) (separate procedure), which accurately describes the procedure performed.

Question 3

Jeremy presented to the ED complaining of severe odynophagia after eating chicken wings. Upon initial x-rays, no perforation of the esophagus was noted. The gastrointestinal specialist was called, and the patient was taken to the endoscopy suite. There, with the patient under moderate sedation, the gastroenterologist performed an esophagoscopy and removed a small chicken bone lodged in the esophagus above the diaphragm. Select the appropriate ICD-10-CM and CPT code(s):

Accepted Answer

The correct ICD-10-CM code for a foreign body in the esophagus is T18.128A, indicating the initial encounter for a foreign body lodged in the esophagus. The correct CPT code for the procedure, esophagoscopy with removal of a foreign body, is 43215.

Question 4

The patient underwent a hemorrhoidectomy for removal of two columns of prolapsed internal hemorrhoids, third-degree, and resolution of a chronic anal fissure-fissurectomy. Select the appropriate ICD-10-CM and CPT code(s):

Accepted Answer

CPT code 46261 represents a hemorrhoidectomy, including fissurectomy, with removal of multiple columns/groups of hemorrhoids, internal and/or external, which matches the procedure described. The ICD-10-CM codes K64.2 and K60.1 accurately represent third-degree hemorrhoids and chronic anal fissure, respectively.

Question 5

Jones presented with pain in the right upper quadrant. Upon a CT of the abdomen and an ultrasound of the gallbladder, a diagnosis of cholelithiasis and acute cholecystitis was confirmed, and the patient was taken to the operating room. The patient underwent a laparoscopic cholecystectomy with a normal intraoperative cholangiogram to remove the gallstones. Select the appropriate ICD-10-CM and CPT code(s):

Accepted Answer

K80.00 is the ICD-10-CM code for Calculus of gallbladder without cholecystitis, which is incorrect given the diagnosis includes acute cholecystitis. However, the correct ICD-10-CM code for cholelithiasis with acute cholecystitis is not provided among the options, making A the closest incorrect option. CPT code 47563 represents a laparoscopic cholecystectomy with cholangiography, matching the procedure described.

Question 6

A 4-year-old male underwent a frenoplasty using the Z technique to correct his speech difficulty due to ankyloglossia. Select the appropriate ICD-10-CM and CPT code(s):

Accepted Answer

Q38.1 is the ICD-10-CM code for ankyloglossia, and 41520 is the CPT code for frenoplasty, which is the surgical correction for this condition.

Question 7

A 45-year-old male with pancreatic cancer presents with a distended abdomen. The ultrasound reveals fluid in the peritoneal cavity. The patient undergoes a therapeutic paracentesis with ultrasound imaging guidance to drain the fluid. Select the appropriate ICD-10-CM and CPT code(s):

Accepted Answer

C25.9 is the ICD-10-CM code for malignant neoplasm of the pancreas, unspecified. 49083 is the CPT code for therapeutic paracentesis with imaging guidance.

Question 8

A 1-year-old female underwent a uvulopalatopharyngoplasty to repair a congenital bilateral cleft lip and cleft hard palate. Select the appropriate ICD-10-CM and CPT code(s):

Accepted Answer

The answer of A 1-year-old female underwent a uvulopalatopharyngoplasty to...

Question 9

McKenna was born at 36 weeks and is now 1 month old. She presented with a reducible right inguinal hernia and hydrocele. She was taken to the OR for a repair. Select the appropriate ICD-10-CM and CPT code(s):

Accepted Answer

The correct ICD-10-CM codes are K40.90 for the unspecified inguinal hernia, without obstruction or gangrene, not specified as recurrent, and N43.3 for the hydrocele. The appropriate CPT code for the repair in a patient under the age of 5 years is 49491, which is for inguinal hernia repair, initial, on an infant under age 6 months.

Question 10

A patient with morbid obesity presents for laparoscopic revision of a previous gastro-restrictive procedure. Select the appropriate ICD-10-CM and CPT code(s):

Accepted Answer

E66.01 is the ICD-10-CM code for morbid (severe) obesity due to excess calories, which is appropriate for a patient with morbid obesity. CPT code 43771 is for laparoscopic placement of an adjustable gastric band, which is a type of revision procedure for previous gastro-restrictive procedures.

Question 11

A patient undergoes a percutaneous liver biopsy with US guidance. The pathology report reveals autoimmune hepatitis. Select the appropriate ICD-10-CM and CPT code(s):

Accepted Answer

Autoimmune hepatitis is coded as K75.4 in ICD-10-CM. The procedure codes are 47000 for the percutaneous liver biopsy and 76942 for the ultrasound guidance, making option C correct.

Question 12

Preoperative diagnosis: Left hydrocele
Postoperative diagnosis: Left hydrocele
Procedure performed: Left hydrocelectomy
Procedure description: The initial incision was made, and the left hydrocele was delivered out of the wound and incised. The hydrocele was emptied of about 500 mL and then incised completely. About 90% of the hydrocele sac was removed with the Bovie. The hydrocele sac was involuted and sewn to itself using running 3-0 Vicryl in the manner of Jaboulay. The testicle was replaced in the left scrotum, and the patient tolerated the procedure well.
Select the appropriate ICD-10-CM and CPT code(s):

Accepted Answer

N43.3 is the ICD-10-CM code for a hydrocele, unspecified, and 55040-LT is the CPT code for a hydrocelectomy, which matches the procedure performed.

Question 13

The patient is seen in the OB/GYN office for follow-up postpartum. She had been seen by her previous physician throughout her pregnancy, but has relocated since the normal vaginal delivery of her daughter 6 weeks ago. Select the appropriate ICD-10-CM and CPT code(s):

Accepted Answer

Z39.2 is the correct ICD-10-CM code for a routine postpartum follow-up, and 59430 is the correct CPT code for a postpartum visit following a vaginal delivery.

Question 14

A 28-year-old patient was seen today for her annual physical exam by her OB/GYN. After discussion with the physician, the patient expressed her decision to have her IUD removed as she and her husband are ready to begin a family. This procedure was performed at this visit. Select the appropriate ICD-10-CM and CPT code(s):

Accepted Answer

The correct ICD-10-CM codes are Z00.00 for an annual physical exam and Z30.432 for the removal of an IUD. The CPT code 99395-25 is for a preventive medicine service for an established patient aged 18-39, and 58301 is for the removal of an IUD.

Question 15

Section: Kidney (left): Adenocarcinoma
MACROSCOPIC
Specimen type: Radical nephrectomy
Laterality: Left
Tumor site: Upper pole
Focality: Unifocal
Tumor size: Greatest dimension is 7.2 cm.
Macroscopic extent of tumor: Tumor extends into major veins.
MICROSCOPIC
Histologic type: Clear cell (conventional) renal carcinoma
Histologic grade: Furhman Nuclear Grade 2
PATHOLOGIC STAGING (pTN)
Primary tumor (pT): pT3
Regional lymph nodes (pN): Nx
Number of lymph nodes examined: 0
Number of lymph nodes involved: 0
Margins: Renal vein margin positive
Adrenal gland: Unevolved
Venous (large vessel) invasion (V) (excluding renal vein and inferior vena cava): Negative
Lymphatic (small vessel) invasion (L): Present
Additional pathologic findings: Chronic glomerulonephritis present in noninvolved renal parenchyma
Clinical history: A 76-year-old male with a left renal mass in the upper pole; hematuria
Gross description section: Received in formalin, labeled "left kidney," is a 12.2- × 7.1- × 2.5-cm kidney with unremarkable perirenal fat present at the upper pole (suture oriented, per requisition). A 2.3 cm in length segment of ureter exits from the hilum. The renal vein appears occluded. The cut sections demonstrate a 7.2- × 1.5- × 1.5-cm brown-orange circumscribed tumor with sharp borders present in the upper pole. Gerota's fascia appears uninvolved. The tumor extends into the renal vein; the venous margin appears positive for tumor.
Microscopic section: Microscopic examination was performed.
Select the appropriate ICD-10-CM and CPT code(s):

Accepted Answer

The answer of Section: Kidney (left): Adenocarcinoma
MACROSCOPIC
Specimen type: Radical nephrectomy
Laterality:...

Question 16

History: The patient is a 79-year-old male with dyspepsia and weight loss. A recent supraclavicular lymph node biopsy revealed signet-ring cell adenocarcinoma.
Specimen site: Stomach
Gross description: Received in formalin is a 10.0- × 6.5- × 3.2-cm segment of stomach, with a palpable firm 4.0- × 2.2-cm mass on the designated lesser curvature. The external surface of the specimen is unremarkable and inked black. The cut surfaces demonstrate the mass and adjacent firm areas of nodularity. The remainder of the gastric mucosa is unremarkable. Six lymph node candidates and representative sections of the stomach are submitted.
Microscopic description: Microscopic examination was performed. See synoptic report. The uninvolved stomach shows chronic inactive gastritis with intestinal metaplasia.
Diagnosis: Stomach (proximal): Invasive adenocarcinoma
Comment: Signet-ring cell carcinomas are not typically graded but are high-grade and would correspond to grade 3.
Select the appropriate ICD-10-CM and CPT code(s):

Accepted Answer

The correct ICD-10-CM code for this diagnosis is C16.5, which specifies a malignant neoplasm of the lesser curvature of the stomach, as the mass was located on the lesser curvature. The CPT codes 88309 and 88307 are used for the pathology examination of the stomach specimen and lymph nodes, respectively. The choice correctly reflects the need for both types of pathology examinations based on the specimen descriptions provided.

Question 17

Specimen site: Cervical biopsy
Pre-operative Diagnosis: Severe squamous dysplasia, consistent with CIN III (high-grade dysplasia)
Gross description: Cervical biopsy: One fragment of gray-white tissue, measuring 0.5 centimeters in diameter. Totally submitted with a request for levels. Submitted request for stains.
Microscopic description: Sections of the cervical biopsy show high-grade dysplasia, consistent with CIN III. No evidence of invasive malignancy is present.
Select the appropriate ICD-10-CM and CPT code(s):

Accepted Answer

The answer of Specimen site: Cervical biopsy
Pre-operative Diagnosis: Severe squamous...

Question 18

Specimen site: Right medial cheek
Specimen site: Left dorsal hand
Gross description: Right medial cheek: The specimen is one gray-white fragment measuring 0.3 × 0.2 cm. Totally submitted in one cassette with a request for levels labeled "A."
Left dorsal hand: The specimen is one gray-white fragment measuring 0.3 × 0.3 cm. Totally submitted in one cassette with a request for levels labeled "B."
Microscopic description: The right medial cheek shows atypical keratinocytes within the entire thickness of the epidermis extending to the stratum corneum. The lesion appears to have been excised. The dermis shows elastosis.
The dorsal hand shows hyperkeratosis. The epidermis is mildly acanthotic. There is extensive dermal elastosis.
Final diagnoses:
1) Right medial cheek, biopsy:
? Squamous cell carcinoma in-situ. (See comment.)
2) Left dorsal hand, biopsy:
? Dermal elastosis.
? No malignant changes seen.
Comment: The lesion from the cheek appears to reside within the confines of the histologic section. The skin lesion shows no invasive malignancy.
Select the appropriate ICD-10-CM and CPT code(s):

Accepted Answer

The correct ICD-10-CM codes are D04.39 for the squamous cell carcinoma in-situ of the right medial cheek and L87.2 for the dermal elastosis of the left dorsal hand. The correct CPT code is 88305 x2 because two separate specimens (right medial cheek and left dorsal hand) were submitted for histopathological examination, each requiring its own level sectioning as indicated by the requests for levels labeled "A" and "B".

Question 19

Specimen site: Gastric biopsy
Gross description: Gastric biopsy: Received in formalin, the specimen consists of two fragments of gray-brown mucosa, each measuring approximately 0.3 centimeter in diameter. Totally submitted for routine and special stains and additional levels.
Microscopic description: Sections show benign-appearing gastric mucosa with acute and chronic inflammatory cells within the lamina propria. The surface and pit-lining epithelium are also infiltrated with neutrophils. There is no dysplasia or malignancy. Special stains for H. pylori are positive.
Final diagnosis:
Gastric biopsy:
? Chronic active gastritis.
? Warthin-Starry stain positive for H. pylori.
? Negative for intestinal metaplasia, dysplasia, or malignancy.
Select the appropriate ICD-10-CM and CPT code(s):

Accepted Answer

The diagnosis of chronic active gastritis and the presence of H. pylori infection are coded as K29.50 and B96.81, respectively. The CPT codes 88305 for the biopsy and 88312 for the special stains (e.g., for H. pylori) accurately reflect the procedures described in the specimen processing.

Question 20

History: 76-year-old female with colonic mass
Diagnosis: Invasive adenocarcinoma, 3.4 × 3.0 cm, involving muscularis propria
All margins negative.
No lymphatic invasion.
No metastatic tumor identified.
Gross description: Received fresh is a right colon, 32 cm in length. Upon opening of the specimen, there is a 3.4- × 3.0-cm nodular mass. 36 lymph nodes were retrieved. Representative sections are submitted.
Microscopic description: Microscopic examination performed
Select the appropriate ICD-10-CM and CPT code(s):

Accepted Answer

The answer of History: 76-year-old female with colonic mass
Diagnosis: Invasive...

Quiz 27: Coding and Surgical Procedures

The patient underwent a hemorrhoidectomy for removal of two columns of prolapsed internal hemorrhoids, third-degree, and resolution of a chronic anal fissure-fissurectomy. Select the appropriate ICD-10-CM and CPT code(s) :

A 4-year-old male underwent a frenoplasty using the Z technique to correct his speech difficulty due to ankyloglossia. Select the appropriate ICD-10-CM and CPT code(s) :

A 45-year-old male with pancreatic cancer presents with a distended abdomen. The ultrasound reveals fluid in the peritoneal cavity. The patient undergoes a therapeutic paracentesis with ultrasound imaging guidance to drain the fluid. Select the appropriate ICD-10-CM and CPT code(s) :

A 1-year-old female underwent a uvulopalatopharyngoplasty to repair a congenital bilateral cleft lip and cleft hard palate. Select the appropriate ICD-10-CM and CPT code(s) :

McKenna was born at 36 weeks and is now 1 month old. She presented with a reducible right inguinal hernia and hydrocele. She was taken to the OR for a repair. Select the appropriate ICD-10-CM and CPT code(s) :

A patient with morbid obesity presents for laparoscopic revision of a previous gastro-restrictive procedure. Select the appropriate ICD-10-CM and CPT code(s) :

A patient undergoes a percutaneous liver biopsy with US guidance. The pathology report reveals autoimmune hepatitis. Select the appropriate ICD-10-CM and CPT code(s) :

The patient is seen in the OB/GYN office for follow-up postpartum. She had been seen by her previous physician throughout her pregnancy, but has relocated since the normal vaginal delivery of her daughter 6 weeks ago. Select the appropriate ICD-10-CM and CPT code(s) :