CPC Exam Question 136

(Full Case:Preoperative diagnosis:Low back pain; possible spinal stenosis L3-4.Postoperative diagnosis:No evidence of discogenic pathology or spinal stenosis at L3-4; normal discography L3-4.Procedure:Awake discography and injection, L3-4.Anesthesia:IV narcotic with reversal and local; propofol given transiently, then patient alert/responsive for pain response during injection.Technique:Patient to OR; right decubitus; sterile prep/drape; C-arm used to mark entry; local ethyl chloride + 1% Xylocaine; docking needle placed posterolateral at L3-4 under AP/lateral; inner needle advanced to disc nucleus center; contrast injected while monitoring patient response; normal bilocular pattern; 1.5 cc volume; no pain with pressurization.
Documentation:No videotape; plain films available; post-discography CT planned/reviewed for other causes.
Question:What CPT and ICD-10-CM coding is reported?)
  • CPC Exam Question 137

    Refer to the supplemental information when answering this question:
    View MR 138093
    What E/M coding is reported?
  • CPC Exam Question 138

    A patient presents to the ER from a nursing home after the patient was found to have foul smelling, large sacral pressure ulcer during daily nursing rounds. The ER provider swabbed the wound for culture (which measured at 7cm in largest diameter); then cleaned the site before painting with povidone around the entire sacrum to reduce cutaneous bacterial load. The provider made an elliptical excision with 3mm margins around the outer edge of the ulcer and removed the lesion in its entirety.
    Further examination revealed deep tissue damage, prompting muscle and
    segmental bone removal. The wound was then closed using a layered skin flap closure.
    What CPTcoding and ICD-10-CM coding is reported?
  • CPC Exam Question 139

    View MR 099401
    MR 099401
    Established Patient Office Visit
    Chief Complaint: Patient presents with bilateral thyroid nodules.
    History of present illness: A 54-year-old patient is here for evaluation of bilateral thyroid nodules. Thyroid ultrasound was done last week which showed multiple thyroid masses likely due to multinodular goiter.
    Patient stated that she can "feel" the nodules on the left side of her thyroid. Patient denies difficulty swallowing and she denies unexplained weight loss or gain. Patient does have a family history of thyroid cancer in her maternal grandmother. She gives no other problems at this time other than a palpable right-sided thyroid mass.
    Review of Systems:
    Constitutional: Negative for chills, fever, and unexpected weight change.
    HENT: Negative for hearing loss, trouble swallowing and voice change.
    Gastrointestinal: Negative for abdominal distention, abdominal pain, anal bleeding, blood in stool, constipation, diarrhea, nausea, rectal pain, and vomiting Endocrine: Negative for cold Intolerance and heat intolerance.
    Physical Exam:
    Vitals: BP: 140/72, Pulse: 96, Resp: 16, Temp: 97.6 °F (36.4 °C), Temporal SpO2: 97% Weight: 89.8 kg (198 lbs ), Height: 165.1 cm (65") General Appearance: Alert, cooperative, in no acute distress Head: Normocephalic, without obvious abnormality, atraumatic Throat: No oral lesions, no thrush, oral mucosa moist Neck: No adenopathy, supple, trachea midline, thyromegaly is present, no carotid bruit, no JVD Lungs: Clear to auscultation, respirations regular, even, and unlabored Heart: Regular rhythm and normal rate, normal S1 and S2, no murmur, no gallop, no rub, no click Lymph nodes: No palpable adenopathy ASSESSMENT/PLAN:
    1) Multinodular goiter - the patient will have a percutaneous biopsy performed (minor procedure).
    What E/M code is reported for this encounter?
  • CPC Exam Question 140

    (A 7-year-old child presents with third-degree circumferential burns of his chest, resulting in restricted chest expansion and concern for respiratory compromise. To relieve pressure caused by the eschar, the surgeon performs anescharotomy. During the procedure,two incisionsare made through the eschar down to the subcutaneous tissue to release the constrictive effects. The burns are full-thickness and involve10% TBSA, resulting in all third-degree burns. What CPT and ICD-10-CM codes are reported for this service?)