View MR 002395 MR 002395 Operative Report Pre-operative Diagnosis: Acute rotator cuff tear Post-operative Diagnosis: Acute rotator cuff tear, synovitis Procedures: 1) Rotator cuff repair 2) Biceps Tenodesis 3) Claviculectomy 4) Coracoacromial ligament release Indication: Rotator cuff injury of a 32-year-old male, sustained while playing soccer. Findings: Complete tear of the right rotator cuff, synovitis, impingement. Procedure: The patient was prepared for surgery and placed in left lateral decubitus position. Standard posterior arthroscopy portals were made followed by an anterior- superior portal. Diagnostic arthroscopy was performed. Significant
synovitis was carefully debrided. There was a full-thickness upper 3rd subscapularis tear, which was repaired. The lesser tuberosity was debrided back to bleeding healthy bone and a Mitek 4.5 mm helix anchor was placed in the lesser tuberosity. Sutures were passed through the subcapulans in a combination of horizontal mattress and simple interrupted fashion and then tied. There was a partial-thickness tearing of the long head of the biceps. The biceps were released and then anchored in the intertubercular groove with a screw. There was a large anterior acromial spur with subacromial impingement. A CA ligament was released and acromioplasty was performed. Attention was then directed to the
supraspinatus tendon tear. The tear was V-shaped and measured approximately 2.5 cm from anterior to posterior. Two Smith and Nephew PEEK anchors were used for the medial row utilizing Healicoil anchors. Side-to-side stitches were placed. One set of suture tape from each of the medial anchors was then placed through a laterally placed Mitek helix PEEK knotless anchor which was fully inserted after tensioning the tapes. A solid repair was obtained. Next there were severe degenerative changes at the AC joint of approximately 8 to 10 mm. The distal clavicle was resected taking care to preserve the superior AC joint capsule. The shoulder was thoroughly lavaged. The instruments were removed and the incisions were closed in routine fashion. Sterile dressing was applied. The patient was transferred to recovery in stable condition.
What CPT?coding is reported for this case?
A. 29827, 29828-51, 29824-51, 29826
B. 29827, 29824-51, 29826-51
C. 29827, 29828-51, 29824-51, 29826, 29805-59
D. 29827, 29824-51, 29826-51, 29805-59
Patient has undergone open surgery for a left total knee arthroplasty. While in the recovery room, he continued to have severe postoperative pain. The surgeon ordered a femoral block for postoperative pain. The anesthesiologist evaluated the patient and performed a left femoral block, which provided significant post-operative pain relief.
What CPT?coding is reported?
A. 01404, 64450, 01996
B. 01380, 64447-59-LT
C. 01402, 64447-59-LT
D. 01402, 64448-59-LT, 01996
A witness of a traffic accident called 911. An ambulance with emergency basic life support arrived at the scene of the accident. The injured party was stabilized and taken to the hospital. What HCPCS Level II coding is reported for the ambulance's service?
A. A0426-QN-SH
B. A0429-QN-SH
C. A0427-QM-HS
D. A0428-QM-HS
A couple presents to the freestanding fertility clinic to start in vitro fertilization. Under radiologic guidance, an aspiration needle is inserted (by aid of a superimposed guiding- line) puncturing the ovary and preovulatory follicle and withdrawing fluid from the follicle containing the egg.
What is the correct CPT?code for this procedure?
A. 58976
B. 58974
C. 58999
D. 58970
An established patient suffering from migraines without aura, no mention of intractable migraine, and no mention of status migrainosus, is seen by his ophthalmologist whoconducts a visual field examination of both eyes. The examination was accomplished plotting four isopters utilizing the Goldmann perimeter testing method. The patient and requesting physician receive the interpretation and report on the same date of service. What procedure and diagnosis codes are reported for this encounter?
A. 92082, G43.009
B. 92082, G43.019
C. 92081, G43.009
D. 92083, G43.019
A cardiologist attempted to perform a percutaneous transluminal coronary angioplasty of a totally occluded blood vessel. The surgeon stopped the procedure because of an anatomical problem creating risk for the patient and preventing performance of the catheterization.
What modifier is appended to the procedure code?
A. 52
B. 53
C. 54
D. 76
View MR 001394 MR 001394 Operative Report Procedure: Excision of 11 cm back lesion with rotation flap repair. Preoperative Diagnosis: Basal cell carcinoma Postoperative Diagnosis: Same Anesthesia: 1% Xylocaine solution with epinephrine warmed and buffered and injected slowly through a 30-gauge needle for the patient's comfort. Location: Back Size of Excision: 11 cm Estimated Blood Loss: Minimal Complications: None Specimen: Sent to the lab in saline for frozen section margin control. Procedure: The patient was taken to our surgical suite, placed in a comfortable position, prepped and draped, and locally anesthetized in the usual sterile fashion. A #15 scalpel blade was used to excise the basal cell carcinoma plus a margin
of normal skin in a circular fashion in the natural relaxed skin tension lines as much as possible The lesion was removed full thickness including epidermis, dermis, and partial thickness subcutaneous tissues. The wound was then spot electro
desiccated for hemorrhage control. The specimen was sent to the lab on saline for frozen section.
Rotation flap repair of defect created by foil thickness frozen section excision of basal cell carcinoma of the back. We were able to devise a 12 sq cm flap and advance it using rotation flap closure technique. This will prevent infection,
dehiscence, and help reconstruct the area to approximate the situation as it was prior to surgical excision diminishing the risk of significant pain and distortion of the anatomy in the area. This was advanced medially to close the defect with 5 0
Vicryl and 6-0 Prolene stitches.
What CPT?coding is reported for this case?
A. 14001
B. 15271
C. 14001, 11606-51, 12034-51
D. 14001, 11606-51
A 44-year-old female patient with chest pains had a CT of her chest that identified a mass in her left lower lung. The patient currently has ovarian cancer with metastases to the liver. The radiologist suspects the cancer has spread to her lungs. The physician performed an outpatient bronchoscopic biopsy and the pathology report documents the mass as a tumor of uncertain behavior.
What ICD-10-CM codes are reported for this patient?
A. R91.8, C56.9, C78.7
B. C56.9, C78.7, C78.02
C. C78.02, C22.9, C79.82
D. D38.1, C56.9, C78.7
A patient with malignant lymphoma is administered the antineoplastic drug Rituximab 800 mg and then 100 mg of Benadryl. Which HCPCS Level II codes are reported for both drugs administered intravenously?
A. J9312 x 80, J1200 x 2
B. J9312, J1200
C. J9312, Q0163
D. J9312 x 80, 00163 x 2
Patient had polyps removed on a previous colonoscopy. The patient returns three months later for a follow-up examination for another colonoscopy. No new polyps are seen.
What diagnosis coding is reported for the second colonoscopy?
A. Z09, Z86.010
B. K63.5
C. Z86.010, K63.5
D. Z09, K63.5
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