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CHAPIER 23 r DiSestive System

PRACTICAT

Using the CPT and ICD-10-CM/ICD-9-CM manuals, code the following:

19. Rigid esophagoscopy with removal of a foreigntody.

CPT Code:

Ligation of an intraoral salivary duct.

CPT Code:

21,. Transection of esophagus with repair of esophageal varices.

CPT Code:

,/22. Enterotomy of the small intestine for removal of a foreign body.

CPT Code:

23. Complicated revision of a colostomy.

CPT Code:

,t. Pr"notomy, labial.

CPT Code:

25. Excision of a

CPT Code:

palate lesion without closure.

29.

n{u. *"^oval of a foreign body from the pharynx.

CPT Code:

27. Amy is an l8-year-old with severe snoring. She is having an adenoidectomy in order to treat her snoring.

,/CW Code: ./

/Zg. partial colectomy with cotostomy.

CPT Code:

Open repair of an incarcerated recurrent inguinal hernia.

CPT Code:

0. Surgical laparoscopic placement of a gastric band.

CPT Code:

Odd-numbered answers are located ln Appendix B, while the full answer key is only avallable in the TEACE rnstfuctor Resources on Evolve.

Copyright @ 2015 by Saunders, an imprint of Elsevier Inc. All rights reserved.

CHAPTER !l r Digestive System

31. Fuli-thickness repair of the vermilion of the lip'

i CPT Code: \'4, ,,,,,0,.,.,

CPT Code:

33. Bilateral Pa

CPT Code:

epair of 1.6-cm laceration of floor of mouth'

rotid duct diversion.

,i. s,ugicar laparoscopic repair of a paraesophageal hernia with fundoplasty

with imPlantation of mesh'

CPT Code:

Biopsy of the stomach by laparotomy'

*d6. Nontune open ileostomY'

CPT Code:

37. Coiorrhaphy for multiple perforations of large

-' auto accihent. No colostomy was required'

rzls. tncision and drainage of perirectal abscess'

CPT Code:

39. Diagnostic abdominal laParoscoPY'

fo. r*urRocEDURE DIAGNoSIS: Screening coionoscopy'

POSTPROCEDURE DIAGNOSIS: Colon polyps'

PREMEDICATIONS: Fentanyl 100 mcg and Versed 4 mg'

PROCEDURE: A colonoscopy was perform:q to th.:,:"cum' The scope

was advanced to the cecum urd.r'dir..t vision without any difflculty'

FINDINGS:Thececum,ascending'transverse',desc11ding'andsigmoid colon *r, t'o'-ui' r" trt" d""""8i"g colott' there was a Z-mm

polyp

that was biopsied and submitted for histoiogy'

ASSESSMENT Diminutive colon polyps'

odd-numbered answers are located rn Appendrx B, while the futl a'swer key is only avallable in

the TEACTT

Instructor Resources on Evolve'

35.

intestine sustained in

Copyright @ 2015 by Saunders, an impdnt of Elsevier Inc' A11 rights reserved

CHAPTER 23 r Digestive System

REPORTS

In Appendix A of this workbook you will find a section titled Reports, which ,onfiins original reports. Read the reports indicated below and supply the appropriate cPT and ICD-L0-CMfiCD-9-CM codes on the following lines:

v42. Report 22

& rcp-ro-cM code(s):

.1& tco-l-cM code(s):

d+. xeport zz

& cvr code(s):

& Ico-ro-cM code(s):

(& tcp-g-cM code(s):

43. Report 31

& cpr code(s):

& cpr code(s):

& lco-ro-cM code(s):

(& ICD-g-cM code(s):

45. Report 33

& cpr code(s):

& rco-ro-cM code(s):

(& ICD-g-cM code(s):

&

&

(e

d. v"port z+ CPT Code(s):

ICD-1O-CM Code(s):

ICD-9-CM Code(s):

& Ur"r to declde number of codes necessary to correctly answer the question. Odd-numbered answers are located ln Appendix B, while the full arlswer key is only available in the TEACfl Instructor Resources on Evolve.

Coppight O 2015 by Saunders, an imprint of Elsevier Inc. AII rights reserved.

CHAPTER 23 r Digestive System

47. Report 35

& crrr code(s):

& Icp-ro-cM code(s):

I& ICD-g-cM code(s):

\46. Report 39

& cpr code(s):

& rco-ro-cM code(s):

(& ICD-g-cM code(s):

& u"ur to decide number of codes necessary to correctly answer the questlon. Odd-numbered answers are located ln Appendix B, whlle the ftrll answer key is only avallable ln the TEACE Instructor Resources on Evolve.

Copyright @ 2015 by Saunders, an imprint of Elsevier Inc. A11 rights reserved.

APPENDIX A r Reports

and cltobrush was then used to obtain cervical curetting. The endocervical os was unable to be demonstrated by the Pipelle curette or the uterine sound. The cytobrush was then used to locate the central endometrial canal, and the Pipelle curette was then used to obtain endometrial curetting. Bimanual examination shows the uteruS to measure 4to 6 weeks, antevefted, smooth, mobile. Adnexa negative. Rectal declined. BUS within normal limits.

IMPRESSION: Clear cell carcinoma of unknown origin.

PLAN: Refer the patient to the University of Minnesota for diagnostic workup and treatment. The patient and University of Minnesota will be advised of the results of the biopsies when they become available.

PATHOLOGY REPORT LATER INDICATED: See Report 54.

PREOPERATM DIAGNOSIS: Atelectasis of the right lower lobe, suspecting either a mucous plug or obstructing cancer.

posToPERATM DIAGNOSIS: Mildly inflamed airways with some thick secretions. No definite mucous plug was seen, and certainly no cancer was noted.

PROCEDURE PERFORMED: Bronchoalveolar lavage, bronchial brushings, and bronchial washings.

For a detail of drugs used and amounts of drugs used, please refer to the bronchoscopy report sheet.

The patient was in the ICU on the ventilator, intubated, and so we simply used ICU sedation. We put the bronchoscope down the endotracheal tube. We could see the trachea, which appeared okay. The carina appeared normal. In the right and left lungs, all segments were patent and entered, and in the right lower lobe and middle lower lobe, there were increased, thick, tenacious secretions. No definite mucous plug. It did take a little suctioning to dislodge all of the mucus; however, it was not as bad as I thought it would be looking at the x-ray. The area was brushed, washed, and then, to be more specific, because of evidence on chest x-ray of something going on in the periphery/ a bronchoalveolar lavage of the right lower lobe is performed. The patient tolerated the procedure well. Specimens were performed. Specimens were sent for appropriate cytological, pathological, and bacteriological studies, and we hope to be able to follow up on that tomorrow.

PATHOLOGY REPORT LATER INDICATED: See Report 66.

PREOPERATM DIAGNOSIS: Chronic adenotonsillitis and chronic tonsillitis.

POSTOPERATM DIAGNOSIS: Chronic adenotonsillitis and chronic tonsillitis.

PROCEDURE PERFORMED: Tonsillectomy and adenoidectomy.

OPERATM NOTE: The patient is a 1S-year-old woman who was seen in the offlce and diagnosed with the above condition. Decision was made in consultation with the patient to undergo the procedure.

She was admitted through the same-day department and taken to the operating room, where she was administered general anesthetic by

Copyright @ 2015 by Saunders, an impdnt of Elsevier Inc. A11 rights reserved.