13 terms

Medical Coding Scenarios

A mother brings her 4-year-old son to the doctor because she found a lump at the front of his neck. After an ultrasound and a blood test, the doctor diagnoses a thyroglossal duct cyst and recommends surgery. On the day of surgery, the surgeon tells the mother that he will perform a Sistrunk operation. Code the diagnosis and procedure codes on the day of surgery.
759.2, 60200
A 36-year-old patient is admitted through the Emergency Department with epigastric abdominal pain and diarrhea. An ultrasound shows calculus in her gallbladder but no obstruction. The doctor diagnoses the pain as cholelithiasis with acute cholecystitis. The doctor performs a laparoscopic cholecystectomy the next day. Code the diagnoses and procedure for this scenario.
574.00, 47562
A mother brings a three-year-old boy in for removal of nasopharyngeal polyps. The physician thinks the procedure may need to be extensive, and he is concerned about the patient's ability to tolerate the procedure in an office setting. They schedule the procedure for the operating room at the local hospital. Upon examination under anesthesia, the physician realizes that the procedure is a simple excision of three nasal polyps. He performs it, and the patient recovers well. Code the diagnosis and procedure for this scenario.
471.0, 30110
A man goes to his doctor complaining of chronic pain in his throat. The doctor performs a laryngoscopy with a flexible fiberoptic scope. While performing the procedure, the doctor completely excises a 1 centimeter lesion in the patient's larynx. The pathology report identifies a benign lesion, and the man's throat pain goes away. Code this diagnosis and procedure.
212.1, 31578
Paul Bunyan presents to the emergency department after accidentally cutting his upper thigh with a chainsaw, resulting in an injury to his common femoral artery. Mr. Bunyan is taken to the operating room, where a surgeon does a direct repair of the blood vessel (femoral artery). The surgeon also performs a 7.5-centimeter complex repair of his leg (with no tendon involvement) after repairing the artery. Code this scenario, making sure to code the two procedures separately . . . and don't forget the E-code!
E920.1, 904.0, 890.1, 35226, 13121
A 64-year-old male patient arrives at the hospital with acute renal failure (unspecified). The IV team is unable to gain access, so the surgical resident is called to obtain vascular access. The resident places a non-tunneled centrally inserted central venous catheter in the patient's right subclavian vein. Code the diagnosis and procedure for this scenario
584.9, 36556
A 40-year-old man with a family history of colon cancer sees his doctor for a check-up. He has no symptoms of illness, but the doctor recommends that he have a screening colonoscopy. On the day of the procedure, the doctor discovers several colon polyps, and he removes them with hot biopsy forceps. Pathology later identifies them as benign. What are the diagnosis and procedure codes for this scenario? Don't forget the V-code!
V16.0, 211.3, 45384
A 13-year-old boy has been having symptoms of recurrent sore throats and excessive snoring at night. His pediatrician, who has been following this for the past year, diagnoses chronic tonsillitis and adenoiditis and recommends a tonsillectomy with adenoidectomy. What are the codes necessary for this scenario on the day of surgery?
474.02, 42821
A 47-year-old patient who has long-standing myasthenia gravis has become a candidate for thymectomy because of an exacerbation of her illness. On the day of surgery, the surgeon uses a transthoracic approach to perform a total thymectomy, but he does not perform a mediastinal dissection. Code the diagnosis and procedure codes for this scenario.
358.01, 60521
Dr. A requested that Dr. B perform a consultation on his patient for a skin condition. The patient reported to Dr. B's office, and he had never been there before. Dr. B performed a detailed examination, a comprehensive history, and his decision-making involved minimal diagnosis options, minimal data, and minimal risk. Dr. B diagnosed the patient with skin tags, and he offered to remove them during that visit. The patient consented, and the doctor removed 25 skin tags. He sent a report to Dr. A and discharged the patient. How would you code the diagnosis and procedure codes for this scenario?
701.9, 99242-57, 11200, 11201
A doctor takes a patient to surgery. The patient has uncontrolled diabetes mellitus (type II) with a peripheral circulatory disorder and gangrene of his bilateral great toes, and he has a 20-year history of cigarette smoking. The surgeon performs an amputation of both great toes, at the metatarsophalangeal joints. Code the diagnoses and procedure for this scenario.
250.72, 785.4, V15.82, 28820-50
A patient with breast cancer (unspecified) with a positive estrogen receptor status undergoes a radical mastectomy, including pectoral muscles and axillary lymph nodes. At the time the surgery was planned, the patient and surgeon agreed that she would have a permanent prosthesis placed when the mastectomy wound healed. The pathology report comes back saying that the surgery was successful in removing all the cancer—there's no evidence of disease and the wound is healing well. There's a global surgical period of 90 days for the mastectomy, but in 45 days, the surgeon returns the patient to the operating room and places a permanent prosthesis. Code the diagnoses and procedures for both cases.
174.9, V86.0, 19305; V10.3, 19342-58
A patient returns to his doctor's office for a scheduled biopsy of a superficial soft tissue mass on his forearm. He had already had a consultation with the doctor about the problem the week before. After the procedure, the patient asks the doctor about the migraine headaches he's been having for the past week. The doctor performs an expanded problem-focused history, a problem-focused examination, and his medical decision-making is straightforward. He diagnoses the patient with a classical migraine without intractability. The pathology report comes back later in the week, and the mass is benign. Code the diagnoses, the procedure, and the E/M code for this scenario
216.6, 25065, 346.00, 99212-25