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NEW QUESTION # 262
View MR 005398
MR 005398
Operative Report
Preoperative Diagnosis: Nonfunctioning right kidney with ureteral stricture.
Postoperative Diagnosis: Nonfunctioning right kidney with ureteral stricture.
Procedure: Right nephrectomy with partial ureterectomy.
Findings and Procedure: Under satisfactory general anesthesia, the patient was placed in the right flank position. Right flank and abdomen were prepared and draped out of the sterile field. Skin incision was made between the 11th and 12th ribs laterally. The incision was carried down through the underlying subcutaneous tissues, muscles, and fascia. The right retroperitoneal space was entered. Using blunt and sharp dissection, the right kidney was freed circumferentially. The right artery, vein, and ureter were identified. The ureter was dissected downward where it is completely obstructed in its distal extent. The ureter was clipped and divided distally. The right renal artery was then isolated and divided between 0 silk suture ligatures. The right renal vein was also ligated with suture ligatures and 0 silk ties. The right kidney and ureter were then submitted for pathologic evaluation. The operative field was inspected, and there was no residual bleeding noted, and then it was carefully irrigated with sterile water. Wound closure was then undertaken using 0 Vicryl for the fascial layers, 0 Vicryl for the muscular layers, 2-0 chromic for subcutaneous tissue, and clips for the skin. A Penrose drain was brought out through the dependent aspect of the incision. The patient lost minimal blood and tolerated the procedure well.
What CPT coding is reported for this case?
Answer: D
Explanation:
The procedure involves a right nephrectomy with partial ureterectomy for a nonfunctioning right kidney with ureteral stricture.
* Procedure Description:
* Right nephrectomy (removal of the kidney).
* Partial ureterectomy (removal of part of the ureter).
* CPT Coding:
* 50220: Nephrectomy, including partial ureterectomy, any open approach.
References:
* AMA's CPT Professional Edition (current year).
* CPT Assistant for detailed coding guidelines on nephrectomy procedures.
NEW QUESTION # 263
Preoperative diagnosis: Right thigh benign congenital hairy nevus. *1
Postoperative diagnosis: Right thigh benign congenital hairy 0 nevus.
Operation performed: Excision of right thigh benign congenital>1
nevus, excision size with margins 4.5 cm and closure size 5 cm.
Anesthesia: General.0
Intraoperative antibiotics: Ancef.0
Indications: The patient is a 5-year-old girl who presented with her parents for evaluation of her right thigh congenital nevus. It has been followed by pediatrics and thought to have changed over the past year. Family requested excision. They understood the risks involved, which included but were not limited to risks of general anesthesia, infection, bleeding, wound dehiscence, and poor scar formation. They understood the scar would likely widen as the child grows because of the location of it and because of the age of the patient. They consented to proceed.
Description of procedure: The patient was seen preoperatively in > I the holding area, identified, and then brought to the operating room. Once adequate general anesthesia had been induced, the patient's right thigh was prepped and draped in standard surgical fashion. An elliptical excision measuring 6 x 1.8 cm had been marked. This was injected with Lidocaine with epinephrine, total of 6 cc of 1% with 1:100,000. After an adequate amount of time, a #15 blade was used to sharply excise this full thickness.
This was passed to pathology for review. The wound required limited undermining in the deep subcutaneous plane on both sides for approximately 1.5 cm in order to allow mobilization of the skin for closure. The skin was then closed in a layered fashion using 3-0 Vicryl on the dermis and then 4-0 Monocryl running subcuticular in the skin, the wound was cleaned and dressed with Dermabond and Steri-Strips.
The patient was then cleaned and turned over to anesthesia for S extubation.
She was extubated successfully in the operating room and taken S to the recovery room in stable condition. There were no complications.
What CPT coding is reported?
Answer: B
Explanation:
52356 = Cystourethroscopy with ureteroscopy, lithotripsy and stent placement Combination code → do not report components separately
NEW QUESTION # 264
(A patient is diagnosed with agangrenous ulceron theright thighwith thefat layer exposedand is currently being treated. What ICD-10-CM coding is reported?)
Answer: A
Explanation:
This scenario involves anon-pressure chronic ulcerwithgangrene. For non-pressure chronic ulcers of thethigh, ICD-10-CM usesL97.1-codes. "Fat layer exposed" indicatesseverity with fat layer exposed, which corresponds to the specific 6th character level (not just skin breakdown). The correct thigh code here isL97.
112(non-pressure chronic ulcer of right thigh with fat layer exposed). Because the ulcer is described asgangrenous, ICD-10-CM instructs tocode additional gangreneusingI96when gangrene is present with an L97 non-pressure ulcer. Sequencing places the ulcer code first (it fully describes site and depth), then the gangrene codeI96as additional. ThereforeI96 + L97.112are both required, and the correct option presented isI96, L97.112(Option C). Mnemonic:L97 = Location/Layer,I96 = Ischemic gangrene add-on.
NEW QUESTION # 265
A patient presents with recurrent spontaneous episodes of dizziness of unclear etiology. Caloric vestibular testing is performed irrigating both ears with warm and cold water while evaluating the patient's eye movements. There is a total of three irrigations.
What CPT coding is reported?
Answer: A
Explanation:
* Procedure: Caloric vestibular testing performed on both ears with three irrigations.
* CPT Code:
* 92537: Caloric vestibular test with recording, bilateral; bithermal (i.e., one warm and one cool irrigation in each ear).
* Modifier -50: Bilateral procedure.
* Code Selection Justification: The procedure performed was bilateral caloric vestibular testing with bithermal irrigation, appropriately coded with 92537 and modifier -50 for bilateral procedures.
References:
* AMA CPT Professional Edition (current year)
NEW QUESTION # 266
A driver loses control of a vehicle and crashes into a guardrail on the side of the highway. The patient sustains a fracture of the anterior fossa cranial base. Imaging confirms Involvement of the sphenoid sinus, but no cerebrospinal fluid (CSF) leak is identified. The patient undergoes a surgical nasal sinus endoscopy with sphenoidotomy lo evaluate and treat the sinus injury. No CSF leak repair is performed.
What is the correct procedure and diagnosis coding combination to report this service?
Answer: A
Explanation:
Procedure Coding (CPT):
31287 - Nasal/sinus endoscopy, surgical; with sphenoidotomy
Correct because the surgeon performed a surgical endoscopic sphenoidotomy to evaluate and treat sphenoid sinus injury.
No CSF leak repair was performed, so codes 31290-31291 are not appropriate.
31231-59 - Nasal endoscopy, diagnostic
Diagnostic endoscopy is separately reportable because:
It was performed to evaluate traumatic injury
It is not bundled into the surgical service when it provides distinct diagnostic information Modifier -59 indicates a separate and distinct service per NCCI edits.
Diagnosis Coding (ICD-10-CM):
S02.109A - Unspecified fracture of base of skull, initial encounter for closed fracture The anterior cranial fossa fracture with sphenoid sinus involvement qualifies as a skull base fracture No CSF leak is documented Correct 7th character "A" for initial encounter Why Other Options Are Incorrect:
A - Incorrect format and duplicated CPT logic
B - 31267 = maxillary sinus, wrong sinus
D - 31291 includes CSF leak repair, which was not performed
NEW QUESTION # 267
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