CHAPrER 21 r Cardiovascular System

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

41. Valvuloplasty of the aortic valve using transventdcular dilation with cardiopulmonary bypass.

CPT Code:

,/ i+

y’+2. Xeptacement aortic valve, with cardiopulmonary bypass, with prosthetic valve.

CPT Code:

43. Valvuloplasty, tricuspid valve, with ring insertion.

CPT Code:

d p”puirof a coronary arteriovenous fistula, without cardiopulmonary bypass.

CPT Code:

d *r”rnal electrical cardioversion.

CPT Code:

47. Percutaneous balloon angioplasty; one coronary vessel.

CPT Code:

t*{. Cpp.(Cardiopulmonary resuscitatio4).

CPT Code:

49. Electrocardiogram with interpretation and report only.

CPT C6de:

C rrrurs graft of the common carotid-ipsilateral iriternal carotid artery using synthetic vein.

CPT Code:

5L. Ligation of temporal artery.

CPT Code:

Odd-numbered answers are located in Appendtx B, while the full arrrwer key ts only avallable tn the TEACE Instructor Resources on Evolve.

Copyrlght @ 2015 by Saunde$, an imprint of Elsevier Irrc. All rights reseryed.

45. Routine ECG with components.

CPT Code:

L2leads with both the professional and technical

CHAPTER 21

a

I Cardiovascular System

,/ v52. Ligation of a common iliac vein.

CPT Code:

53. Open ftansluminal balloon angioplasty aorta.

CPT Code:

,An. Coronary artery bypass, single artery, for coronary atherosclerosis of native coronary artery in a transplanted heart.

CPT Code:

ICD-10-CM Code:

(ICD-9-CM Code:

four veins, no arteries. Diagnosis of acute55. Coronary artery bypass, coronary insufficiency.

& cpr code(s):

& tco-ro-cM code(s):

(& ICD-q-cM Code(s):

teriovenous fistula of a’Iower extremity.

CPT Code(s):

ICD-10-CM Code(s):

ICD-9-CM Code(s):

& Ur”. to declde number of codes necessary to conectly answer the question. Odd-numbered ansyyers are located in Appendix B, while the full anxwer key is only avallable in the TEACH Instructof Resources on Evolve,

&

&

@

/ g/SO. nepair of injury to intra-abdominal blood vessel, inferior vena cava,

hepatic vein, with a vein graft.

& cpr code(s):

& tco-ro-cM Code(s):

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

57. Percutaneous insertion of an intra-aortic balloon assist device due to initial episode of acute myocardial infarction apd cardiogenic shock.

& cpr code(s):

& tco-ro-cM code(s):

/ (& ICD-o-cM code(s): I

VSa. nepair of a traumatic ar

Copy,right @ 2015 by Saunders, an impdnt of Elsevier Inc. Al1 rights teserved.

59. Repair congenital

CHAITTER 21 r

atrial septal defect, secundum, with

Cardiovasculat System

bypass and patch.

& cpr code(s):

& Ico-to-cM code(s):

.1& lco-o-cM code(s): ) ffiO. Repair of a patent ductus arteriosus by division on a 16-year-old patient.

& cpr code(s):

& Ico-ro-cM code(s):

1& Ico-e-cM code(s):

61. Reoperation of one arterial coronary bypass graft and one vein bypass graft for arteriosclerosis of native arteries, 3 months following the initial procedure.

& cpr Code(s):

& tco-ro-cM code(s):

1& rco-l-cM code(s):

B U””* to decide number of codes necessary to conectly answer the qucstloL odd-numbered answerc are located ln Appendix B, whlle the full answer key is only avallable ln the TEACE Instructor Resources on Evolve.

Copyright O 2015 by Saunders, an impdnt of Elsevier Inc. All rights reserved.

CHAI/IER 2t t Cardiovascular System

REPORTS

In Appenitix A of this workbook you will find a section titled Reports, which con{iins original reports. Read the reports indicated below and supply the appropriate cPT and ICD-10-CM/ICD-9-CM codes on the following lines:

tz. x”portzs & cpr code(s):

& tco-ro-cM code(s):

1& tco-l-cM code(s): -.-) 63. Report 26

& cpr code(s):

& Ico-ro-cM code(s):

, (& ICD-q-cM Code(s): /

J o+. Report 27

CPT Code(s):

ICD-1O-CM Code(s):

ICD-9-CM Code(s):

& Ur”r to decide number of codes necessary to correctly anslver the questlon. Odd-numbered answers are located in Appendix B, while the full answer key is only avallable in the TEACH InstrEctor Resources on Evolve.

&

&

(&

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APPENDIX A T RepoItS

PROCEDURE PERFORMED: Fiberoptic bronchoscopy, bronchial biopsy, bronchial washings, bronchial brushings.

PREPROCEDURE DIAGNOSIS: Abnormal chest x-ray.

POSTPROCEDURE DIAGNOSIS: Inflammation in all lobes, pneumonia. With pleural plaquing consistent with possible candidiasis.

The patient was already on a ventilator, so the bronchoscope tube was introduced through the endotracheal tube. We saw 2.5 cm above the carina of the trachea, which was red and swollen, as was the carina. The right lung-all entrances were patent, but they were all swollen and red, with increased secretions. The left lung was even more involved, with more swelling and more edema and had bloody secretions, especially at the left base. This area from the carina all the way down to the smaller airways on the left side had shown white plaquing consistent with possibie candidiasis. These areas were brushed, washed, biopsied. A biopsy specimen was also sent for tissue culture, as well as two biopsy specimens sent for pathology. Sheath brushings were also performed. The patient tolerated the procedure well, was still in the ICU, monitored throughout the procedure’

PROCEDURES PERFORMED: Left-sided heart catheterization, selective coronary angiography, and left ventricuiography.

INDICATION: Chest pain and abnormal Cardiolite stress test.

COMPLICATIONS: None.

RESULTS:

I. HEMODYNAMICS: The left ventricular pressure before the Lv-gram was 11,7lL with an LVEDP of 4. After the LV-gram, it was 11114 with an LVEDP of 10. The aortic pressure on pullback was 111177.

II. LEFT VENTRICULOGRAPHY The left ventriculography showed that the left ventricle was of normal size. There wele no significant segmental wall motion abnormalities. The overall left ventricular systolic function was normal with an ejection fraction of better tll,an 600/o.

III. SELECTIVE CORONARY ANGIOGRAPHY: A. RIGHT CORONARY ARTERY: The right coronary artery is a medium to large size dominant artery that has about 8Oo/o to 9Oo/o proximal/mid eccentric stenosis. The rest of the artery has only mild surface irregularities. The PDA and the posterolateral branches are small in size and have only mild surface irregularities.

B. LEFT MAIN CORONARY ARTERY: The left main has mild distal narrowing.

C. LEFT CIRCITMFLEX ARTERY: The left circumflex artery was a medium size, nondominant artery. It gave rise to a very high first obtuse marginal/intermedius, which was a bifurcating medium size artery that has only mild surface irregularities. The second obtuse marginal was also a medium size artery that has about 2oo/o to 25o/o proximal narrowing. After that second obtuse marginal, the circumflex artery was a small size artery that has about 2Oo/o to 30olo narrowing, a small aneurysmal segment. After

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I i

APPENDIX A r Reports

that, it continued as a small third obtuse marginal that has mild atherosclerotic disease.

D. LEFI ANTERIOR DESCENDING CORONARY ARTERY: The left anterior descending artery was a medium size artery that is mildly calcified. It gave rise to a very tiny flrst diagonal that has mild diffuse atherosclerotic disease. Right at the origin of the second diagonal, the LAD has about 30olo narrowing. The rest of the artery was free of significant obstructive disease. The second diagonal was also a small caliber artery that has no significant obstructive disease.

CONCLUSION:

1. Normal overall left ventricular systolic function 2. Severe single vessel atherosclerotic heart disease

RECOMMENDATIONS: Angioplasty stent of the right coronary artery.

PREOPERATM DIAGNOSIS: Atherosclerotic heart disease, coronary artery disease with depressed LV function.

POSTOPERATM DIAGNOSIS: Same.

PROCEDURE PERFORMED: Single vessel coronary artery bypass grafting, LIMA to LAD, off-pump.

ANESTHESIA: General endotracheal.

SPONGE COUNT, NEEDLE COUNT, INSTRUMENT COLINT: Correct.

ESTIMATED BLOOD LOSS: Approximately 666 cc and CellSaver given back is approximately 287 cc.

DRAINS: Four 19-French round Blake drains, one in the left chest, one in the right chest, one over the heart, and one over the pericardial wall, placed to Pleur-evac suction.

INDICATIONS: The patient is a 62-year-old man who has undergone approximately 72 heart catheterizations in the last several years. He has had recurrent in-stent stenosis of the proximal LAD lesion and also a branch of an OM with disease proximally. The patient is taken to the operating room because of recurrent angina, Class IIi anginal symptoms.

PROCEDURE: After informed consent was obtained, the patient was taken to the operating room. The patient was properly identifled. A Swan-Ganz catheter was placed and a right arterial line was placed. A Foley catheter was inserted. The patient was prepped from his chin to both feet bilaterally. A midline sternotomy was performed. The sternum was divided with the sternal saw and the left internal mammary was harvested in a standard fashion.

Simultaneously, the right greater saphenous vein was harvested beginning in the thigh and extending down to the level of the knee. The vein was adequate for bypass grafting. It was excised. The wound was then closed in layers.

Once the LIMA was nearly completely dissected free, the patient was heparinized. The LIMA was divided distally and noted to have excellent flow. It was tied distally. LIMA bed was examined for bleeding. There appeared to be no bleeding present from the LIMA bed. Attention was then turned to the pericardium. The pericardium was opened. Pericardial stay

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APPENDIX A T RepOTtS

sutules were placed. The left side of the pericardium was fashioned so that the LIMA coutd sit nicely to the LAD under the lung’ Deep pericardial stitch was placed allowing the heart to be elevated and brought medially. A stay ,- sutuie was placed around the proximal LAD and around the distal LAD. The octopus stabilizing device was used to stabilize the LAD at its mid portion. The proximal stay suture was placed down on the LAD. The LAD was opened and the LIMA had been fashioned for the anastomosis, and the LiVa to LAD anastomosis was carried out using a 7-0 Prolene in a continuous running fashion using a single knot technique. LIMA pedicle was then sutured down. There appeared to be no leak present from the LIMA anastomosis. The starfish stabilizing device was placed on the apex of the heart. The heart was elevated. The lateral wall of the heart was examined extensively for the OM branch that had some proximal disease in it. This artely was not able to be identif,ed. The heart was covered heavily in fat making it somewhat more difficult, but a thorough examination was carried orri. At this point I actually broke scrub, went to the cathetenzatron laboratory, re-examined the heart catheterization, and then went back to the OR a$ain looking for that vessel. It almost could have been acting like a high diagbnal vessel as it was a high OM, but again in this territory in this diitribution I could not identify that vessel, so only a single vessel LIMA to LAD anastomosis was created and the patient ended up with a single bypass. I think he should do well with just a single bypass’

The surgical sites were all examined for bleeding, and there appeared to be no bleeding present. The patient was reversed with 50 mg of Protamine and four Blake drains were placed, one in the left chest, one in the right chest, one over the heart, and one in the pericardial wall. The patient tolerated the procedure well. The preoperative and postoperative transesophageal echocardiogram looked fine. Sternal wires were placed and then the wound was closed in layers. Initial cardiac index here revealed a cardiac index of approximately 2.4 on low dose nitro drip.

PREOPERATIVE DIAGNOSIS: Symptomatic right internal carotid artery stenosis.

POSTOPERATM DIAGNOSIS: Symptomatic right internal carotid artery stenosis.

OPERATIVE PROCEDURE:

1. Right carotid thromboendarterectomy with patch placement’ 2. Intraoperative electroencephalogram monitoring.

INDICATION: This 3O-year-old woman has a tight right internal carotid artery stenosis. She has had an episode of amaurosis fugax. She has some othei medical problems that also complicate her overall situation, but she has a significantly tight stenosis that is symptomatic, and I would recommend an endarterectomy for this. The procedure, along with the risks, has been previously discussed with the patient. Please see the clinic notes. we will tre Ooing this with the patient awake. we also willbe doing EEG monitoring though because of the patient’s overall condition, and if she does not end up needing to be intubated during the middle of the case, we will still be able to monitor her brain activity.

PROCEDURE: This was done with the patient under cervical block. Local anesthesia was also infiltrated (0.5olo Marcaine with epinephrine). Dissection

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APPENDIX A r Reports

was carried down through a cervical oblique incision along the anterior border of the sternocleidomastoid muscle. Dissection was carried down to the carotid artery. The common carotid as well as the intemal and external carotid arteries and superior thyroid arteries were all dissected free sharply and circumferentially controlled with vessel loops. The common carotid was controlled with umbilical tape and Rumel tourniquet. The patient was systemically heparinized. ACTs were obtained and followed. The ICA was occluded, then the common and then the extemal carotid. Arteriotomy was made. The plaque was hemorrhagic and ulcerated. It was quite friable. we were able to dissect this out with Freer elevator. This came out quite nicely. The distal endpoint feathered off nicely, but we did place one single tacking suture at the 6-o’clock position. This was 7-0 prolene. we then used the Impra carotid patch to close the arteriotomy site. This was done with a Cy-7 Gore-Tex suture in a running fashion. We heparinized, backbled, and forebled. Intermittently, we had her move her left hand during the case. After suturing the suture line, we opened up the external caroiid and the common carotid. After about 10 heartbeats, we then opened up the internal carotid artery. There was bleeding from needle holes. This was controlled with FloSeal. There was good flow through all the arteries at the end of the procedure by Doppler. A 10-mm flat Jackson-pratt drain was placed before closure of the wound. Hemostasis was present. At the end of the procedure in the admit room, she was awake and following commands and moving all of her extremities. She went to the recovery room in stable condition. I met with the patient’s family postoperatively to discuss the operation. ADDENDUM: It should be noted that this procedure was done with intraoperative EEG monitoring. No changes were noted in the EEG during the procedure. clamp time was 40 minutes. A patch closure was used as noted. She was also reversed with 40 mg of protamine at the end of the procedure.

rNDrcATroN: Prolonged fetal heart rate deceleration. (report delivery complicated by fetal heart rate)

PROCEDURE: vacuum-assisted vaginal delivery. (report delivery yacuum assisted)

coMPLrcATroNS: shoulder dystocia, relieved with McRobert’s maneuver. (report delivery complication due to shoulder presentation)

PREAMBLE: The patient is a 33-year-old gravida 3, para 2, 3g week, 3 days gestation, admitted from the emergency department secondary to pelvic pain (not reported because the pain is part of delivery). The patient wai quite uncomfortable and had artificial rupture of membranes followed by labor progression to full dilation. She then began pushing, and some prolonged fetal heart rate decelerations dor.m to about 90 beats per minute were noted (supports delivery complicated by fetal heart rate). Because of this, a decision was made to proceed with vacuum extraction (supports delivery yacuum assisted) to assist in expediting delivery. PROCEDURE NOTB: Maternal bladder was emptied using straight catheter. Pelvic examination was carried out and the cervirwas cbnfirmed to be fully dilated. Fetal vertex was present at +1 station. The small kiwi cup vacuum (supports delivery vacuum assisted) was then applied to the fetal vertex. on the second pull, there was one pop off but this was after good

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CHAPIER 22 t Hemic, Lymphatic, Mediastinum, and Diaphragm

PRACTICAL

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

vd+. tn1..tion procedure for identification of the sentinel node with intradermal radioisotope injection for the staging of clinically negative axillae in a patient with primary, malignant neoplasm of the central portion of the right breast.

& cpr code(s):

& tco-ro-cM code(s):

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

35. Radical cervical lymphadenectomy for patient with malignant primary cancer of the nipple of the left breast. Pathology findings of the lymphadenectomy were positive.

& cpr code(s):

& Ico-ro-cM code(s):

1& tco-o-cM code(s): ) /

r/36. Drainage of an extensive lymph node abscess. Pathology report indicated Staphylococcus.

& cpr code(s):

& Ico-ro-cM code(s):

(& tcn-q-cM code(s):

37. Autologous bone marrow transplantation for a patient who has acute myelogenous leukemia that has not shown any signs of remission.

& cpr code(s):

& Ico-ro-cM code(s):

, {& lco-o-cM code(s): 4a. Purtiul splenectomy for a 3-year-o1d child with sickle cell disease, Hb-C

with crisis.

CPT Code:

ICD-1O-CM Code:

(ICD-9-CM Code:

& Ur”. to decide number of codes rrecessary to corectly answer the question. Odd-numbered answers are located ln Appendix B, while the full answer key ls only available ln the TEACff Instructor Resources on Evolve.

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

CFIAPTER 22 t Hemic, Lymphatic,

39.

Mediastinum, and DiaPhragm

Harvesting of bone marrow subsequent transPlantation

for transplantation from a father for into the daughter. RePort onIY the

of abdominal apProach.

harvesting service.

CPT Code:

ICD-10-CM Code:

(ICD-9-CM Code:

-)

1, Repair of laceration of diaphragm by means CPT Code:

41. Excision of

CPT Code:

mediastinal cyst.

,/+2. Resection of diaphragm with simple repair.

CPT Code:

Preparation of stem (hematopoietic that included thawing of previously cells.

CPT Code:

,1n. tururoscopic removal of the spleen.

45. A radiologist performs lymphoscintigraphy in the radiology department. A few hours later, the patient is taken to the operating room where the general surgeon iniects blue dye into the internal mammary lymph node and then excises a sentinel lymph node’

43. progenitor) cells for transplantation frozen cells and washing of the

Odd-numbered answers are located in Appendix Instructor Resources on Evolve.

CPT Code:

CPT Codes: -26 (for performing both the injection in the radiology department [nuclearand imaging of the radioisotoPe

medicine, lymph nodesl), -59 (for injecting the

blue dye), and (for excision of the sentinel lymph node in the operating room)

B, while the full arlswer key is only available in the TEACH

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CHAPIER 22 ; Hemic, Lymphatic, Mediastinum, and Diaphragm

REPORT

In Appenilix A of this workbook you will find a section titled Reports, which contains original reports. Read the report indicated below and supply the appropriate CPT and ICD-10-CM/ICD-9-CM codes on the following lines:

.,4 . Report 89

CPT Code:

ICD-10-CM Codes:

(External Cause code for how accident occurred),

(Y Code)

(CD-9-CM Codes: (E code for how accident occuued))

odd-numbered answers are located ln Appendix B, while the ftrll answer key is only available in the TEACII Instructor Resources on Evolve.

Copyright @ 20L5 by Saunders, an imprint of Elsevier Inc. Al1 rights reseryed.

APPENDIX A r Reports

He was patched with TobraDex ointment without Telfa for 24 hours, and we will make affangements to see him within the week.

PREOPERATM DIAGNOSIS: Splenic hematoma. POSTOPERATIVE DIAGNOSIS: Same.

PROCEDURE PERFORMED: Splenectomy.

ANESTHESIA: General.

PROCEDURE: A surgical technique was used to remove the spleen due to splenic hematoma following trauma in football game, kicked. The patient was given general anesthesia. The anesthesiologist inserted a temporary tube into the patient’s stomach to empty it. This helped to decompress the stomach and prevent postoperative nausea. A catheter was inserted into the bladder to drain the urine. Surgery was done with the patient lying flat on his back. Several small incisions were made into the abdomen. One was used for the laparoscope, which was attached to a camera that sent images to the video monitor. The other incisions were used to hold or manipulate tissue in the abdomen. carbon dioxide gas is insufflated into the abdominal cavity to allow room to work and to allow visualizing the area. parts of the spleen were freed from surrounding tissue. Blood vessels to the stomach and spleen were visualized, clipped with metal clips, and divided. once the spleen was dissected free of its attachments in the abdominal cavity, it was placed in a special surgical plastic bag and removed through one of the small abdominal incisions. At the end of the surgery, carbon dioxide gas was removed. The small incisions were closed with suture, the skin cleaned, and the incisions covered with a small dressing. Patient tolerated the procedure well.

PREOPERATM DIAGNOSIS: Prosrate cancer. POSTOPERATM DIAGNOSIS: Same. PROCEDURE PERFORMED: Cryoablation of prostate including suprapubic catheter insertion, transrectal ultrasound for prostate volume determination, placement of probes, and guidance of tissue ablation. Suprapubic catheter insertion.

cLrNrcAL NorE: This gentleman has had prostate cancer. He has elected to proceed with cryoablation. PROCEDURE NOTE: The patient was given a spinal anesthetic, prepped and draped in the lithotomy position. The Foley catheter placed into the bladder and transrectal ultrasound probe introduced. Prostate measurements and volumes were determined. Using the Cryoguide system, an B probe freeze was selected. Probes were placed under ultrasound guidance. once all temperature monitors and Cryoprobes were placed the Foley catheter was withdrawn and patient then cystoscoped using the flexible instrument. This ensured the needles had not violated the urethra and the probes were in good position. A 12 French suprapubic catheter was then placed using a trocar technique under endoscopic and ultrasound guidance into the anterior wall of the bladder using a single pass technique. once probe

l

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