CARDIOVASCULAR
1. Code the CPT and ICD-10 Procedural Codes for the Op Report
Below:Diagnosis: Multiple Myeloma; Operation: Placement of P.A.S. Port, left
arm.Indications: The patient, age 48, is currently under therapy for multiple
myeloma and will require chronic venous access for continued treatment. She was
referred for placement of a P.A.S. port device in the left arm. The risks,
benefits and options associated with this procedure are understood by the
patient and she has elected to proceed with surgery under local anesthesia as
described.
Procedure: This patient was placed on the operating room table in the
supine position with appropriate warming and monitoring devices in place. The
left arm was circumferentially prepped with Betadine and sterilely draped. 1%
plain Xylocaine was used to infiltrate the tissue of the antecubital fossa and
good anesthesia was obtained. A transverse incision was fashioned through which
a branch of the basilic vein was identified. A 5.6 French catheter and sensing
wire assembly was inserted into the vein and its tip was advanced to the caval
atrial junction. Catheter position was confirmed electromagnetically. The
sensing wire was removed and the catheter was attached to a miniature port
which was anchored in a subcutaneous space of the forearm. The system was
flushed with heparinized saline, and dynamics were found to be excellent. With
hemostasis intact and sponge and needle counts being correct the wound was irrigated
with saline and closed in layers using 3-0 Vicryl on the subcutaneous tissues
and 4-0 Vicryl subcuticular sutures in the skin. Sterile dressing was applied
and the patient was transported to the AKU in good condition.
b) 36569
c) 36561
d) 36571
2. Preoperative diagnosis: 68-year-old male in coma;Postoperative
diagnosis: 68-year-old male in coma; Procedure performed: Placement of a triple
lumen central line in right subclavian vein. With the usual Betadine scrub to
the right subclavian vein area and with a second attempt, the subclavian vein
was cannulated and the wire was threaded. The first time the wire did not
thread right, and so attempt was aborted to make sure we had good
identification of structures. Once the wire was in place the needle was removed
and a tissue dilator was pushed into position over the wire. Once that was
removed, then the central lumen catheter was pushed into position at 17 cm and
the wire removed. All three ports wereflushed. The catheter was sewn into
position, and a dressing applied.
a) 36011, R40.0
b) 36011, R40.20
c) 36556, R40.0
d) 36556, R40.20
3. Diagnosis: Cardiac Tamponande.Ten-year-old boy was admitted with
cardiac tamponade. initial pericardiocentasis yielded pus.Procedure: A
subxiphoid tube-pericardiostomy was done and thick, purulent material was
drained out. At surgery, however, an intrapericardial mass was discovered.
Successful excision was performed and the patient made an uneventful recovery.
histopathology of the mass revealed features of an intrapericardial teratoma.
a) 33015, 33020
b) 33015, 33020, 33050
c) 33015, 33050
d) 33020, 33050
4. What code would you use to report the percutaneous insertion of a
dual chamber pacemaker by means of the subclavian vein?
a) 33249
b) 33217
c) 33208
d) 33240
5. Patient has to return to the OR 6 weeks after the initial combined
arterial/venous grafting coronary artery bypass operation. A short saphenous
vein was used.
a) 33533
b) 33533, 33517
c) 33533, 33517, 33530
d) 33533, 33517-51, 33530-78
6. The physician performed a four-vessel autogenous (one vein, three
arteries) coronary bypass. Select the CPT code(s) for this procedure
a) 33517, 33535
b) 33535, 33517
c) 33518, 33534
d) 33513
7. Preoperative diagnosis: Atherosclerotic heart disease;
Postoperative diagnosis: Atherosclerotic heart disease;Operative procedure:
Coronary bypass grafts x 2 with a single graft from the aorta to the distal
left anteriordescending and from the aorta to the distal right coronary artery.
Procedure: The patient was brought to the operating room and placed in a supine
position. Under general intubation anesthesia, the anterior chest and legs were
prepped and draped in the usual manner. A segment of greater saphenous vein was
harvested from the left thigh, utilizing the endoscopic vein harvesting
technique, and prepared for grafting. The sternum was opened in the usual
fashion, and the left internal mammary artery was taken down and prepared for
grafting. The flow through the internal mammary artery was very poor. The
patient did have a 25-mm difference in arterial pressure between the right and
left arms the right arm being higher. The left internal mammary artery was
therefore not used.The pericardium was incised sharply and a pericardial well
created. The patient was systemically
heparinized and placed on bicaval to aortic cardiopulmonary bypass
with the sump in the main pulmonary artery for cardiac decompression. The
patient was cooled to 26, and on fibrillation an aortic cross clamp was applied
and potassium-rich cold crystalline cardioplegic solution was administered
through the aortic root with satisfactory cardiac arrest. Subsequent doses were
given down the vein grafts as the anastomoses were completed and via the
coronary sinus in a retrograde fashion. Attention was directed to the right
coronary artery. The end of the greater saphenous vein was then anastomosed
thereto with 7-0 continuous Prolene distally. The remaining graft material was
then grafted to the left anterior descending at the junction of the middle and
distal third. The aortic cross clamp was removed after 149 minutes with
spontaneous cardioversion. The usual maneuvers to remove air from the left
heart were then carried out using transesophageal echocardiographic technique.
After all the air was removed and the patient had returned to a satisfactory
temperature, he was weaned from cardiopulmonary bypass after 213 minutes
utilizing 5 g per kilogram per minute of dopamine. The chest was closed in the
usual fashion. A sterile compression dressing was plied, and the patient
returned to the surgical intensive care unit in satisfactory condition.
a) 33511, 33517, I70.90
b) 33511, 33508, I25.10
c) 33534, 33508, I25.810
d) 33511, 33517, I25.10
8. A patient presented for a median sternotomy for exploration of the
space around the lung sacs. A cyst was excised in the mediastinum. Select the
CPT code for this procedure.
a) 39010, 39200
b) 39402
c) 39200
d) 39010
9. A 57-year-old man has a Tesio catheter placed via the subclavian
vein. Both catheter sites are attached to a subcutaneous port. Choose the
code(s) for the service.
a) 36558 x 2
b) 36561
c) 36561 x 2
d) 36566
10. The man in the previous question had to return to the OR to have
the Tesio catheter and port removed 6 weeks later due to infection. Choose the
code(s) and modifiers for this subsequent service.
a) 36589-79
b) 36590-58
c) 36590-78 x 2
d) These services cannot be separately coded
11. A patient presents to the cardiac procedure room for replacement
of a ventricular electrode that was inserted 17 days prior. Select the CPT code
for this procedure.
a) 33211-79
b) 33218-78
c) 33216-78
d) this service is not billable
12. Julie, a 28-year-old ESRD patient was
seen by Dr. Jeri in an outpatient hospital facility for treatment of an
obstructed hemodialysis AV graft. Dr. Jeri provided moderate conscious sedation
to Julie for transluminal balloon angioplasty of peripheral dialysis segment
with diagnostic angiography . This procedure lasted 45 minutes. Julie had an
excellent result and was released to home after recovery from the treatment.
Dr. Jeri performed the professional fluoroscopic guidance, radiological
supervision and interpretation with this procedure. What code(s) capture this
service?
a. 36902
b. 36905
c. 36904,36907
d. 37248
13. Dr. Sacra performed a CABG surgery on Fred five months ago. Today,
Dr. Sacra completed another coronary artery bypass using three venous grafts
with harvesting of a femoropopliteal vein segment. How would Dr. Sacra report
her work for the current surgery?
a. 33512, 33530-51, 35572-51
b. 33535, 35500-51, 33519
c. 33512, 33530, 35572
d. 33535, 33519, 33530-51, 35500
14. What do the primary codes 33880 and 33881 include?
a. Placement of all distal extensions, if required in the distal
thoracic aorta
b. Placement of all proximal extensions in the thoracic aorta
c. Repair of extensions in the thoracic aorta
d. Repositioning of all leads and extensions in the thoracic aorta
15. What code would you report for a cervical approach of a
mediastinotomy with exploration, drainage, removal of foreign body, or biopsy?
a. 39010
b. 39000
c. 39200
d. 39401
16. Mrs. Reyes had a temporary ventricular pacemaker placed at the
start of a procedure. This temporary system was used as support during the
procedure only. How would you report the temporary system?
a. 33210
b. 33211
c. 33207
d. 33210, 33207-51, 33235-51
17. A 35-year-old female patient with a venous catheter requires a
blood sample for hematology testing.The sample is collected via her PICC
catheter. How would you report this procedure?
a. 36415
b. 36592
c. 36591
d. 37799
18. A patient underwent a secondary percutaneous transluminal
thrombectomy for retrieval of a short segment of embolus evident during another
percutaneous intervention procedure. How would you report this secondary
procedure?
a. 37184, 37186
b. 37186 in addition to the primary procedure
c. 37185, 76000
d. 37187
19. Mr. Azeri, a 68-year-old patient, has a dual-chamber pacemaker.
The leads in this system were recalled. The leads were extracted via
transvenous technique, the generator was left in place, and new leads were
inserted via transvenous technique. How would you report this procedure?
a. 33214, 33215-51, 33208-51, 33218-51
b. 33215, 33210-51, 33216-51
c. 33208, 33235-51, 33217-51
d. 33235, 33217-51
20. Procedure: Dual chamber pacemaker defibrillator implantation.
Indications: A 67-year-old white gentleman who has significant underlying
ischemic cardiomyopathy with EF of 25 percent, prior infarcts, remote history
of syncope and at high risk for malignant ventricular arrhythmias. He has had a
recent T wave alternans test which was clearly abnormal. He has had episodes of
resting bradycardia also noted. He also meets Madit II criteria for ICD
implantation. Description of Procedure: After informed consent had been
obtained, the patient was brought to the outpatient hospital lab in the fasting
state. The left anterior chest was prepped and draped in a sterile fashion.
Intravenous sedation and local anesthetic were given. After local anesthetic, a
5 cm incision was made at the left deltopectoral groove. With blunt dissection
and cautery, this was carried down through the prepectoralis fascia. The
cephalic vein was identified and ligated distally. Through the venotomy, a
subclavian venogram was performed to provide a roadmap. The atrial and
ventricular leads were then advanced into the vessel to the level of the right
atrium under fluoroscopic guidance. The ventricular lead was maneuvered to the
right ventricular outflow tract and then through the RV apex where it was
actively fixed. Good sensing and pacing thresholds were demonstrated. The lead
was anchored to the pre-pectoralis fascia with interrupted 2-0 Tycron sutures.
10 volt pacing did not result in diaphragmatic capture. The atrial lead was
maneuvered to the anterolateral right atrial wallwhere it was actively fixed.
Good sensing and pacing thresholds were demonstrated. The lead was anchored to
the pre-pectoralis fascia with interrupted 2-0 Tycron sutures. 10 volt pacing
did not result in diaphragmatic capture. A subcutaneous pocket was created with
good hemostasis achieved. The pocket was subsequently irrigated with solution
of Bacitracin. The generator was connected to the lead and then placed in the
pocket with no tension on the lead. The deep fascial layer was closed with
interrupted 2-0 Vicryl suture. The subcutaneous closure was made with running
3-0 Vicryl suture. Subcuticular closure was made with running 4-0 Vicryl
suture. Steri-strips were applied. Ventricular fibrillation was induced with a
T wave shock. This was successfully sensed and terminated with a 15 joule shock
to sinus rhythm. High voltage impedence was 39 ohms. Dry dressing was placed
over the wound. The patient returned to thefloor in stable condition without
apparent complications. Which of the following codes accurately describes the
basic procedure summarized in this report?
A. 33207
B. 33208
C. 33240, 33208
D. 33249
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