CPC 4 series (Digestive System)

  1. 1 : Pre-op Diagnosis: Acquired Velopharyngeal Incompetency following Cleft palate correction. Post-op Diagnosis: Acquired Velopharyngeal Incompetency following Cleft palate correction. Procedure Performed: Revision Palatoplasty.for cleft palate complication. Description: A 6 years old male patient has brought to the operating room for correction of velopharyngeal incompetency following the previous palatoplasty procedure. He has been prepped and draped in usual sterile fashion. After induction of general anesthesia, The physician revises the previous cleft palate incisions to lengthen the soft palate. The incisions are made in the palatal mucosa adjacent to the alveolar (tooth-bearing) bone. The mucosa is elevated and loosened from the bony palate. The Mucosal advancement pedicle flaps utilizing posterior palatine blood supply are developed and sutured to increase the anterior-posterior length of the soft palate. The physician sutures all remaining midline incisions in layers. The patient tolerated the procedure well and successfully transferred to PACU. What code best describes the service done by the Surgeon.

  1. 2 : Arulmozhi a 12-year-old patient who affected by chronic tonsillitis is scheduled for excision of tonsils today. Physician removes the tonsils by grasping the tonsil with a tonsil clamp and dissecting the capsule of the tonsil. The tonsil is removed. Bleeding vessels are clamped and tied. How would you report the procedure?

  1. 3 : Sriram has a mass on esophagus and stenotic stomach encountered for upper endoscopy today. The physician passes an endoscope through the patient's mouth into the esophagus. Biopsy is taken from the mass in esophagus and submitted for pathological evaluation. Scope is further advanced into stomach where the stricture is found and a balloon on a catheter is advanced through the endoscope and through the stricture. The balloon is inflated to 40mm diameter and dilated. The endoscope is removed. Code the procedure.

  1. 4 : Pre-Op diagnosis: Bile duct stricture, Pancreatic duct stone. Post-Op diagnosis: Bile duct stricture, Pancreatic duct stone. Planned Procedure: ERCP Sphincteroplasty and calculus removal. Description: Patient was taken to Endoscopic suite. Patient was positioned in prone and sedated with MAC anesthesia. The physician passes the endoscope through the patient's oropharynx, esophagus, stomach, and into the small intestine. The ampulla of Vater is cannulated and filled with contrast. The pancreatic duct is visualized, and a calculus is found and removed then common bile duct is visualized, and a stricture is found and a sphincterotomy is performed to reach the area and balloon dilator is inserted and inflated and the desired outcome is achieved.Code the procedure(s)

  1. 5 : Bharath has severe abdominal pain and encountered hospital where acute appendicitis with perforation and peritonitis was diagnosed. Physician done Appendectomy surgery. What codes you would report for this procedure?

  1. 6 : Karuppaiah a 56 –year old male patient undergone colonoscopy and two polyps from descending colon was removed with hot biopsy forceps and three polyps from transverse colon were removed with snare technique and the excised area in descending colon showed bleeding which was cauterized using electro cautery. What codes you would report for this scenario.

  1. 7 : Preoperative Diagnosis: Lower right inguinal pain Postoperative Diagnosis: Right Inguinal hernia Procedure: This 28-year-old patient presented with lower right inguinal pain and on examination was found to have a right inguinal hernia which is sliding. The decision to perform a right inguinal hernia repair was made. The procedure was performed in the outpatient hospital surgery center. Risks and benefits of the surgery were discussed with the patient and the patient decided to proceed with the surgery. A skin incision was placed at the umbilicus where the left rectus fascia was incised anteriorly. The rectus muscle was retracted laterally. Balloon dissector was passed below the muscle and above the peritoneum. The sliding hernia sac was easily identified and was well-defined. It was dissected off the cord anteromedially. It was taken back down and reduced into the peritoneal cavity. Mesh was then tailored and placed overlying the defect, covering the femoral, indirect, and direct spaces, tacked into place. After this was completed, there was good hemostasis. The cord, structures, and vas were left intact. The wounds were closed with 0 Vicryl for the fascia, 4-0 for the skin. Steri-Strips were applied. The patient was awakened and carried to the recovery room in good condition, having tolerated the procedure well. What are the correct procedure and diagnostic codes?

  1. 8 : Pre - Op diagnosis: Hemorrhoids, Anal fistula. Post- Op diagnosis: Hemorrhoids, Anal fistula. Procedure performed: Excision of hemorrhoids and Anal fistula. Description: The physician explores the anal canal and where he identifies the internal and external hemorrhoid in left lateral column. He made an incision and around the hemorrhoid and removed. Fistula inside the anal canal identified is then dissected from subcutaneous tissue and removed. The incisions are closed with sutures. What CPT codes should be used for this scenario?

  1. 9 : Edapadi palanisamy a 64 year-old male patient who has congenital cleft lip disorder encountered today for repair of his deformity. Dr.Tamilisai completed cleft lip repair bilaterally. What CPT code should be reported for this procedure?

  1. 10 : Pre-Op diagnosis: Esophageal stricture. Post-Op diagnosis: Esophageal stricture. Procedure Performed: Endoscopic esophageal dilation. Description of the procedure: Patient was taken to the endoscopic suite. The physician inserts the flexible endoscope through the mouth into the esophagus. The endoscope is advanced under direct vision through the esophagus where stricture is present, a balloon on a catheter is advanced through the endoscope and through the stricture. The balloon is inflated to 25mm and dilation performed. After successful dilation endoscope was advanced to stomach and duodenum and visualized and no abnormalities found. The endoscope was removed. What codes you would report?

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