AAPC - Chapter 13 Practical Applications

CASE 2 DIAGNOSES: 1. Complete procidentia (The stated diagnosis is Complete Procidentia, and this is well supported in the body of the operative note. A review of several medical dictionaries shows the definition of Procidentia, prolapse of an organ or part.) 2. Recurrent urinary tract infections (A history of postmenopausal vaginal bleeding, anemia and recurrent urinary tract infection (UTI).) 3. Postmenopausal vaginal bleeding (Select codes for the definitive diagnoses.) PROCEDURES: 1. Vaginal hysterectomy 2. Anterior and posterior colporrhaphy 3. Cystoscopy 4. Vaginal vault suspension SPECIMENS: Uterus and cervix. FINDINGS: A thick hypertophic ulcerated cervix was noted. The adnexa were small and atrophic. Complete procidentia with cystocele and rectocele. (All of these problems are addressed in the body of the note below.) Cystoscopy done after indigo carmine was administered,(Indigo carmine is a dye injected during urogynecologic procedures for better visualization of structures/fluids etc. by turning the urine red.) at the end of the case, revealed bilateral strong ureteral jets. INDICATIONS: Pt. with history of postmenopausal vaginal bleeding, anemia and recurrent urinary tract infections, although she denied any urinary incontinence. Her cervix was found to be ulcerated, erythematous and hypertrophic. Cervical biopsy was negative for neoplasia. She desires surgical management of these problems. OPERATION: The patient was taken to the operating room and placed in lithotomy position while awake. The patient has a history of bilateral knee replacements and cannot bend her legs. We put her in lithotomy position using Yellofin stirrups, keeping her legs without any bend and positioning her while she was awake in a comfortable way.(Lithotomy position is typically supine with the knees bent and legs elevated in stirrups. Use of this unusual set of Yellofin stirrups does not impact the coding.) The patient was then placed under general anesthesia. An exam under anesthesia (An exam cannot be billed separately if a therapeutic procedure is performed during the same encounter.) was done with findings of a complete procidentia with ulcerations posteriorly. The vagina and perineum was prepped in the usual sterile fashion. A tenaculum was then placed on the right and left lateral cervix. A circumferential incision was made at the cervicovaginal junction using Bovie cautery. The vesicovaginal fascia was then dissected anteriorly using a combination of sharp dissection with Metzenbaum scissors and blunt dissection. Attention was then turned posteriorly. The posterior peritoneum was grasped with a half curve, identified a then incised using Mayo scissors. A weighted speculum was then placed in the posterior cul-de-sac. The uterosacral ligaments were identified and clamped bilaterally with Heaney clamps, and a transection suture using 0 Vicryl suture was placed at the tip of the clamp system in both the right and left side. The uterocervical ligaments were then tagged and held for use during the vaginal vault suspension. Attention was then turned to the anterior peritoneum. A finger was placed in the posterior cul-de-sac up around the uterine fundus distending the anterior vaginal epithelium and allowing the anterior peritoneum to be entered safely using Mayo scissors. The cardinal ligaments were clamped and cut bilaterally. The utero-ovarian ligaments were identified, cut, suture-ligated, and then free tied bilaterally. The uterus was then removed from the vagina (This is the completion of the vaginal hysterectomy. Note that the uterus was not weighed, which will limit the code to be chosen.) and sent to pathology. All pedicles were then inspected and were found to be hemostatic. We could not visualize the ovaries (Note that the tubes and ovaries were not removed, only examined. The final code choice includes this information.) but were palpated and felt to be atrophic. At this point, we began the vaginal vault suspension. (Colpopexy using uterosacral ligaments by vaginal approach.) There was some oozing from the patient's left side near the vaginal cuff area. This was controlled with a figure-of-eight suture of 0 Polysorb. (Control of normal intraoperative bleeding is included in surgical procedures and is not billed separately.) Other small areas along the cuff were touched with the Bovie, and hemostasis was very good at this point. The uterosacral ligament remnant was put under pressure to palpate the ligament through its course to near the ischial spine. The bladder was drained with a Foley. A long Allis clamp was placed on the uterosacral near the ischial spine by tugging gently on the remnant that was stretched out and using the more inferior fibers. A suture of 0 Polysorb was placed through the ligament with care to drive the needle from superior to inferior, to avoid the ureter. A second suture was placed slightly more distal with 0 Maxon and then more distal again a 0 Polysorb. These were all held while a similar procedure was repeated on the left side with palpation of the ligament and the ischial spine and taking the inferior fibers. All of the sutures were held while the anterior and posterior repairs were made. The anterior vagina was then inspected and the cystocele identified. The vaginal wall was trimmed anteriorly. The posterior vagina was also inspected and excessive tissue was excised. At this point the vaginal cuff appeared hemostatic and was closed by first taking the 0 Polysorb, which is the distal uterosacral stitch and making an angle stitch to close the vagina. The anterior and posterior vaginal walls were closed as well as the pubocervical fascia anteriorly (Anterior colporrhaphy.) and the rectovaginal fascia posteriorly (Posterior colporrhaphy.) to get fascia to fascia closure. Once each of the angle stitches had been placed, they were held and not tied down yet. The 0 Maxon were then placed in a similar fashion through the anterior vaginal fascia and mucosa and the posterior fascia and mucosa. Lastly the 0 Prolene, which were the most superior stitches, were placed through the anterior posterior vaginal cuff, but these were taken slightly away from the cut edge so that the knots could be buried but again taking fascia and vaginal mucosa. Then a 0 Polysorb figure-of-eight suture was placed across the midline and vaginal mucosa so that we could completely bury the Prolene sutures at the end of the case. At this point, all of the sutures were tied except the Polysorb to close the mucosa in the midline. There appeared to be excellent vaginal support at this point.(Colpopexy using uterosacral ligaments by vaginal approach.) The Foley catheter was removed. The 17-French cystoscope (Cystoscopy performed only to verify that there was no damage to the bladder and ureters, which run parallel to the uterine artery near the cervix. Great care is usually taken not to sever the ureter when transecting the uterine artery in a vaginal hysterectomy. Injection of Indigo Carmine allows the surgeon to confirm the patency in the ureter as the red urine enters the bladder. The operative note indicates "strong uterine jets", which confirm ureteral patency.) sheath was placed through the urethra. The 70-degree lens was used with sterile water infusing to inspect the bladder. There was moderate trabeculation of the bladder.(This is a thickening of the bladder muscle.) There were no mucosal lesions to explain her infections. There were no stones, stitches or other lesions. A quarter of an ampule of indigo carmine had been given about 10 minutes earlier IV. Strong ureteral jets were observed from both sides, although the right side concentrated the dye faster than the left side by about 5 minutes. The bladder was drained and the urethra was inspected with the 0-degree lens and there were no urethral lesions. The bladder was drained and the Foley catheter replaced. The last midline 0 Polysorb suture was closed over the midline to bury the Prolene. All the sutures were cut and the cuff was irrigated with the cystoscopy fluid. A rectal exam was done which did not yield any sutures. The vagina was then irrigated and was found to be hemostatic. A vaginal pack was then placed. The patient was awakened from general anesthesia and brought to the PACU in stable condition. What are the CPT and ICD-10-CM codes?

57260 58260-51 57283-59 N81.3 N95.0 N32.89

CASE 1 DIAGNOSES: Stage III cystocele, stage II uterine prolapse. (Do not code the cystocele separately as it is included in the diagnosis code for the uterine prolapse.) PROCEDURE: Pessary fitting. INDICATIONS: A 75 year-old, gravida 4, para 4,(This information indicates that the patient has had four pregnancies with four term births and the last two babies were quite large.) female with pelvic organ prolapse. She had atrophic vaginitis so we had her use Premarin vaginal cream twice a week for six weeks. She is back for a pessary fitting today. FINDINGS: She has a third-degree cystocele, and after examination we've determined she actually has a third-degree uterine prolapse.(The diagnosis is cystocele with uterine prolapse. Stage III uterine prolapse is considered a complete prolapsed.) Her vaginal tissues are improved, although still atrophic, but much less thin than prior appointment. DESCRIPTION OF PROCEDURE: After her exam, I started with a #4 ring pessary with support. This was clearly not large enough and the cystocele was coming around it. I then went to a #5 ring pessary with support with the same problem. I went to the #6 ring pessary with support.(The provider indicates the size of the pessary that he is fitting.) It did not lodge behind her pubic bone very well, but it definitely reduced all of her prolapse. She mentioned earlier in the appointment that she could not void when she came in today. She has not tried reducing it. I am hopeful that the pessary may help with that. The #6 was comfortable for her. I stood her up and put her through some maneuvers and it stayed nicely in place. Then she went walking with the pessary in place for 10 or 15 minutes and went up and down the stairs. She definitely was able to void more easily with it in. It was comfortable and she did not really notice it was in. On recheck it still seemed like she had a little more room in the pelvis. I removed the #6 and went up to a #7 size. This seemed to reduce the prolapse a bit better, but was a little uncomfortable for her. We went back to the #6 ring pessary with support. She was able to remove it and place it with instruction in our clinic today. DISPOSITION: We have ordered the #6 ring pessary (If the provider supplied the pessary, a HCPCS Level II code would be reported.) with support and it will be sent to her. After she gets the pessary, she will remove it once a week and leave it out overnight. She will continue to use the Premarin vaginal cream twice a week. She will return to clinic after she has used the pessary for 2 or 3 weeks, so we can check her tissues. She is to report if she has vaginal discharge or bleeding, as she is at risk for getting ulceration from the pessary. I answered all of her questions about her condition of pelvic organ prolapse and treatment with estrogen and pessary. She will call if she has any bleeding. What are the CPT® and ICD-10-CM codes reported?

57160 N81.3

CASE 3 Indications: 21-year-old, G3, P1-0-2-1,(Patient has been pregnant three times, has given birth to a term infant one time, has had two abortions/miscarriages and has one living child.) found to have an abnormal cervical Pap test (Abnormal cervical Pap smear is the diagnosis.) with possible LGSIL.(Low-Grade Squamous Intraepithelial Lesion is documented as possible so it is not coded.) She presents for follow-up pap and colposcopy. EXAM: Pubic hair is shaved. Negative inguinal adenopathy. The urethra, the introitus, and anus are grossly normal. Vagina is long, and an extra-long Pederson speculum is needed. Cervix is posterior, parous. Uterus anteverted, normal size. Some tenderness of the adnexa to deep palpation. No cervical motion tenderness. Normal discharge. Pap test was performed.(Pap test is performed.) COLPOSCOPIC PROCEDURE: Speculum was inserted for the colposcopy. An extra-long, narrow Pederson speculum was required and the cervix was visualized. 3% acetic acid was placed and the T-zone is large and bleeds to touch. The 3% acetic acid was placed, and several aceto-white lesions were noted, particularly at the 12- and 11 o'clock positions. Lugol solution was placed, and there was no uptake at the 6- and 11 o'clock portions of the cervix. 4% topical lidocaine was placed without epinephrine, followed by 1 cc of 1% lidocaine also without epinephrine. A LEEP (Loop Electrocautery Excision Procedure biopsy.) biopsy was taken of the cervix without difficulty and this also cauterized the bleeding. Instructions given to the patient that she must refrain from intercourse for at least 1 week. She is aware to call if any severe pain, bleeding that does not stop, foul odor, or fever. She is aware the results will take approximately 1-2 weeks and she will receive direct notification. What are the CPT® and ICD-10-CM codes?

57460 R87.619

CASE 10 PREOPERATIVE DIAGNOSIS: Severe cervical dysplasia. POSTOPERATIVE DIAGNOSIS: Severe cervical dysplasia. PROCEDURE PERFORMED: Cold knife conization. ANESTHESIA: General. COMPLICATIONS: None. ESTIMATED BLOOD LOSS: 25 cc. FLUIDS: 500 cc crystalloid. DRAINS: Straight catheter x 1. INDICATIONS: All risks, benefits and alternatives of this procedure were discussed with the patient and informed consent was obtained. DESCRIPTION OF PROCEDURE: The patient was taken to the operating room where general anesthesia was obtained without difficulty. She was prepped and draped in the normal sterile fashion after being placed in the dorsal lithotomy position. Attention was turned to the patient's pelvis where a weighted speculum was placed inside the patient's vagina. The anterior lip of the cervix was grasped with a single-tooth tenaculum and a paracervical block was performed using 10 units of Pitressin and 20 cc of normal saline. A #2-0 Vicryl stitch was used at the 3 o'clock and 9 o'clock positions on the cervix to ligate the cervical branch of the uterine artery. PROCEDURE (continued): A #11 blade was then used to incise in a circumferential fashion. This incision was carried down to the cervix using a cone shape. The cervical biopsy was removed and marked at the 12 o'clock position using a silk suture. The cervical bed was cauterized using the Bovie cautery with good hemostasis noted. The FloSeal was placed into the cervical bed and the cervical stitches were tied together in the midline. Good hemostasis was noted. All instruments were removed from the patient's vagina. All sponge, needle and instrument counts were correct x 2. The patient was taken out of the dorsal lithotomy position and taken to the recovery room awake and in stable condition. What are the CPT® and ICD-10-CM codes reported?

57520 D06.9

CASE 4 CHIEF COMPLAINT: Contraceptive placement of IUD (This is the reason for the visit.) INDICATIONS: Ms. Barrett is coming into the office for placement of an IUD. She is a 29-year-old, gravida 1, para 1-0-0-1 (This patient has been pregnant once having recently given birth to her first child who is currently alive.) who is status post a normal spontaneous vaginal delivery of a male infant weighing 4,086 grams. She has not had intercourse since delivery. She is interested in a Skyla IUD at this time. PROCEDURE: After obtaining consent, the patient is placed in the dorsal lithotomy position. A speculum was placed in the vagina to visualize the cervix. The cervix was cleaned three times with Betadine. Following this, a single-tooth tenaculum was placed on the anterior lip of the cervix. The uterus was sounded to approximately 6.5 cm. The Skyla IUD 13.5 mg, was then placed in the usual fashion (This is the insertion of an intrauterine birth control device.) and the strings cut to 2.5 cm. The lot number is TU003SL. The patient tolerated the procedure well, and hemostasis was achieved at the tenaculum site after removal. The patient tolerated the procedure well and was provided instructions to return if she should have any difficulties. What are the CPT® and ICD-10-CM codes?

58300 J7301 Z30.430

CASE 5 ABC Hospital Indication: 30 year-old G0P0Ab0 (The patient has never been pregnant.) with irregular periods. She is infertile and requires hysterosalpingogram for evaluation to see if there is a cause for the infertility. (Reason for the procedure.) PROCEDURE NOTE: The patient was brought to the outpatient surgical suite. After written consent was obtained and written final verification, the cervix was visualized with a Pedersen speculum, anesthetized with Cetacaine spray and swabbed with three swabs of Betadine scrub and an endocervical prep. A single-tooth tenaculum was placed on the anterior lip of the cervix without problems. An HSG catheter was introduced through the cervix. At this point the balloon was insufflated with 1 ml of normal saline within the cervix, speculum was then removed. Ethiodol contrast, approximately 8 ml, was instilled under fluoroscopic guidance.(This describes the hysterosalpingogram and injection procedure which allows for examination of the uterus and fallopian tubes for any abnormalities or blockages.) Under fluoroscopic guidance, the uterus shape was found to be normal. The tubes filled and spilled on the left. The right tube filled normally but no spill could be documented due to exuberant spill from the left. (This documentation reports the findings of the HSG.) The patient was instructed to roll completely for two revolutions. An additional film was taken which showed normal dispersion. Plan: Follow-up as scheduled. What are the CPT® and ICD-10-CM codes?

58340 74740-26 N97.9

CASE 9 ANESTHESIA: General with LMA. PREOPERATIVE DIAGNOSIS: Patient requesting sterilization. POSTOPERATIVE DIAGNOSIS: Sterilization. PROCEDURE PERFORMED: Tubal ligation with bilateral Falope-ring application. COUNTS: Needle, sponge and instrument counts were correct. INTRAOPERATIVE MEDICATIONS: 0.25% Marcaine with epinephrine. OPERATIVE FINDINGS: The left ovary was mildly adhered to the side of the uterus. The right ovary appeared normal. Both tubes appeared normal. The upper abdomen appeared normal. There was a small subserosal fibroid approximately 1 to 1.5-cm on the left upper aspect of the uterus. DESCRIPTION OF PROCEDURE: After informed consent, Ms. Mathews was taken to operating suite #4 and a general anesthetic was administered. She was placed in the dorsal lithotomy position. She was sterilely prepped and draped in the usual manner. A sponge stick was placed vaginally. An infraumbilical incision was made and a non-bladed trocar and sheath were placed. Proper placement was confirmed and insufflation was performed. A suprapubic incision was then made and the suprapubic trocar and sheath were placed under direct visualization. Findings were made as noted above and the right tube was ligated with the Falope-ring, and then the left. Pictures were taken to document proper placement. All instruments were removed and gas was allowed to escape. The sheaths were removed. Marcaine with epinephrine were placed again at the incision sites and they were closed with Monocryl in a subcuticular manner. The patient was allowed to emerge from the anesthetic and was transferred to the Postanesthesia Care Unit in stable condition. What are the CPT® and ICD-10-CM codes?

58671 Z30.2

CASE 6 PROCEDURE PERFORMED: Amniocentesis. INDICATIONS: The patient is a 28 year-old G4 P2103 at 36 2/7, here in the office today for amniocentesis for FLM secondary to Rh isoimmunization to D antigen. Following informed consent she elected to proceed with the amniocentesis. PROCEDURE: An ultrasound was carried out that revealed a single intrauterine gestation of 36+2 weeks in vertex presentation. A site for amniocentesis was identified in the left upper uterine segment which did not transgress the placenta and a image was retained for the record. The amniocentesis site was sterilely prepped and draped with a sterile towel and an alcohol based solution. Following this using direct ultrasound guidance a 22-gauge amniocentesis needle was sharply inserted in the amniotic fluid cavity. This returned clear amniotic fluid. 20 cc was easily aspirated and 10cc sent for FLM and 10cc held for possible OD450 if needed. The patient tolerated the procedure very well and normal fetal cardiac activity was seen following the procedure. The patient will be sent for a follow-up NST. Rhogam is not indicated as the patient is already sensitized. What are the CPT® and ICD-10-CM codes?

59000 76946 O36.0130 Z3A.36

CASE 7 OB DELIVERY NOTE Indications: 31 y/o G3P1 at 39 and 4/7 weeks admitted in labor. She has been followed in the OB clinic with 12 normal antenatal visits. Stage I: Patient was admitted with a cervical exam of 3/c/-1. She slowly progressed to 5 cm dilation. She had SROM at 0330 which showed light meconium. She continued to labor and reached the end of stage I at 1000, a period of 10 hours. FHTs showed some periods of reactivity but responded to stimulation. Stage II: Duration of Stage II (from pushing to delivery) was approximately 3 hours. A pediatric team was present. There was slight meconium staining present at delivery. Presentation was OP with right shoulder anterior shoulder. There was no nuchal cord. The cord was clamped x2 and cut and the baby was handed to pediatric team. Gender: Male Weight: 3772 grams. Apgars 8 /9 Stage III: Placenta delivered spontaneously with gentle traction and fundal massage and was intact. Vagina and cervix examined for lacerations. Inspection revealed a small second degree perineal laceration which was repaired with 3.0 Polysorb in the usual sterile fashion in layers. Another small lateral cutaneous tear was repaired with 3.0 polysorb and a figure-of-eight stitch. Good hemostatis was noted. Patient will return to clinic for follow-up in 6 weeks. What are the CPT® and ICD-10-CM codes?

59400 O70.1 O77.0 Z37.0 Z3A.39

CASE 8 PROCEDURE: D&E ANESTHESIA: Moderate sedation. INDICATIONS: The patient is a 29 year-old gravida 1 at 20-5/7 weeks with multiple fetal anomalies, who desires a termination of pregnancy. She has previously had dilators placed. DESCRIPTION OF PROCEDURE: The patient was brought to the operating room, and moderate sedation was administered by the anesthesia team. The patient then placed in the dorsal lithotomy position and was prepped and draped in usual sterile fashion. The dilators were removed. The patient's cervix was dilated to 5-6 cm. There was a bulging bag that ruptured during vaginal prep. A speculum was attempted to be placed, but the fetus was already delivering into the vagina. The umbilical cord was severed at this time, and no fetal heart beat was noted on ultrasound. Ultrasound guidance was used for the entire procedure. Gentle traction was applied and the fetus delivered intact. There was no respiratory or cardiac effort noted. Bierer forceps were then used to remove the placenta intact. A speculum was placed, and an atraumatic tenaculum was placed on the anterior lip of the cervix and a standard D&C was then performed until the characteristically gritty texture was noted on the endometrium. There was a small amount of bleeding noted from the lower uterine segment; 20 units of Pitocin was added to the patient's IV fluids and pressure was held against lower uterine segment for 5 minutes. At this time, hemostasis was noted to be excellent. The speculum was then removed, and the patient was taken out of the dorsal lithotomy position after her perineum was cleansed. The patient's anesthesia was discontinued and she was brought to the recovery room in stable condition. There were no complications during the procedure. The patient tolerated the procedure well. SPECIMEN(S): The products of conception were sent to pathology for cytogenetics and pathologic evaluation. PLAN: The patient will follow-up in the outpatient clinic. DIAGNOSIS: Intrauterine pregnancy at 20-5/7 weeks with multiple fetal anomalies. What are the CPT® and ICD-10-CM codes?

59841-22 Z33.2 O35.9XX0