Coding: Digestive System Ch. 11
A 45 year-old woman underwent a laparoscopic cholecystectomy. The procedure was performed for recurrent bouts of acute cholecystitis. What CPT® and ICD-10-CM codes are reported?
. 47562, K81.0 Rationale: In the CPT® Index, look for Cholecystectomy/Laparoscopic which directs you to 47562-47564. 47600 and 47605 are open cholecystectomy codes. By turning to the numeric section of CPT and reviewing the code descriptions, you can verify that 47562 is the appropriate code for a laparoscopic cholecystectomy with no additional procedures performed.Acute cholecystitis is indexed in ICD-10-CM Alphabetic Index under Cholecystitis/acute for code K81.0. Verify code selection in the Tabular List.
How many lobes are in the liver?
4 lobes Rationale: The human liver has four lobes: the right lobe and left lobe, which may be seen in an anterior view, plus the quadrate lobe and caudate lobe.
A patient presents with a 2 cm benign lip lesion. The provider decides to remove the lesion along with a portion of the lip by performing a wedge excision. Single-layer suture repair is performed. What CPT® code(s) is/are reported for this service?
40510 Rationale: Because the physician is not only removing the lesion, but also removing part of lip, code 11422 is not reported. The lesion and a portion of the lip are removed by a transverse wedge technique. Look in the CPT® Index for Wedge Excision/Lip referring you to code 40510. The code description for code 40510 includes primary closure (suture repair) indicating an integumentary system repair code (12011) is not reported separately.
What CPT® code is reported for an intraoral incision and drainage of a hematoma of the tongue, submandibular space?
41008 Rationale: CPT® code 41008 is specifically for Intraoral incision and drainage of abscess, cyst, or hematoma of tongue or floor of mouth; submandibular space. Look in the CPT® Index for Drainage/Hematoma/Mouth/Submandibular Space. The code selection is made because it is intraoral, not extraoral.
A 12 year-old patient had an adenoidectomy in 2013 and a second adenoidectomy this year. What CPT® code(s) is/are reported for the second adenoidectomy performed this year?
42836 Rationale: Sometimes adenoid tissue, even after it has been removed, will grow back when a few cells are left behind. For the removal of the secondary adenoid tissue, report code 42836 which represents the secondary adenoidectomy. Look in the CPT® Index for Adenoids/Excision with a code range of 42830-42836. In this case, the patient is over 12 years of age upon presentation for the secondary adenoidectomy, further supporting the criteria for 42836.
What is the CPT® code for removal of a foreign body from the esophagus via the thoracic area?
43045 Rationale: In the CPT® Index, look for Esophagus/Removal/Foreign Bodies which directs you to 43020, 43045, 43194, 43215, 74235. There are two open approaches and two endoscopic approaches in the CPT® code book for the removal of a FB from the esophagus. 43020 is via a cervical approach and 43045 is via a thoracic approach, making code 43045 the correct choice.
A patient is admitted for a simple primary examination of the gastrointestinal system to rule out GI cancer. An Esophagogastroduodenoscopy (EGD) is performed, which includes examination of the esophagus, stomach and portions of the small intestine. During the examination, a stricture of the esophagus is identified and subsequently dilated via balloon dilation (20 mm). What CPT® and ICD-10-CM codes are reported?
43249, K22.2 Rationale: In the CPT® Index, look for Esophagogastroduodenoscopy/Flexible Transoral/Dilation of Esophagus which directs you to 43233, 43249. The procedure began as a diagnostic EGD which is represented by code 43235. During the exam, a stricture of the esophagus is identified and a surgical endoscopic balloon dilation is performed. The stricture of the esophagus is dilated 20 mm confirming 43249 is the correct code for the procedure. Surgical endoscopy always includes diagnostic endoscopy.Look in the ICD-10-CM Alphabetic Index for Stricture/esophagus referring you to K22.2. Reviewing the code descriptor in the Tabular List indicates stricture of esophagus as one of the conditions listed. We do not code GI cancer because it has not been established as a definitive diagnosis and rule-out diagnoses are not reported in outpatient coding
A 66 year-old female is admitted to the hospital with a diagnosis of stomach cancer. The surgeon performs a total gastrectomy with formation of an intestinal pouch. Due to the spread of the disease, the physician also performs a total en bloc splenectomy. What CPT® codes are reported?
43622, 38102 Rationale: In the CPT® Index, look for Gastrectomy/Total, you are directed to 43620-43622. A review of the code descriptors confirms CPT® code 43622 represents the complete gastrectomy with intestinal pouch formation. Code 38102 represents the en bloc total splenectomy and is an add-on code so it is modifier 51 exempt. In the CPT® Index, look for Splenectomy/Total/En bloc which directs you to 38102.
What is the correct CPT® coding for a partial distal gastrectomy with Roux-en-Y reconstruction with vagotomy?
43633, 43635 Rationale: In CPT® Index, look for Gastrectomy/Partial, which directs us to several codes including 43631-43635. When reviewing these codes in the main section of CPT®, code 43633 code descriptor represents a partial gastrectomy with Roux-en-Y reconstruction. Next, look for Vagotomy/with Partial Distal Gastrectomy in the CPT® Index. Code 43635 represents the vagotomy. Modifier 51 is not used as code 43635 is an add-on code and is modifier 51 exempt.
A 4 year-old patient, who accidentally ingests valium found in his mother's purse, is found unconscious and rushed to the ED. The child is treated by the ED physician, who inserted a tube orally into the stomach and performed a gastric lavage, removing the stomach contents. What CPT® and ICD-10-CM codes are reported?
43753, T42.4X1A, R40.20 Rationale: Code 43753 is the correct CPT® code for gastric lavage performed for the treatment of ingested poison. Look in the CPT® Index for Gastric Lavage, Therapeutic/Intubation. The ICD-10-CM code for the poisoning is found in the Table of Drugs and Chemicals by looking for Valium/Poisoning, Accidental (unintentional) column, referring you to code T42.4X1-. In the Tabular List a 7 th character is needed to complete the code. A is reported as the 7 th character because this was the patient's initial encounter.The next code is the manifestation of ingesting the Valium, unconsciousness. Unconsciousness is found in the ICD-10-CM Alphabetic Index and directs you to see Coma R40.20. The Tabular List confirms this code is reported for unconsciousness.
What CPT® coding is reported for a peritoneoscopy with laparoscopic partial colectomy and anastomosis?
44204 Rationale: A peritoneoscopy is a separate procedure and is not separately reportable when it is performed with a more extensive procedure. It is incidental to the laparoscopic partial colectomy and anastomosis. Look in the CPT® Index for Colectomy/Partial/with Anastomosis/Laparoscopic. The code is selected based on whether additional procedures, such as a coloproctostomy, is performed. There are no additional procedures in this case making 44204 the correct code choice.
A 28 year-old female had symptoms of RLQ abdominal pain, fever and vomiting. She was diagnosed with acute appendicitis. The surgeon makes an abdominal incision to remove the appendix. The appendix was not ruptured. The incision is closed. What CPT® and ICD-10-CM codes are reported for this encounter?
44950, K35.80 Rationale: In the CPT® Index, look for Appendectomy/Appendix Excision, you are directed to 44950, 44955, 44960. Look for the description for these codes in the main section of CPTÒ. 44950 is Excision, Appendectomy which correlates with the procedure performed. The appendectomy was performed via open incision and not laparoscopicallyAccording to the ICD-10-CM Official Coding Guidelines Section I.B.4, I.B.5, and I.C.18, if a definitive diagnosis is established, it is reported. Any signs or symptoms that would be an integral part of a definitive diagnosis/disease process would not be separately reported. RLQ abdominal pain, fever and vomiting are signs and symptoms of acute appendicitis; only the definitive diagnosis code, K35.80, is reported. In the ICD-10-CM Alphabetic Index, look for Appendicitis/acute which refers you to K35.80. Verification in the Tabular List indicates this code is for unspecified acute appendicitis which includes: Acute appendicitis NOS and Acute appendicitis without (localized) (generalized) peritonitis.
A female patient was taken to the emergency room for severe abdominal pain, nausea and vomiting. A WBC (white blood cell count) was taken and the results showed an elevated WBC count. The general surgeon suspected appendicitis and performed an emergency appendectomy. The patient had extensive adhesions secondary to two previous cesarean deliveries. Dissection of this altered the anatomical field and required the surgeon to spend 40 additional intraoperative minutes. The surgeon discovered the appendix was not ruptured nor was it hot. Extra time was documented in order to thoroughly irrigate the peritoneum. What CPT® and ICD-10-CM codes are reported?
44950-22, R10.9, R11.2, D72.829 Rationale: Code 44950 represents the appendectomy performed. In the CPT® Index, look for Appendectomy/Appendix Excision. Modifier 22 is appended due to the extensive adhesions that required 40 additional minutes be spent in order to perform the procedure safely and correctly.The signs and symptoms are reported because the surgeon suspected appendicitis but it is never confirmed. In the ICD-10-CM Alphabetic Index, look for Pain(s)/abdominal, which directs you to R10.9. Next, in the Alphabetic Index look for Nausea/with vomiting and you are directed to R11.2. Then, look for Leukocytosis, abnormally large number of leukocytes, which directs you to D72.829. Verification in the Tabular List confirms code selections.
A 20 year-old patient presented to the hospital for a sigmoidoscopy due to a history of bloody stools for three weeks duration. The patient was prepped and the sigmoidoscope was passed without difficulty to about 40 cm. The entire mucosal lining was erythematosus. There was no friability of the overlying mucosa and no bleeding noted. No pseudo polyps were identified. Biopsies were taken at about 30 cm; these were thought to be representative of the mucosa in general. The scope was retracted; no other abnormalities were seen. What CPT® and ICD-10-CM codes are reported?
45331, K92.1 Rationale: CPT® code for a sigmoidoscopy with single or multiple biopsies is reported 45331. This is indexed in CPT® under Sigmoidoscopy/Biopsy. Diagnostic sigmoidoscopy is always bundled with a surgical sigmoidoscopy when both are performed in the same operative session. The ICD-10-CM code for bloody stools is found looking in the ICD-10-CM Alphabetic Index for Blood/in/feces or Hematochezia ( see also Melena) and refers you to K92.1. When a patient comes in with a GI symptom (bloody stool, abdominal pain, etc.) and no definitive diagnosis is documented, the symptom(s) should be reported. Verify code selection in the Tabular List.
A 43-year-old male has a chronic posterior anal fissure. The posterior anal fissure was excised down to the internal sphincter muscle. Which CPT® code is reported?
46200 Rationale: In the CPT® Index, look for Anus/Fissure/Excision. You are referred to 46200. This is the correct code. There was a removal (excision) of a fissure, not fistula, without a sphincterotomy or hemorrhoidectomy.
What CPT® coding is reported when a physician makes two separate incisions to perform a laparoscopic appendectomy and laparoscopic cholecystectomy?
47562, 44970-59 Rationale: Code 47562 represents the laparoscopic cholecystectomy. In the CPT® Index look for Laparoscopy/Biliary Tract/Cholecystectomy or Cholecystectomy/Laparoscopic. You are directed to 47562-47564. Next, look in the CPT® Index for Laparoscopy/Appendix/Appendectomy. This directs you to 44970. Both codes can be reported because the physician made two separate laparoscopic site incisions to remove the gallbladder and appendix. We indicate this by appending modifier 59 to the 2 nd code.
Surgical laparoscopy with a cholecystectomy and exploration of the common bile duct for cholelithiasis. What CPT® and ICD-10-CM codes are reported?
47564, K80.20 Rationale: Look in the CPT® Index for Cholecystectomy/Laparoscopic which refers you to 47562-47564. Code 47564 is accurate for laparoscopic cholecystectomy when the exploration of the common bile duct is also performed.There is a diagnosis of cholelithiasis but no mention of obstruction and not with cholecystitis. The correct ICD-10-CM code is K80.20. In the ICD-10-CM Alphabetic Index, look for Cholelithiasis (cystic duct) (gallbladder) (impacted) (multiple) which instructs you to see Calculus, gallbladder. Look for Calculus/gallbladder you are directed to K80.20. Verify code selection in the Tabular List.
Margaret has a cholecystoenterostomy with a Roux-en-Y. Five hours later, she has an enormous amount of pain, abdominal swelling and a spike in her temperature. She is returned to the OR for an exploratory laparotomy and subsequent removal of a sponge that remained behind from surgery earlier that day. The area had become inflamed and was demonstrating early signs of peritonitis. What is the correct coding for the subsequent services on this date of service? (The same surgeon took her back to the OR as the one who performed the original operation.)
49402-78 Rationale: CPT® code 49402 represents the removal of a foreign body (sponge from previous surgery) from the peritoneal cavity. In the CPT® Index, look for Removal/Foreign Body/Peritoneum. Modifier 78 indicates this was an unplanned return to the OR by the same physician for a related procedure following an initial procedure during the initial procedure's postoperative period.
A 55-year-old patient underwent a repair of an initial left inguinal hernia. An incision was made at the groin. A hernia sac was readily identified and cleared from the surrounding tissue, inverted into the preperitoneal space, and plugged. Mesh was tacked to the surrounding muscle layers and then placed over the entire floor. What CPT® code(s) is/are reported?
49505-LT RATIONALE: In the CPT® Index, look for Hernia Repair/Inguinal/Initial, Child 5 Years or Older. You are referred to 49505 and 49507. Review the codes to choose the appropriate service. 49505 is the correct code. The repair was through an incision (not by laparoscopy) on an initial inguinal hernia on a patient over five years of age and the hernia was not incarcerated or strangulated. According to CPT® guidelines, "With the exception of the incisional hernia repairs (49560-49566), the use of mesh or other prosthesis is not separately reported." It is inappropriate to code the mesh in this scenario. Modifier LT is appended to indicate the hernia is on the left side.
A 42 year-old patient is brought to the operating room for a repair of a recurrent incarcerated incisional hernia using mesh. What CPT® and ICD-10-CM codes are reported?
49566, 49568, K43.0 Rationale: An incisional hernia (ventral hernia) is a bulging of the abdominal wall at the site of a past surgical incision. This is an incarcerated incisional hernia which means the intestine is protruding through an abnormal opening in the abdominal wall. This repair was performed by an open approach because it is not documented as being performed laparoscopically. In the CPT® Index look for Hernia Repair/Incisional/Recurrent/Incarcerated referring you to code 49566. When a recurrent incisional hernia is repaired, the age of the patient is not a factor in choosing the correct CPT® code. Mesh was used in the repair. Coding Tip note under code 49566 states, "with the exception of the incisional hernia repairs (see 49560-49566) the use of mesh or other prostheses is not separately reported". This means the coder can use two codes for this operative case. Look in the CPT® Index for Hernia Repair/Incisional/Implantation, Mesh or Prosthesis directing you to 49568. 49568 is an add-on code and an instructional note beneath the code states, "Use 49568 in conjunction with 11004-11006, 49560-49566." The CPT codes for the operative session are 49566 and 49568.Look in the ICD-10-CM Alphabetic Index for Hernia/incarcerated ( see also Hernia, by site, with obstruction). Look for Hernia/incisional/with/obstruction which directs you to K43.0. Review of the Tabular List verifies that code K43.0 is reported for an incarcerated incisional hernia.
What is the CPT® code for a test used to diagnose lactase intolerance? It involves the patient ingesting lactose sample followed by collections of exhaled air at different time intervals to measure the hydrogen levels in the breath.
91065 Rationale: This scenario is describing a diagnostic GI study/test. It indicates testing of breath hydrogen. In the CPT® Index, look for Gastroenterology, Diagnostic/Breath Test/Hydrogen; you are directed to code 91065. The code descriptor for 91065 indicates it is reported when determining lactase deficiency, fructose intolerance, bacterial overgrowth or orocecal gastrointestinal transit. A parenthetical note below the code description instructs that the code should be used once for each administered challenge.
When reporting an encounter for screening of malignant neoplasms of the intestinal tract, what does the 5th character indicate?
Anatomic location being screened in the intestinal tract. Rationale: Subcategory Z12.1 identifies screening for malignant neoplasms of the intestinal tract. The 5th character identifies the anatomic location in the intestinal tract.
A patient is seen in the outpatient GI lab of the hospital for rectal bleeding. A colonoscopy revealed three polyps in the transverse colon. The polyps were removed by snare technique and determined to be benign. What is the correct diagnosis code for this procedure?
D12.3 Rationale: The definitive diagnosis is polyps and identified as benign. Rectal bleeding is a sign of polyps in the colon and not coded. In the ICD-10-CM Alphabetic Index, look for Polyp, polypus/colon/transverse directing you to D12.3. You can also use the Table of Neoplasms and look for Neoplasm, neoplastic/Intestine, intestinal/large/transverse; the Benign column indicates D12.3.
Name the three sections of the small intestine.
Duodenum, jejunum, ileum Rationale: The three sections of the small intestine are the duodenum, jejunum, and the ileum. The ilium (note spelling) is one of the bones located in the pelvis. The sigmoid, rectum, and cecum are parts of the large intestine.
The patient is a 65-year-old female with Type 2 diabetes. She is seen today by her primary care physician for extreme abdominal bloating and discomfort after eating. The patient also complains of constant heartburn. This occurrs frequently and is not relieved by anything the patient has tried. The patient recorded her blood sugar this morning as 178. Her A1C taken in the office was 8.2. The physician diagnoses gastroparesis due to the patient's diabetes. Code the ICD-10-CM diagnosis(es).
E11.43, K31.84 Rationale: Gastroparesis is also called delayed gastric emptying. Gastroparesis may occur when the vagus nerve is damaged and the muscles of the stomach and intestines do not work normally. Food then moves slowly or stops moving through the digestive tract. The most common cause of gastroparesis is diabetes. In this case, the physician did link the gastroparesis to the patient's diabetes so we will use a diabetic complication code. In ICD-10-CM Alphabetic Index look for Diabetes, diabetic/type 2/with gastroparesis which directs you to E11.43. Even if the provider had not linked the gastroparesis with diabetes, because it is listed under 'with' in the Alphabetic Index, there is a presumed causal relationship. In the Tabular List there is an instructional note for code K31.84 that indicates to Code first underlying disease, if known and code E11.43 is listed. There is also an Excludes2 note under category code K31 which indicates that code E11.43 can be reported with codes in category K31.
What is the correct ICD-10-CM code for a 30 year-old obese patient with a BMI of 32.5?
E66.9, Z68.32 Rationale: In the ICD-10-CM Alphabetic Index, look for Obesity. You are directed to E66.9. In the Tabular List under category code E66 there is an instructional note to use additional code to identify body mass index (BMI), if known (Z68.-). Code Z68.32 represents an adult BMI of 32.0-32.9.
A patient is seen in the ED for nausea and vomiting that has persisted for 4 days. The ED physician treats the patient for dehydration which is documented in the patient's record as the final diagnosis. What ICD-10-CM code(s) is/are reported for this encounter?
E86.0 Rationale: Dehydration is the definitive diagnosis. Nausea and vomiting are signs and symptoms of dehydration and would not be coded. This is supported by General Coding Guideline 1.B.5, Conditions that are an integral part of a disease process. In the ICD-10-CM Alphabetic Index, look for Dehydration which directs you to E86.0. Verify code selection in the Tabular List.
What is the term that describes the removal of a portion or all of the stomach?
Gastrectomy Rationale: The prefix gastr- refers to the stomach and the suffix -ectomy indicates removal of.
What ICD-10-CM code is reported for acute gastritis with bleeding?
K29.01 Rationale: In ICD-10-CM, Gastritis is identified by specific 4th character codes to indicate with or without bleeding. Look in the ICD-10-CM Alphabetic Index for Gastritis (simple)/acute (erosive)/with bleeding which refers you to K29.01. Verify code selection in the Tabular List.
What is the correct ICD-10-CM code for a patient with IBS?
K58.9 Rationale: IBS stands for Irritable Bowel Syndrome. Look in the ICD-10-CM Alphabetic Index for Syndrome/irritable/bowel which refers you to code K58.9. Verify the code in the Tabular List.
A patient with a large prolapsed hemorrhoid arrives at the Emergency Department. After multiple attempts, the provider is unable to reduce it. The physician applies granulated sugar to the hemorrhoid and is then able to reduce the hemorrhoid. What is the correct diagnosis code?
K64.8 Rationale: Hemorrhoids are dilated or enlarged varicose veins which occur in and around the anus and rectum. The condition can be complicated by thrombosis, strangulation, prolapse, and ulceration. To find hemorrhoids in the ICD-10-CM Alphabetic Index, locate Hemorrhoids/Prolapsed directing you to K64.8. Verify code selection in the Tabular List.
What ICD-10-CM code is reported for internal hemorrhoids?
K64.8 Rationale: Look in the ICD-10-CM Alphabetic Index for Hemorrhoids (bleeding) (without mention of degree)/internal (without mention of degree) which refers you to K64.8. Verification in the Tabular List confirms code selection.
What is the correct ICD-10-CM coding for diverticulosis of the small intestine which has been present since birth?
Q43.8 Rationale: If a condition has been present since birth, it is considered congenital. Look in the ICD-10-CM Alphabetic Index for Diverticulosis/small intestine which refers you to K57.10. Verification in the Tabular list has an Excludes1 note under category code K57 for a congenital diverticulum of intestine and directs you to code Q43.8. Congenital diverticulum is in the list of congenital malformations beneath code Q43.8.
CASE 2 Procedure: Uvulopalatopharyngoplasty. (The procedure is to repair the uvula and tonsils.) Indication: A 63-year-old with obstructive sleep apnea. He is intolerant of CPAP. Description of Procedure: I identified the patient and he was brought to the operating room. General endotracheal anesthesia was induced without complication. Tonsillar pillars and palate were injected with 0.25% Marcaine. The right tonsil was grasped with an Allis forceps and dissected from the tonsillar fossa(Right tonsillectomy. It's not billable because it's included in the primary procedure.) with a combination of blunt and cautery dissection. The posterior pillar remained intact as I proceeded to do similar mobilization of the left tonsil.(Left tonsillectomy. It's not billable because it's included in the primary procedure - cannot be unbundled.) I then made a mucosa incision across the base of the palate approximately 0.5 cm from the base of the uvula, connecting the anterior tonsillar incisions. The muscular portion of the uvula and edge of the soft palate was then opened. Posterior pillar was opened inferiorly on the right tonsil fossa, and extended through the palate to include the uvula, and then extended inferiorly on the left side. The uvula, edge of the soft palate, and both tonsils were removed in total. Hemostasis was achieved with electrocautery. The mucosal incision was then closed with interrupted Vicryl sutures. The oral cavity was irrigated with clindamycin solution.The patient was awakened, extubated, and brought safely to the recovery room. What are the CPT® and ICD-10-CM codes for this service? CPT® code: [a] ICD-10-CM code: [b]
Specified Answer for: a 42145 Specified Answer for: b G47.33
CASE 6 Preoperative Diagnosis: Morbid obesity. Sleep apnea. BMI 40.Postoperative Diagnosis: Morbid obesity. BMI 40.Procedure Performed: Laparoscopic sleeve gastrectomy. Intraoperative esophagogastroduodenoscopy.Intraoperative endoscopyAnesthesia: General endotracheal anesthesia.Operative Procedure: The patient was brought to the operating room and placed on the OR table in supine position. Once general endotracheal anesthesia was achieved and pre-op antibiotics were given, the abdomen was prepped and draped in the standard surgical fashion. Access to the abdominal cavity was through a 1 cm supraumbilical incision with an Optiview trocar. Co2 was insufflated to achieve an intraabdominal pressure of approximately 15 mmHg. Accessory trocars were placed in the subxiphoid, right, mid, and left upper quadrants of the abdomen, as well as in the right and left lower quadrants of the abdomen. All this was done under appropriate videoscopic observation.The pyloric channel was then identified and approximately 4 cm proximal to it, the short gastric vessels of the greater curvature are taken down all the way up to the GE junction with the harmonic scalpel. A 38 french bougie is passed into the stomach into the pyloric channel and with the help of the linear cutter, the stomach is transected in a vertical fashion creating a gastric tube which is approximately 100 mm in diameter. The staple line is then over sewn with a running 2-0 Vicryl suture. Good hemostasis was achieved.Then I performed intraoperative esophagogastroduodenoscopy. The scope was advanced through the oropharynx, and under direct vision it was taken down through the esophagus and into the sleeve. There was no evidence of leak, bleeding, or any other abnormalities. A patent sleeve was seen all the way down to the pylorus. The scope was then retrieved carefully.A placement of a drain through the subhepatic space and extraction of the specimen through a right lower quadrant incision was done. All trocars were removed under appropriate videoscopic observation. There was no evidence of bleeding from any of the trocar sites. All the trocar sites were suture closed and injected with local anesthesia. The patient tolerated the procedure well. He was extubated on the table and transferred to the recovery room in stable condition. There were no complications. What are the CPT® and ICD-10-CM codes for this service? CPT® code(s): [a] ICD-10-CM code(s): [b], [c]
Specified Answer for: a 43775 Specified Answer for: b E66.01 Specified Answer for: c Z68.41
CASE 5 Preoperative Diagnosis: History of rectal carcinoma.Postoperative Diagnosis: History of rectal carcinoma.Procedure Performed: Closure of loop ileostomy with small bowel resection and enteroenterostomy with intraoperative flexible sigmoidoscopy.Description of Procedure: After induction of adequate general endotracheal anesthesia,(General anesthesia.) the patient was carefully positioned in the supine modified lithotomy position in Allen stirrups.(Lying on back with legs in stirrups.) Great care was taken to pad and protect all areas of potential bodily injury. Digital rectal examination revealed a widely patent circumferentially intact pouch anal anastomosis within 1 cm of the dentate line. Flexible sigmoidoscopy was performed revealing healthy pink mucosa. The abdomen was prepped and draped in the usual sterile manner, and a parastomal incision(Cutting around the ostomy opening to release it from the abdominal wall and surrounding area.) was made and carried down sharply into the peritoneal cavity. Meticulous hemostasis was obtained with electrocautery. A 360 degree subfascial mobilization was undertaken until approximately 40 cm of each the afferent and efferent limb reached above the skin in a tension-free manner. Betadine was insufflated down each limb to verify that no enterotomies or seromyotomies were made.(Verification that the colon is without injury or puncture from the dissection.) The mesentery was scored and vessels were divided with a 10 mm LigaSure Impact. The bowel was circumferentially cleared of fat proximally and distally, and each end was divided with a GIA 100 mm stapling device with blue cartridge. The field was protected with blue towels and the antimesenteric border of each staple line was excised. A side-to-side functional end- to-end anastomosis was fashioned with a GIA 100 mm stapling device.(Reattachment of the two ends of the colon in a side-by-side fashion.) The staple line was reinforced for hemostasis with 3-0 PDS 2 suture where necessary and the afferent limb was secured to the efferent limb with 3-0 PDS 2 seromuscular Lembert type sutures. After verification of the meticulous hemostasis, the apical enterotomy was secured with a GIA 100 mm stapling device. The anastomosis was healthy pink and widely patent and circumferentially intact and easily returned into the peritoneal cavity, after copious irrigation and verification of meticulous hemostasis. What are the CPT® and ICD-10-CM codes for this service? CPT®: [a] ICD-10-CM : [b], [c]
Specified Answer for: a 44625 Specified Answer for: b Z43.2 Specified Answer for: c Z85.048
CASE 4 Extent of Examination: Proximal sigmoid colon.Reason(s) for Examination: Proctitis.Postoperative assessment: Proctitis. Description of Procedure:Informed consent was obtained with the benefits, risks, including the risk of perforation and alternatives to sigmoidoscopy explained. The patient agreed to proceed. No contraindications were noted on physical exam. Patient was re-examined and no interval changes were noted from the preoperative history & physical. After being placed on the table, patient identification was verified prior to the procedure. Immediately prior to sedation for endoscopy the patient's ASA classification was Class 2: Mild systemic disease. Monitored anesthesia care (MAC) was administered by the anesthesia team.(This is important for the anesthesiologist.) The quality of the prep was adequate. Prior to the exam, a digital exam was performed and it was unremarkable. The procedure was performed with the patient in the left lateral decubitus position. The sigmoidscope was inserted to the proximal sigmoid colon.(This is pertinent as the correct code is selected by the level of exam in the colon.) In the rectum, a retroflex was performed. The withdrawal time from the proximal sigmoid colon was 8 minutes. The patient tolerated the procedure well. There were no complications. The heart rate was normal. The oxygen saturation and skin color were normal. IV moderate sedation was administered under direct supervision of the physician. Upon discharge from the endoscopy area, the patient will be recovered per established procedures and protocols. Findings: In the rectum, mild segmental inflammation with erythema(These are the symptoms of proctitis; only use symptoms in the absence of a definitive diagnosis.) was seen. There was no mucosal bleeding. What are the CPT® and ICD-10-CM codes for this service? CPT® code: [a] ICD-10-CM code: [b]
Specified Answer for: a 45330 Specified Answer for: b K62.89
CASE 9 Extent of Examination: Terminal ileum.Reason(s) for Examination: Hx of rectal cancer s/p Low Anterior Resection (LAR) and colonic J pouch for closure of loop ileostomy.Description of Procedure:Informed consent was obtained with the benefits, risks, including the risk of perforation and alternatives to colonoscopy explained. The patient agreed to proceed. No contraindications were noted on physical exam. Monitored anesthesia care (MAC) was administered. The bowel was prepared with Fleets enemas. The quality of the prep was fair. Prior to the endoscopic exam, a digital rectal exam was performed and it was unremarkable. The procedure was performed with the patient in the left lateral decubitus position. The cecum was identified by the ileocecal valve. The withdrawal time from the cecum was 7 minutes. The patient tolerated the procedure well. There were no complications. The exam was limited by poor preparation. Findings: At the splenic flexure, moderate inflammation with erythema, granularity, friability, and hypervascularity was seen. There was no mucosal bleeding. In the proximal descending colon, moderate segmental inflammation with erythema, granularity, friability, and hypervascularity. In the rectum an abnormality was noted. Anastomosis is patent and normal. No evidence of polyp. Just proximal prior to anastomosis - significant diffuse colitis was noted.What are the CPT® and ICD-10-CM codes for this service? CPT® code: [a]ICD-10-CM codes: [b], [c]
Specified Answer for: a 45378 Specified Answer for: b K52.9 Specified Answer for: c Z85.048
CASE 8 Extent of Examination: Terminal ileum.Reason(s) for Examination: Anemia, Fe DeficiencyDescription of Procedure:Informed consent was obtained and I explained about the benefits, risks, including the risk of perforation and alternatives to colonoscopy. The patient agreed to proceed. No contraindications were noted on physical exam. Monitored anesthesia care (MAC) was administered by the anesthesia team. The bowel was prepared with GoLYTELY prep. The quality of the prep is based on the Ottawa bowel preparation quality scale. Total score: Right: 1 + Middle: 1 + Left: 1 + Fluid: 0 = 3/14. Prior to the exam, a digital exam was performed; hemorrhoids were noted. The procedure was performed with the patient in the left lateral decubitus position. The instrument was inserted in the anus and advanced to the terminal ileum. The cecum was identified by the following: the ileocecal valve and the appendiceal orifice. In the rectum, a retroflex was performed. The patient tolerated the procedure well. There were no complications. Findings: In the rectum, a few medium-size uncomplicated internal hemorrhoids were seen. The internal hemorrhoids were not bleeding. There was no evidence of inflammation, friability, granularity, or bleeding. Biopsy were taken. In the ascending colon and cecum there was mild granularity and red spots that were nonspecific and possibly due to air insufflation. No friability, ulcerations or bleeding. Biopsy taken. The remainder of the colon was normal. The terminal ileum was normal. What are the CPT® and ICD-10-CM codes for this service? CPT code: [a]ICD-10-CM codes: [b], [c]
Specified Answer for: a 45380 Specified Answer for: b D50.9 Specified Answer for: c K64.8
CASE 7 Preoperative Diagnosis: Cholelithiasis, chronic cholecystitis, and acute pancreatitis. Postoperative Diagnosis: Cholelithiasis, chronic cholecystitis, and acute pancreatitis, pathology pending. Procedure Performed: Laparoscopic cholecystectomy, with intra-operative fluoroscopic cholangiography. Anesthesia: General anesthesia and 0.5% Marcaine (10 cc/s). Estimated Blood Loss: minimal. Drains: None. Specimen: Gallbaldder. Operative indications: This is a 49-year-old female with the above diagnosis who presents for elective laparoscopy, cholecystectomy and intra-operative cholangiography. Operative Procedure: The patient was brought to the OR suite with PAS stocking in place. She was transferred to the operative table, given a general anesthetic, positioned supine on the table, and the operative field was sterilely prepped and draped. A vertical incision was made in the base of the umbilicus and deepened through the fascia. Stay sutures of 0-Proline were placed, and the abdomen was entered under direct vision. A Hassan cannula was anchored in place with the stay sutures and the abdomen was insufflated to 15 mm Hg with CO2 gas. A 10 mm, 30-degree scope was assembled, focused, weight-balanced, and placed into the abdomen. Cursory evaluation revealed no other obvious pathology with the exception of the gallbladder. Under direct vision, 3-5 mm ports were placed in the epigastrium, right upper quadrant, and right lower quadrant. The patient was placed in reverse Trendelenberg position, with the right side up. The fundus of the gallbladder was grasped and retracted over the dome of the liver. Adhesions to the gallbladder were taken down with sharp and blunt dissection while carefully maintaining hemostasis with electrocauterery. The ampulla of the gallbladder was grasped with a second instrument and retracted downward and laterally, displaying the angle of Calot distracted from the portal structures, The cystic duct and artery were dissected circumferentially. A single clip was placed on the distal cystic duct and an opening created just proximal to it. The cholangiogram apparatus was introduced into the abdomen via the 5 mm RUQ port and the 5-French whistle-tip ureteral catheter was threaded into the common bile duct through the opening in the cystic duct. The cholangiogram was performed under fluoroscopy and was normal, demonstrating filling of the duct with defects and prompt flow into the duodenum. The cholangiogram apparatus was withdrawn from the abdomen, and the cystic duct was clipped twice proximally, and divided. The cystic artery was clipped once distally, twice proximally, and divided. The cystic duct and artery were dissected circumferentially, clipped once distally, twice proximally and divided. Care was taken not to encroach upon the common bile duct or portal structures. The gallbladder was taken down from the liver using the hook-dissector and cautery carefully maintaining hemostasis during the process. The right upper quadrant was irrigated with saline and suctioned dry. Hemostasis was confirmed. There was no bile drainage from the gallbladder bed in the liver. A 5 mm, 30-degree scope was assembled, focused, white-balanced, and placed into the epigastric port. The gallbladder was removed under direct vision through the umbilical port. The other ports were removed under direct vision, and hemostasis was achieved. The abdomen was de-insufflated. The fascia in the umbilical incision was closed with a figure of eight suture of 0 vicryl. The wounds were infiltrated with a total of 10 cc's of 0.5% marcaine. The skin incisions were closed with subcuticular sutures of 4.0 vicryl. Steri-strips and sterile dressings were applied. After a correct sponge, instrument, and needle count, the patient was awakened, extubated, and taken to the recovery room in good condition. What are the CPT® and ICD-10-CM codes for this service? CPT® code: [a] ICD-10-CM codes: [b], [c]
Specified Answer for: a 47563 Specified Answer for: b K80.10 Specified Answer for: c K85.90
CASE 3 Extent of Examination: Upper gastrointestinal endoscopy.Reason(s) for Examination: Gastroesophageal Reflux Disease (GERD).(This shows medical necessity for the procedure.)Description of Procedure:Informed consent was obtained with the benefits, risks, including the risk of perforation and alternatives to upper GI endoscopy were explained. The patient agreed to proceed. No contraindications were noted on physical exam. Anesthesia was administered by the ICU staff. (See anesthesiologist report) Monitored anesthesia care (MAC) was administered by anesthesia team. The procedure was performed with the patient in the left lateral decubitus position. The instrument was inserted through the mouth to the second part of the duodenum. The patient tolerated the procedure well. There were no complications. The heart rate was normal. The oxygen saturation and skin color were normal. Upon discharge from the endoscopy area, the patient will be recovered per established procedures and protocols. Findings: The esophagus was examined and no abnormalities were seen. The gastroesophageal junction (upper level of gastric folds) was located 40cm from the incisors. The stomach was examined and no abnormalities were seen. The small bowel was examined and no abnormalities were seen.(An upper gastrointestinal endoscopy to the duodenum was performed.) What are the CPT® and ICD-10-CM codes for this service?
Specified Answer for: a 43235 Specified Answer for: b K21.9
CASE 10 Preoperative Diagnosis: Severe obesity. Hypertension. BMI 53. Postoperative Diagnosis: Severe obesity. Hypertension. BMI 53. Procedure Performed: Laparoscopic antecolic Roux-en-Y gastric bypass with 150 alimentary limb, and a 40 cm biliopancreatic limb.Anesthesia: General endotracheal anesthesia.Operative Procedure: The patient was brought to the operating room and placed on the OR table in supine position. Once endotracheal anesthesia was achieved and pre-op antibiotics were given, the abdomen was prepped and draped in the standard surgical fashion. Access to the abdominal cavity was through a 1 cm supraumbilical incision with an Optiview trocar. CO2 was insufflated to achieve an intraabdominal pressure of approximately 15 mmHg. Accessory trocars were placed in the subxiphoid, right, mid and left upper quadrants of the abdomen, as well as in the right and left lower quadrants of the abdomen. All of this was done under appropriate videoscopic observation.The procedure begins with identification of the gastroesophageal junction and dissection of the angle of His. On the lesser curvature of the stomach, a window is dissected into the lesser sac. A linear stapler is passed, and the stomach is transected. Reinforcement of the staple line was done with a continuous absorbable seromuscular suture, creating a pouch approximately 50 cc in diameter. An Ewald tube is used to calibrate the pouch. At this point, the ligament of Treitz is identified and 40 cm from the ligament of Treitz, the small bowel was transected. The distal limb of the small bowel is then brought to the upper abdomen, and a side-to-side gastrojejunostomy between the pouch and the alimentary limb is performed with a linear stapler. The gastrojejunostomy site is then closed with a double layer of running 2-0 Vicryl sutures. The anastomosis was observed for leakage with air and Methylene blue. There was no evidence of leakage.I then proceeded 150 cm distal from the gastrojejunostomy. A side-to-side jejunojejunostomy was created between the biliopancreatic limb and alimentary limb. This was performed using two applications of the linear stapler. The jejunojejunostomy site was closed with several applications of the linear stapler. Hemoclips were applied to the suture line for hemostasis. Good hemostasis was evident. A 19 French Blake drain was placed over the gastrojejunal anastomosis. All trocars were removed under appropriate videoscopic observation. There was no evidence of bleeding from any of the trocar sites. The trocar sites were suture closed and injected with local anesthesia. The patient tolerated the procedure well. She was extubated on the OR table and transferred to the recovery room in stable condition. There were no complications. What are the CPT® and ICD-10-CM codes for this service? CPT® code: [a] ICD-10-CM codes: [b], [c], [d]
Specified Answer for: a 43644 Specified Answer for: b E66.01 Specified Answer for: c I10 Specified Answer for: d Z68.43
CASE 1 Preoperative Diagnosis: Right-sided colonic polyps.Postoperative Diagnosis: Right-sided colonic polyps.Procedure: Laparoscopic right hemicolectomy with ileocolic anastomosis.Description of Procedure: After induction of adequate general endotracheal anesthesia,(General anesthesia.) the patient was carefully positioned in the supine, modified-lithotomy position and Allen stirrups. Great care was taken to carefully pad and protect all areas of potential bodily injury. The abdomen was prepped and draped in the usual sterile manner.(Positioning and draping the patient is standard of care - not billable.)Using a supra-umbilical vertical incision, a Hasson technique(Type of laparoscopic approach. The Hasson technique employs an open type of port insertion site for laparoscopic procedures.) was employed to carefully place a 10 mm cannula. Carbon dioxide pneumoperitoneum of 15 mmHg was achieved, after which a 30-degree telescope was carefully introduced. Under direct vision, two left-sided ports were placed: one in the left lower quadrant, one in the left upper quadrant, each lateral to the epigastric vessels through horizontal stab wounds.(Placement of the trocars for visualization into the abdominal cavity.) With a combination of head up, head down, and right side up, the entire right colon was mobilized from the duodenum, pancreas, and right ureter, using 10 mm diameter Babcock grasping forceps and 5 mm diameter harmonic scalpel.(The colon is freed away from it's attachments to other structures. The Babcock grasper holds the colon in place while the harmonic scalpel cuts away the connections.)After complete mobilization and copious irrigation and verification of meticulous hemostasis, the supraumbilical port was lengthened to 4 cm, through which an Alexis wound protector was placed. The entire right colon was withdrawn.(Pulled to outside the cavity through the extended incision.) High ligation of the ileocolic arcade and the right branch of the middle colic(The division of the colon.) were undertaken using 10 mm diameter LigaSure Atlas.(Device used to seal or divide the circulation to that portion of the bowel slated for removal.) The Atlas was used for the remaining mesentery. The bowel was circumferentially cleared of fat proximally and distally, and each end was divided with a GIA 100 mm stapler with a blue cartridge. The field was draped with blue towels, and the antimesenteric border of each staple line was excised along with the terminal ileum. A side-to-side, functional end-to-end anastomosis was fashioned between the remaining ileum and colon with a GIA 100 mm stapling device with a blue cartridge.(Reattachment of the two ends of the colon: ileocolostomy.) The staple line was verified for hemostasis, after which the afferent limb was secured to the efferent limb with 3-0 PDS II seromuscular Lembert-type sutures. After verification of anastomotic hemostasis, the apical enterotomy was also secured with a GIA 100 mm stapling device with a blue cartridge. The anastomosis was healthy, pink, widely patent, circumferentially intact, and easily returned into the peritoneal cavity.(The externalized colon is reinserted into the abdominal cavity after it is checked for hemostasis and perfusion.)After copious irrigation and verification of meticulous hemostasis, the fascia was closed with interrupted No. 1 Vicryl plus figure-of-eight sutures. The subcutaneous layers were irrigated and meticulous hemostasis was verified. Port sites were closed in a similar manner. The skin was closed and covered by dry dressings,(After the trocars are removed, the stab sites are sutured closed.) and the patient was discharged to the recovery room in stable condition, without having suffered any apparent operative complications. What are the CPT® and ICD-10-CM codes for this service? CPT® code(s): [a] ICD-10-CM code(s): [b]
Specified Answer for: a 44205 Specified Answer for: b K63.5
What is the name of the portion of the large intestine that runs horizontally across the abdomen?
The transverse colon Rationale: The name of the large intestine that runs horizontally across the abdomen is the transverse colon.
A patient with hypertension is scheduled for same day surgery for removal of her gallbladder due to chronic gallstones. She is examined preoperatively by her cardiologist to be cleared for surgery. What ICD-10-CM codes are reported by the cardiologist?
Z01.810, K80.20, I10 Rationale: In the ICD-10-CM Alphabetic Index look for Examination/preoperative; there is a note - see Examination, pre-procedural. Look for Examination/pre-procedural/cardiovascular which refers you to Z01.810. Next, look for Calculus/gallbladder which refers you to K80.20 and Hypertension which refers you to I10. Verify all code selections in the Tabular List. Correct codes and sequencing are Z01.810, K80.20 and I10. Sequencing of preoperative clearance first (the reason for the visit), then the reason for the surgery, and last, any other findings or diagnoses. (Sequencing rule from Official Coding Guidelines of ICD-10-CM Section IV.M.)
