AAPC Chapter 11: Digestive System
Code intraoral incision and drainage of hematoma of tongue, submandibular space. What CPT® code is reported?
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.
CASE 3 Procedure: Uvulopalatopharyngoplasty. 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 with a combination of blunt and cautery dissection. The posterior pillar remained intact as I proceeded to do similar mobilization of the left tonsil. 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?
42145 G47.33
A patient presents for esophageal dilation. The physician begins dilation by using a bougie. This attempt was unsuccessful. The physician then dilates the esophagus transendoscopically using a balloon (25mm). What CPT® code(s) is/are reported?
43220 Rationale: Because the esophageal dilation using a bougie (43450) was unsuccessful, it is not reported. The esophagus was successfully dilated by performing transendoscopic balloon dilation 43220. This is the only code reported. In the CPT® Index, look for Esophagus/Dilation/Endoscopic. You are directed to 43195, 43196, 43212-43214, 43220, 43226, 43229, 43233, 43248, 43249
CASE 7 Extent of Examination: Upper gastrointestinal endoscopy. Reason(s) for Examination: Gastroesophageal Reflux Disease (GERD). 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. What are the CPT® and ICD-10-CM codes for this service?
43235 K21.9
A 33 year-old male patient presents to the endoscopy suite to determine if he has an ulcer. The physician performs a diagnostic scope through the esophagus, stomach and into the duodenum and jejunum. During the scope the patient has a severe drop in blood pressure and the physician discontinues the procedure, but not before observing and diagnosing a bleeding ulcer on the stomach lining as well a perforated ulcer in the jejunum. A repeat examination is planned. What CPT® and ICD-10-CM codes are reported?
43235-53, K25.4, K28.5 Rationale: Code 43235 represents an Upper GI down into the small intestine or esophagogastroduodenoscopy (EGD). In the CPT® Index, look for Endoscopy/Gastrointestinal/Upper/Exploration. We append modifier 53 since the procedure was terminated after anesthesia due to extenuating circumstances and a repeat examination is planned. In the ICD-10-CM Alphabetic Index look for Ulcer/stomach/with/hemorrhage (K25.4). Next, look for Ulcer/gastrojejunal/with/perforation which directs you to K28.5. We code for the two ulcers found, K25.4 for the bleeding stomach ulcer and K28.5 unspecified as acute or chronic for the perforated ulcer in the jejunum.
A patient suffering from cirrhosis of the liver from alcohol abuse presents with a history of coffee ground emesis (bleeding). The surgeon diagnoses the patient with esophageal gastric varices. Two days later, in the hospital GI lab, the surgeon ligates the varices with bands via an UGI endoscopy. What CPT® and ICD-10-CM codes are reported?
43244, K70.30, I85.11, F10.10 Rationale: Ligation of esophageal gastric varices endoscopically is coded with CPT® code 43244. This is indexed in CPT® under Ligation/Esophageal Varices. In the ICD-10-CM Alphabetic Index, look for Varices - see Varix. Look for Varix/esophagus/in (due to)/cirrhosis of liver/bleeding. You are directed to I85.11. In the Tabular List there are two instructional notes. The first one is under subcategory code I85.1-. It instructs you to code first underlying disease, which in this case, is the cirrhosis of the liver from the alcohol. Look for Cirrhosis/liver/alcoholic and you are directed to K70.30. The other instructional note is under category code I85 which says to use an additional code to report alcohol abuse and dependence. Alcohol abuse is reported with code F10.10.
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.
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.
CASE 6 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 Steri-Strips, 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?
43644 E66.01; I10; Z68.43
What CPT® and ICD-10-CM codes are reported for a gastric restriction by placing a gastric band via laparoscopic surgery for an adult patient diagnosed as morbidly obese having a BMI of 43, type 2 uncontrolled diabetes and elevated blood sugar readings daily?
43770, E66.01, Z68.41, E11.9 Rationale: In the CPT® Index, look for Laparoscopy/Stomach/Gastric Restrictive Procedures which refers to 43770-43775, 43848, 43886-43888 or Laparoscopy/Gastric Restrictive Procedures and you are directed to 43644, 43645, 43770-43775. In reviewing the code descriptions, 43770 is correct code for placement of adjustable gastric bands laparoscopically. Look in the ICD-10-CM Alphabetic Index for Obesity/morbid. You are directed to code E66.01. An instructional note beneath E66 states, "Use additional code to identify body mass index (BMI), if known (Z68.-)". Turning to Z68 in the Tabular List, you find a list of subcategories specific to adult and pediatric BMI ranges. The patient has a BMI of 43 falling into the range of ICD-10 code Z68.41. Next, look for Diabetes/type 2, directing you to subcategory code E11.9 Verification of the codes in the Tabular List confirms code selections.
CASE 4 Preoperative Diagnosis: Morbid obesity. Sleep apnea. BMI 40. Postoperative Diagnosis: Morbid obesity. BMI 40. Procedure Performed: Laparoscopic sleeve gastrectomy. Intraoperative esophagogastroduodenoscopy. Intraoperative endoscopy Anesthesia: 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?
43775 E66.01; Z68.41
What CPT® and ICD-10-CM codes represent the creation of an opening into the stomach to insert a temporary feeding tube for nutritional support in an adult patient with proximal esophageal carcinoma due to alcohol dependence? A gastric tube was not created.
43830, C15.3, F10.20 Rationale: A gastrostomy is the creation of an opening into the stomach. Look in the CPT® Index for Gastrostomy/Temporary which refers you to 43830. You could also look for Stomach/Creation/Stoma Temporary which refers you to 43830, 43831. Code 43830 represents an open placement (accessing the stomach through the abdominal wall) for a feeding device, such as a tube. In the ICD-10-CM Alphabetic Index look for Carcinoma, which directs us to see also, Neoplasm, by site, malignant. Go to the Table of Neoplasms and look for Neoplasm, neoplastic/esophagus/proximal (third)/Malignant Primary column referring you to code C15.3. The Tabular List confirms that code C15.3 represents the primary cancer of the upper or proximal third of the esophagus. There is an instructional note to report an additional code to identify alcohol abuse or dependence (F10.-). Alcohol dependence is reported with code F10.20.
Code peritoneoscopy with laparoscopic partial colectomy and anastomosis. What CPT® code(s) is/are reported?
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 collection 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.
CASE 2 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, 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. Using a supra-umbilical vertical incision, a Hasson technique 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. 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. 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. High ligation of the ileocolic arcade and the right branch of the middle colic were undertaken using 10 mm diameter LigaSure Atlas. 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. 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. 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, 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?
44205 K63.5
CASE 1 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, the patient was carefully positioned in the supine modified lithotomy position in Allen 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 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. 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?
44625 Z43.2; Z85.048
CASE 10 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. 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. 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 was seen. There was no mucosal bleeding. What are the CPT® and ICD-10-CM codes for this service?
45330 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?
45378 K52.9; Z85.048
CASE 8 Extent of Examination: Terminal ileum. Reason(s) for Examination: Anemia, Fe Deficiency Description 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?
45380 D50.9; K64.8
A patient is seen in the gastroenterologist's clinic for a diagnostic colonoscopy. When performing the service, the physician notes suspicious looking polyps and removes three using a snare technique to send to pathology for further testing. What is/are the correct CPT® code(s) to report?
45385 Rationale: A surgical endoscopy always includes a diagnostic endoscopy so only the surgical is reported. Reporting 45385 is the correct code for the colonoscopy with removal of polyps by snare technique. In the CPT® Index, look for Colonoscopy/Flexible/Removal/Polyp which directs you to 45384, 45385. Reviewing the descriptions of both codes directs you to 45385 which includes use of snare technique.
A 45 year-old patient with liver cancer is scheduled for a liver transplant. The patient's brother is a perfect match and will be donating a portion of his liver for a graft. Segments II and III will be taken from the brother and then the backbench reconstruction of the graft will be performed, both a venous and arterial anastomosis. The orthotopic allotransplantation will then be performed on the patient. What CPT® codes are reported?
47140, 47146, 47147, 47135 Rationale: In the CPT® Index, look for Hepatectomy/Partial/Donor, or Transplant/Liver/Allograft/Preparation Liver 47143 - 47147. Code 47140 represents the portion of the liver taken from the donor, Segments II and III, to be allotransplanted. Codes 47146 and 47147 represent the backbench work with venous and arterial anastomosis. A vein and an artery are anastomosed so only report each of these codes one time. The final code of 47135 represents the orthotopic allotransplantation into the patient; this is found in the CPT® Index under Transplantation/Liver.
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.
CASE 5 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. 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?
47563 K80.10; K85.90
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 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.
Code proximal subtotal pancreatectomy, with total duodenectomy, partial gastrectomy, choledochoenterostomy, and gastrojejunostomy, with pancreatojejunostomy. What CPT® code is reported?
48150 Rationale: The CPT® code 48150 is specifically for pancreatectomy, proximal subtotal with total duodenectomy, partial gastrectomy, choledochoenterostomy, and gastrojejunostomy (Whipple-type procedure); with pancreatojejunostomy. Look in the CPT® Index for Pancreas/Excision/Partial.
A 57 year-old patient with chronic pancreatitis presents to the operating room for a pancreatic duct-jejunum anastomosis by the Puestow-type operation. What are the correct CPT® and ICD-10-CM codes for the encounter?
48548, K86.1 Rationale: In the CPT® Index, look for Puestow Procedure. Code 48548 represents a Puestow-type procedure for the anastomosis of the pancreatic duct to the jejunum. Code K86.1 represents the chronic pancreatitis. Look in the ICD-10-CM Alphabetic Index for Pancreatitis/chronic (infectious).
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. What CPT® code is reported?
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 procedures 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.
Approximately how long is the large intestine in normal anatomy?
5ft. long Rationale: The large intestine is about five feet long.
What is the correct coding for a physician who performs an UGI radiological evaluation of the esophagus, stomach and first portion of the duodenum with barium and double-contrast in the hospital GI lab? (Physician is not employed by the hospital)
74246-26 Rationale: A radiological evaluation is an X-ray. UGI stands for Upper Gastrointestinal (GI). Look in the CPT® Index for Gastrointestinal Tract/X-ray/with Contrast (for the double-contrast). You are directed to code 74246-74249. Code 74249 represents the same procedure if done with small intestine follow through, but here we only performed up to the first portion of duodenum making 74246 the most appropriate code. The UGI is performed in the hospital using hospital equipment. The physician is not indicated to be an employee of the hospital so we must report the professional services (component) only by appending modifier 26.
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.
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.
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.
How do you report a screening colonoscopy performed on a 65 year-old Medicare patient with a family history of colon cancer? The physician was able to pass the scope to the cecum. What CPT® and ICD-10-CM codes are reported?
G0105, Z12.11, Z80.0 Rationale: For a Medicare patient the preferred code to report a screening colonoscopy is HCPCS code G0105 Colonoscopy/Screening/Individual at high risk. In the ICD-10-CM Alphabetic Index, look for Screening/colonoscopy which directs you to Z12.11. An instructional note under Z12 instructs the coder, "Use additional code to identify any family history of malignant neoplasm (Z80.-)". Since the patient is high risk due to a family history of colon cancer, look for Z80 in the Tabular List. Category Z80 required a 4th character to identify the organ system of the cancer. Fourth character 0 is used for Family history of primary malignancy neoplasm of digestive organs. To find the code from the Alphabetic Index look for History/family (of)/malignant neoplasm/gastrointestinal tract.
A 42-year-old patient visits his doctor for chest pain and a dry cough lasting for two months. After evaluating the patient, the physician states the patient has GERD. What is/are the correct diagnosis code(s)?
K21.9 Rationale: GERD is the definitive diagnosis. Chest pain and a dry cough are both symptoms of GERD and are not reported separately. GERD is an acronym for Gastroesophageal Reflux Disease. In the ICD-10-CM Alphabetic Index, look for Disease/gastroesophageal reflux (GERD) or look for GERD, and you are guided to K21.9. There is no indication the patient has esophagitis.
What ICD-10-CM code is reported for acute gastritis with bleeding?
K29.01 Rationale: In ICD-10-CM, Gastritis is identified by specific four character codes to indicate with or without bleeding. Look in the ICD-10-CM Alphabetic Index for Gastritis (simple)/acute (erosive)/with bleeding K29.01.
What ICD-10-CM code(s) is reported for ulcerative colitis with rectal bleeding?
K51.911 Rationale: Look in the ICD-10-CM Alphabetic Index for Colitis/ulcerative (chronic)/with complication/rectal bleeding which directs you to K51.911. Verify the code in the Tabular List. This is a combination code that covers both ulcerative colitis and rectal bleeding. An additional code for rectal bleeding would not be reported.
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 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) K64.8. Verification in the Tabular List confirms code selection.
What are the two processes of digestion?
Mechanical and chemical Rationale: Digestion consists of two processes, mechanical and chemical. Mechanical digestion is chewing the food and your stomach and smooth intestine churning the food, and chemical digestion is the work the enzymes do by breaking large carbohydrate, lipid, protein and nucleic acid molecules into their subcomponents of nutrients.
In ICD-10-CM, how is Crohn's disease of the small intestine with intestinal obstruction reported?
One combination code is reported to indicate Crohn's disease of the small intestine with intestinal obstruction. Rationale: In ICD-10-CM there are combination codes to include the anatomic site (i.e., small intestine, large intestine) as well as the associated complications of Crohn's disease. Example: K50.012 Crohn's disease of small intestine with intestinal obstruction.
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 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.
Where is the vermilion border located?
Upper and lower lips Rationale: The cutaneous portion of the upper lip extends from the bottom of the nose to the nasolabial folds laterally to the vermilion border or lipstick area of the lips. It is the red margin of the upper and lower lips.
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.
Z01.810, K80.20, I10 Rationale: In the ICD-10-CM Alphabetic Index look for Examination/preoperative - see Examination, pre-procedural. Look for Examination/pre-procedural/cardiovascular referring you to Z01.810. Next, look for Calculus/gallbladder K80.20 and Hypertension which refers you to I10. Correct codes and sequencing are Z01.810, K80.20 and I10. Sequencing of preoperative clearance first, 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.)
What ICD-10-CM code is reported for a patient with a family history of colon cancer?
Z80.0 Rationale: Family history of a disease/condition is represented by Z codes. Look in the ICD-10-CM Alphabetic Index for History/family (of)/malignant neoplasm (of) NOS/gastrointestinal tract which refers you to code Z80.0. The Tabular List verifies code Z80.0 is reported for a family history of malignant neoplasm of digestive organs.
