cpt/hcpcs coding block 2 Cumulative Coding Challenge 13

Secondary ICD-10-CM Code(s): _____ Your Answer:h66.93

Code all documented conditions that coexist at the time of the encounter/visit that require or affect patient care, treatment, and management. These conditions may be sequenced as secondary diagnoses. This patient was diagnosed with recurrent acute otitis media in both ears. To locate these codes turn in the "Index to Diseases" to the main term otitis and the sub-terms media, acute and subacute. The code listed is H66.90. When you go to the Tabular List to confirm your code you will see that there are codes for acute otitis media specific to the right and left ear. Since our documentation indicates the patient has this diagnosis in both ears and in order to code to the highest degree of specificity, you should assign the bilateral code for acute otitis media. The final code is H66.93; Otitis media, unspecified, bilateral.

Primary ICD-10-CM Code: _____ Your Answer:J35.2

First list the ICD-10-CM code for the diagnosis, condition, problem, or other reason for the encounter/visit shown in the medical record to be chiefly responsible for the services provided. This patient was diagnosed with adenoidal hypertrophy. To locate this code turn in the "Index to Diseases" to the main term hypertrophy, hypertrophic and the sub-term adenoids. The code listed is J35.2; hypertrophy of adenoids.

Operative Report

PREOPERATIVE DIAGNOSIS: Recurrent acute otitis media. Adenoidal hypertrophy. POSTOPERATIVE DIAGNOSIS: Same. OPERATION PERFORMED: Bilateral myringotomy with insertion of tympanostomy tubes. Adenoidectomy. INDICATIONS: The patient is a 10-year-old white male with a history of recurrent acute otitis media in both ears, refractory to antibiotics. He is also noted to snore loudly and on exam has markedly enlarged adenoidal tissue. DESCRIPTION OF PROCEDURE: The patient was taken to the operating room and placed in the supine position. General endotracheal anesthesia was induced without difficulty. The operating microscope was placed over the right ear. A speculum was introduced and cerumen removed with a curet. A small incision was made in the anterior inferior quadrant of the tympanic membrane, and a tympanostomy tube was inserted without difficulty. Cortisporin eardrops and a cotton ball were then placed in the external auditory canal. The operating microscope was then placed over the opposite ear, and a tympanostomy tube was inserted in an identical fashion. The operating table was rotated 90 degrees, and the patient was draped in the usual sterile fashion. Mouth gag retractor was placed with care to avoid trauma. Exam failed to reveal a submucous cleft or pulsatile adenoidal tissue. The adenoidal pad was removed with multiple swipes of the adenoid curet. Hemostasis was obtained using the electrocautery unit. The nose and mouth were irrigated with saline and suctioned. The mouth gag retractor was let down for a period of 1 minute. Reinspection revealed adequate hemostasis. The case was terminated. The patient was allowed to awaken from anesthesia. He was extubated in the operating room. He was transferred to the post anesthesia recovery room in stable condition. EBL: 20 ml. Fluids: 200 ml crystalloid. Complications: None.

Primary CPT Code: _____ Your Answer:42830

To locate the code for the adenoidectomy turn in the "CPT Index" to the main term adenoids and the sub-term excision; this lists codes 42830-42836. The code for an adenoidectomy performed on a patient younger than age 12 is 42830; adenoidectomy, primary; younger than age 12. This code would be reported as 42830. The adenoidectomy is sequenced first because it is the most complex, risky procedure performed. Since the adenoidectomy is the primary procedure the adenoidal hypertrophy was sequenced as primary of the two possible primary diagnoses because it is the one relates to the primary procedure.

Secondary CPT Code(s): _____ Your Answer:69436-50-51

To locate the code for the bilateral myringotomy with insertion of tympanostomy tubes turn in the "CPT Index" to the main term tympanostomy and the sub-term general anesthesia; this lists 69436. The code for a tympanosotomy performed under general anesthesia is 69436; tympanosotomy (requiring insertion of ventilating tube), general anesthesia. To indicate that this procedure was performed bilaterally the modifier 50 would be appended. To indicate that multiple procedures were performed during the same operative session the modifier 51 would be appended. This code would be reported as 69436-50-51.