This assignment is for someone familiar with 3MEncoder and (ICD-10-CM).
Answer the questions in bold for both case studies. There are 15
questions in all.
LOCATION: Outpatient, Hospital
PATIENT: Daniel Briggstad
ATTENDING PHYSICIAN: Jeff King, MD
SURGEON: Jeff King, MD
PREOPERATIVE DIAGNOSES 1. Recurrent otitis media. 2. Retained right PE tube and granulation tissue. 3. Left otitis media with effusion.
POSTOPERATIVE DIAGNOSES 1. Recurrent otitis media. 2. Retained right PE tube and granulation tissue. 3. Left otitis media with effusion. 4. Right tympanic membrane perforation.
PROCEDURES PERFORMED 1. Removal of right PE tube and granulation tissue from the tympanic membrane. 2. Left myringotomy with tympanostomy tube placement.
ANESTHESIA: General inhalation.
SURGICAL INDICATIONS: A 4-year-old male with a history of bilateral PE tubes. Since extrusion of the PE tubes, he has had recurrent episodes of otitis media. There is also granulation tissue around the right PE tube.
PROCEDURE: After consent was obtained, the patient was taken to the operating room and placed on the operating table in supine position. After the adequate level of general inhalation anesthesia was obtained, the patient was draped in the appropriate manner for PE tube placement. Attention was first focused on the right ear. Utilizing an ear speculum and microscope, the external canal was cleared of cerumen. The retained extruded PE tube was removed from the tympanic membrane. In addition, granulation tissue was also removed. Subsequent examination shows a perforation of the posterior inferior area. There is no effusion. Due to the significant size of the perforation, no PE tube was placed. Attention was then focused on the left side. The ear canal was cleared of wet debris and cerumen. The tympanic membrane was noted to be opaque. The myringotomy incision was then placed in the anterior inferior quadrant. Serous effusion was suctioned. A bobbin tympanostomy tube was then placed without difficulty. Cortisporin otic suspension and a cotton ball were then placed.
The patient tolerated the procedure well, and there was no break in technique. The patient was awakened and taken to the postanesthesia area in good condition.
Abstracting & Coding Questions:
1. Was the removal of the tube from the right ear reported?
2. Was the removal of the tube from the left ear reported?
3. What procedure was performed on the left ear?
4. What three modifiers were reported with the CPT codes assigned for this case?
5. What CPT code(s) would be reported for this case?
6. What ICD-10-CM code(s) would be reported for this case?
LOCATION: Inpatient, Hospital
PATIENT: Benito Castro
ORDERING PHYSICIAN: Gregory Dawson, MD
ATTENDING/ADMIT PHYSICIAN: Gregory Dawson, MD
RADIOLOGIST: Morton Monson, MD
PERSONAL PHYSICIAN: Ronald Green, MD
EXAMINATION: Placement of a tunneled hemodialysis catheter.
CLINICAL SYMPTOMS: End-stage renal disease.
PLACEMENT OF TUNNELED #14.5 FRENCH HEMODIALYSIS CATHETER: The patient is a 62-year-old male with a history of renal failure. Placement of a tunneled hemodialysis catheter was requested by Dr. Green.
Prior to the start of the study, the procedure was explained to the patient, including the risks, complications, and alternatives. The patient understood and consented to the exam.
The patient was prepped and draped in the usual sterile fashion. An Ioban II (antimicrobial film) was placed on the skin. A 21-gauge micropuncture needle was advanced into the right internal jugular vein in the lower neck region using sterile technique under ultrasound guidance following administration of local anesthesia (1% lidocaine). Utilizing the Microvena kit, a 0.18 stainless steel wire was used to measure the distance from the junction of the right atrium/superior vena cava to the skin site, and the catheter was cut to size. A #5 French straight catheter was advanced into the internal jugular vein. The catheter was then placed to flush.
A small skin incision was placed in the upper chest region. Following administration of local anesthesia (1% lidocaine), a tunnel was obtained between the two skin incisions. A vascular sheath was then placed through the tunnel, and the catheter was advanced through the peel-away sheath.
The #5 French straight catheter was then removed under a Rosen wire, and a #10 French peel-away sheath was placed into the right internal jugular vein. The dilator and wire were then removed, and the end of the peel-away sheath was crimped to avoid blood loss with the patient holding his breath. The tip of the catheter was then advanced through the peel-away sheath with the tip of the junction of the right atrium/superior vena cava. The peel-away sheath was then removed and the catheter was adjusted to obtain a smooth transition. The cuff of the catheter was approximately 1 to 2 cm from the incision site. A single 2–0 Prolene suture was then placed at the catheter insertion
site, and three sutures were placed at the lower neck incision site. There was no evidence of bleeding.
Contrast was infused through the single port, which revealed adequate placement. Post placement chest x-ray did not reveal a pneumothorax.
The patient tolerated the procedure well. The patient denied pain and shortness of breath at termination of the study.
IMPRESSION: Placement of a tunneled #14.5 French hemodialysis catheter through the right internal jugular vein as described above.
Abstracting & Coding Questions:
1. Was the catheter inserted by the radiologist?
2. Was the catheter inserted into the venous or arterial system?
3. Was the catheter inserted centrally or peripherally?
4. Was the catheter tunneled?
5. Was a subcutaneous port/pump inserted?
6. Does the age of the patient affect CPT code assignment?
7. Is ultrasound guidance separately reported?
8. What CPT code(s) would be reported for this case?
9. What ICD-10-CM code(s) would be reported for this case?