A 63-year-old man sustained a gunshot wound through the right maxillary sinus penetrating into the right neck. CT scan revealed no hard evidence of arterial injury but a bullet was directly in line with the internal jugular vein. He was sent to the operating room for neck exploration to rule out va...
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A 63-year-old man sustained a gunshot wound through the right maxillary sinus
penetrating into the right neck. CT scan revealed no hard evidence of arterial injury but
a bullet was directly in line with the internal jugular vein. He was sent to the operating
room for neck exploration to rule out vascular injury and injury to the aerodigestive tract
(respiratory and digestive tracts). A sternocleidomastoid incision was performed and
carried down through the platysma muscle. There was no penetration of the internal
jugular vein, but a foreign body was identified resting on the internal jugular vein at
approximately the level of the angle of the mandible and it was removed. The parotid
gland was noted to have a blast injury near the tail. This was not surgically repaired or
resected. Once all bleeding was controlled, a
10 French round drain was placed in the wound. The wound was copiously irrigated.
The platysma muscle was closed and the skin was closed with subcuticular closure.
What CPT® code is reported?
24579-RT, S42.451A
Rationale: In the CPT® Index look for Fracture/Humerus/Condyle/Open Treatment
which refers to 24579. The manipulation and internal fixation is included in 24579. The
application of the first cast is always bundled with the initial surgical service and not
reported separately.
In the ICD-10-CM Alphabetic Index look for Fracture, traumatic/humerus/lower
end/condyle/lateral (displaced) referring you to S42.45-. In the Tabular List seven
characters are required to report the code. The 6th character is specific to left or right.
Documentation supports this as the right elbow, and the 7th character A is supported as
this is the initial surgical procedure. The complete code is S42.451A. This is the open
treatment of a closed fracture, so the 7th character B is not reported. - ANSWER {8}
A patient is seen in the hospital's outpatient surgical area with a diagnosis of a
displaced fracture of the lateral condyle, right elbow. An ORIF (open reduction)
procedure was performed and included the following techniques: An incision was made
in the area of the lateral epicondyle. This was carried through subcutaneous tissue, and
the fracture site was easily exposed. Inspection revealed the fragment to be rotated in
two places about 90 degrees. It was possible to manually reduce this quite easily, and
the manipulation resulted in an almost anatomic reduction. This was fixed with two pins
driven across the humerus. The pins were cut off below skin level. The wound was
closed with plain catgut subcutaneously and 5-0 nylon for the skin. Dressings and a
long arm cast were applied. What CPT® and ICD-10-CM codes are reported?
,29881
Rationale: In the CPT® Index look for Arthroscopy/Surgical/Knee. You are referred to
29866-29868, 29871-29889. Review the codes to choose appropriate service. 29881 is
the correct code because the tear was in the medial meniscus. A meniscectomy as well
as debridement with a shaver (or chondroplasty) were performed. 29877 is not reported
as this is included in 29881. 29880 is not appropriate because a meniscectomy was not
performed in both the medial and lateral compartments. The surgery started out as a
diagnostic procedure, but changed when the physician decided to perform surgical
procedures on the knee. - ANSWER {8}
The patient has a torn medial meniscus. An arthroscope was placed through the
anterolateral portal for the diagnostic procedure. The patellofemoral joint showed grade
2 chondromalacia on the patellar side of the joint only, this was debrided with a 4.0-mm
shaver. The medial compartment was also entered and a complex posterior horn tear of
the medial meniscus was noted. It was probed to define its borders. A meniscectomy
was carried out to a stable rim. What CPT® code(s) is/are reported?
23076-RT
Rationale: The 4 cm mass was removed from the soft tissue of the shoulder. To access
the mass, the provider had to go through the proximal aspect of the teres minor muscle.
The mass was located distal to the inferior glenohumeral ligament (IGHL). Masses that
are removed from joint areas as opposed to masses removed close to the skin require
special knowledge and become more of an orthopedic concern due to joint involvement.
Therefore, it is reported from codes within the musculoskeletal section. Code 23076 is
used because dissection was carried through the proximal aspect of the teres minor. In
the CPT® Index, look for Excision/Tumor/Shoulder directing you to 23071-23078. -
ANSWER {8}
This 45-year-old male presents to the operating room with a painful mass of the right
upper arm. General anesthesia was induced. Soft tissue dissection was carried through
the proximal aspect of the teres minor muscle. Upon further dissection a large mass
was noted just distal of the IGHL (inferior glenohumeral ligament), which appeared to be
benign in nature. With blunt dissection and electrocutery, the 4 cm mass was removed
en bloc and sent to pathology. The wound was irrigated, and repair of the teres minor
with subcutaneous tissue was closed with triple-0 Vicryl. Skin was closed with double-0
Prolene in a subcuticular fashion.
What CPT® code is reported?
J44.1, J45.901
Rationale: COPD stands for Chronic Obstructive Pulmonary Disease. In the ICD-10-CM
Alphabetic Index look for Asthma, asthmatic (bronchial) (catarrh)
(spasmodic)/with/chronic obstructive pulmonary disease/with/exacerbation (acute)
referring you to 144.1. The code can also be located by looking for
Disease/lung/obstructive (chronic)/with/acute/exacerbation NEC guiding you to code
44.1. There is an instructional note for category J44 to code also type of asthma, if
, applicable. Asthma 145.901 is reported. Verify code selection in the Tabular List. -
ANSWER {4}
A 70-year-old patient with decompensated COPD is admitted to the hospital with acute
exacerbation of bronchial asthma. What diagnosis(es) code(s) is (are) reported?
E00.9, F79
Rationale: In the ICD-10-CM Alphabetic Index look for Hypothyroidism/iodine-
deficiency/congenital and you are directed to see Syndrome, iodine-deficiency,
congenital. Syndrome/iodine-deficiency, congenital which directs you to code E00.9. In
the Tabular List category EOO directs us to use additional code (F70-F79) to identify
associated intellectual disabilities. In the Alphabetic Index look for Disability,
disabilities/intellectual which guides you to code F79. Confirm code selection in the
Tabular List. - ANSWER {4}
A lab screening shows congenital iodine-deficiency hypothyroidism for an infant with
identified intellectual disability. What ICD-10-CM code(s) is/are reported?
G43.B1
Rationale: When a migraine does not respond to medication it is considered intractable.
In the ICD-10-CM Alphabetic Index, look for Migraine/ophthalmoplegic/intractable
referring you to G43.B1. Verify code selection in the Tabular List. The note under
category code G43 Migraine confirms that pharmacoresistant is considered intractable.
- ANSWER {4}
A 32-year-old patient with an ophthalmoplegic migraine is not responding to medication
and is admitted to the observation unit. What ICD-10-CM code is reported?
N18.30, D63.1
Rationale: In the ICD-10-CM Alphabetic Index look for Anemia/in (due to) (with)/chronic
kidney disease or Anemia/erythropoietin resistant anemia
(EPO resistant anemia) guiding you to code D63.1. In the Tabular List at D63.1 there is
an instructional note stating to code first underlying chronic kidney disease. Look in the
Alphabetic Index for Disease, diseased/kidney/chronic/stage 3 (moderate) guiding you
to code N18.3, which will provide coding for stages 3a (N18.31) and 3b (N18.32) based
on glomerular filtration rate. Because the subdivision of stage is not documented,
unspecified is used. Verify code selection in the Tabular List. - ANSWER {4}
A patient sees the nephrologist for a B-12 injection to treat erythropoietin resistant
anemia due to stage 3 chronic kidney disease. What ICD-10-CM codes are reported?
H44.641, Z18.11
Rationale: In the ICD-10-CM Alphabetic Index look for Foreign body/intraocular/old,
retained/magnetic/posterior wall guiding you to code H44.64-. In the Tabular List, 6h
character 1 is assigned for the right eye. Subcategory code H44.6 has instructions to
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