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Questions and Answers
What are the CPT® and ICD-10-CM codes reported for Case 8?
What are the CPT® and ICD-10-CM codes reported for Case 8?
15260-E2, 67966-51-E2, 67971-51-E2, 67875-51, C44.119
What are the CPT® and ICD-10-CM codes reported for Case 9?
What are the CPT® and ICD-10-CM codes reported for Case 9?
66982-RT, H26.9
What are the CPT® and ICD-10-CM codes reported for Case 10?
What are the CPT® and ICD-10-CM codes reported for Case 10?
66984-LT, H26.9
What are the CPT® and ICD-10-CM codes for CASE 1?
What are the CPT® and ICD-10-CM codes for CASE 1?
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What are the CPT® and ICD-10-CM codes for CASE 2?
What are the CPT® and ICD-10-CM codes for CASE 2?
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What are the CPT® and ICD-10-CM codes for CASE 3?
What are the CPT® and ICD-10-CM codes for CASE 3?
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What are the CPT® and ICD-10-CM codes for CASE 4?
What are the CPT® and ICD-10-CM codes for CASE 4?
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What are the CPT® and ICD-10-CM codes for CASE 5?
What are the CPT® and ICD-10-CM codes for CASE 5?
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What are the CPT® and ICD-10-CM codes for CASE 6?
What are the CPT® and ICD-10-CM codes for CASE 6?
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What are the CPT® and ICD-10-CM codes for CASE 7?
What are the CPT® and ICD-10-CM codes for CASE 7?
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What are the CPT® and ICD-10-CM codes for CASE 8?
What are the CPT® and ICD-10-CM codes for CASE 8?
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Study Notes
Case 1: Scleral Buckle and Cryoretinopexy
- Procedure performed: Scleral buckle, cryoretinopexy, drainage of subretinal fluid, C3F8 gas injection in the right eye.
- Anesthesia used: Laryngeal mask anesthesia.
- Primary diagnosis: Retinal detachment, confirmed postoperatively.
- Multiple retinal tears identified and treated with cryoretinopexy.
- Scleral buckle applied around the eye with 5-0 nylon sutures.
- Subretinal fluid drained via sclerotomy and C3F8 gas injected.
- Patient received postoperative pain control and eye care measures.
- CPT® and ICD-10-CM codes: 67107, H33.021.
Case 2: Nasolacrimal Duct Probing
- Condition addressed: Dacryostenosis in both eyes.
- Procedure performed: Nasolacrimal duct probing bilaterally under general anesthesia.
- Upper punctum dilated; nasolacrimal duct probed and irrigated for patency.
- TobraDex eye drops administered post-procedure.
- CPT® and ICD-10-CM codes: 68811-50, H04.553.
Case 3: Bilateral Otoplasty
- Condition: Bilateral protruding ears.
- Type of procedure: Bilateral otoplasty performed under general anesthesia.
- Incision made anterior to the sulcus of the ear for access.
- Concha sutured back to correct ear position using Mustarde' sutures.
- Symmetry checked post-operation; both ears corrected.
- CPT® and ICD-10-CM codes: 69300-50, Q17.5.
Case 4: Right Stapedectomy
- Condition treated: Right otosclerosis causing conductive hearing loss.
- Procedure type: Right stapedectomy performed under general endotracheal anesthesia.
- Footplate of the stapes removed; graft placed over the oval window.
- Platinum Teflon cup piston used to establish ossicular continuity.
- Postoperative care instructions provided to the patient.
- CPT® and ICD-10-CM codes: 69660-RT, 21235-51-RT, H80.81.
Case 5: Adenoidectomy and Ventilation Tube Placement
- Diagnosis: Adenoidal hypertrophy and serous otitis media with effusion.
- Procedure performed: Bilateral ventilation tube placement and adenoidectomy under general anesthesia.
- Thickened eardrums observed; tubes placed after tympanostomy.
- Adenoidectomy performed using powered adenoidectomy blade.
- CPT® and ICD-10-CM codes: 42830, 69436-50-51, J35.2, H65.93.
Case 6: Tympanoplasty
- Condition: Tympanic membrane perforation with conductive hearing loss in the right ear.
- Procedure: Right tympanoplasty via postauricular approach under general anesthesia.
- Graft harvested from temporalis fascia; perforation edges freshened before graft placement.
- Closure of incision done in layers with specific sutures.
- CPT® and ICD-10-CM codes: 69620-RT, H72.01, H90.11, H74.01.
Case 7: Removal of Foreign Body
- Diagnosis: Foreign body in the right external ear canal.
- Procedure: Removal of foreign body using microscope, performed under general anesthesia.
- Foreign body identified and removed atraumatically; ear canal remained intact.
- CPT® and ICD-10-CM codes: 69205-RT, T16.1XXA.
Case 8: Excision for Basal Cell Carcinoma
- Diagnosis: Left lower eyelid basal cell carcinoma.
- Procedure: Excision of carcinoma with flaps and full-thickness skin graft; tarsorrhaphy.
- Tumor resection with subsequent flap advancement from the upper eyelid.
- Multiple sutures used for securing graft; pressure dressing applied afterward.
- CPT® and ICD-10-CM codes: 15260-E2, 67966-51-E2, 67971-51-E2, 67875-51, C44.119.
Case 9: Cataract Surgery
- Diagnosis: Cataract in the right eye.
- Procedure performed: Complex phacoemulsification and peripheral iridectomy in the right eye.
- Anesthesia: Topical anesthetic used; patient informed of potential risks.
- Lens removed, and appropriate surgical techniques applied for cataract extraction.
- CPT® and ICD-10-CM codes not provided.### Surgical Procedures Overview
- Instruments used strategically to stretch the iris, enhancing visibility during cataract surgery.
- Capsulorrhexis created using cystotome needle for flap initiation and capsulorrhexis forceps for continuous tear.
- Hydrodissection and hydrodelineation of lens conducted using a flat tip hydrodissection cannula.
Phacoemulsification Process
- Phacoemulsification unit utilized to remove lens nucleus; followed by irrigation and aspiration for residual cortex removal.
- Bag inflated with Amvisc plus prior to lens insertion; lens model SI40MB with 27.5 diopters injected and dialed into position.
Postoperative Protocol
- Amvisc plus removed with irrigation and aspiration; anterior chamber inflated with balanced salt solution to achieve desired firmness.
- Vancomycin (0.1 cc) injected into the anterior chamber as a preventative measure.
- Wounds checked for leakage; confirmed watertight and globe firmness assessed.
- Speculum disinserted post-operation; patient given postoperative eye care instructions including topical eye drops and follow-up needs.
Coding Information
- CPT Code for first procedure: 66982-RT
- ICD-10-CM Code: H26.9
Case 10 Summary
- Patient diagnosed with left eye cataract; preoperative diagnosis matched postoperative findings.
- Intravenous sedation and local anesthesia administered via mixture of Bupivacaine and Lidocaine.
- Limbal incision performed and Provisc injected into anterior chamber for clarity during surgery.
Intraocular Lens Insertion
- Capsulotomy performed with a 6 mm oval shape; hydrodissection method applied using balanced salt solution.
- Lens nucleus removed through phacoemulsification and residual cortex extracted via irrigation and aspiration.
- AcrySof foldable posterior chamber intraocular lens inserted into capsular bag and centered appropriately.
Postoperative Care
- Provisc removed; pupil constricted with Miochol before wound check.
- Watertight wound confirmed; collagen shield applied soaked with Ciloxan and Pred Forte.
- Standard postoperative patch and shield placed; patient stable upon transfer to recovery room.
Coding Information for Case 10
- CPT Code for second procedure: 66984-LT
- ICD-10-CM Code: H26.9
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Description
Challenge your knowledge with the AAPC Chapter 15 flashcards focused on practical applications in coding for medical procedures. This quiz covers anesthesia, diagnoses, and surgical procedures, providing a comprehensive overview for coding professionals.
