Questions and Answers
What are the CPT and ICD-10-CM codes reported for CASE 1?
57160, N81.3
What are the CPT and ICD-10-CM codes reported for CASE 2?
57260, 58260-51, 57283-59, N81.3, N95.0, N32.89
What are the CPT and ICD-10-CM codes reported for CASE 3?
57460, R87.619
What are the CPT and ICD-10-CM codes reported for CASE 4?
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What are the CPT and ICD-10-CM codes reported for CASE 5?
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What are the CPT and ICD-10-CM codes reported for CASE 6?
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What are the CPT and ICD-10-CM codes reported for CASE 7?
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What was the gestational age of the patient in Case 8?
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What was the weight of the baby in Case 1?
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What were the Apgar scores for the baby in Case 1?
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What procedure was performed in Case 9?
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What anesthesia was used for the procedure in Case 10?
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What was noted about the left ovary during the procedure in Case 9?
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What was the diagnosis in Case 10?
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What was the CPT® code for the procedure in Case 8?
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What was the ICD-10-CM code for the diagnosis in Case 9?
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What was the estimated blood loss during the procedure in Case 10?
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Which of the following codes are associated with the procedure in Case 1? (Select all that apply)
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Which of the following codes are associated with the procedure in Case 10? (Select all that apply)
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Study Notes
Case 1: Pessary Fitting
- Diagnoses include stage III cystocele and stage II uterine prolapse; cystocele is not coded separately.
- Patient is a 75-year-old female with atrophic vaginitis receiving Premarin vaginal cream twice weekly.
- Underwent pessary fitting; initially fitted with #4, #5, and #6 ring pessaries; ultimately settled on #6.
- Patient experienced improved comfort and urinary function with pessary in place; instructed to remove weekly.
- Final codes: CPT 57160, ICD-10-CM N81.3.
Case 2: Surgical Management of Complete Procidentia
- Diagnoses: complete procidentia, recurrent urinary tract infections, and postmenopausal vaginal bleeding.
- Procedures included vaginal hysterectomy, anterior and posterior colporrhaphy, cystoscopy, and vaginal vault suspension.
- Significant findings include a thick, ulcerated cervix and complete procidentia with cystocele and rectocele.
- Cystoscopy revealed bilateral strong ureteral jets after indigo carmine administration.
- Final codes: CPT 57260, 58260-51, 57283-59; ICD-10-CM N81.3, N95.0, N32.89.
Case 3: Abnormal Cervical Pap Test
- Patient is a 21-year-old female with an abnormal Pap test and possible LGSIL.
- Colposcopy performed; acetic acid application revealed aceto-white lesions.
- LEEP biopsy taken; instructions given to avoid intercourse for one week post-procedure.
- Final codes: CPT 57460, ICD-10-CM R87.619.
Case 4: IUD Placement
- Patient is a 29-year-old female seeking Skyla IUD insertion post-delivery.
- Procedure involved cleaning the cervix, using a speculum, and positioning the IUD.
- The IUD was placed successfully, patient tolerated the procedure well.
- Final codes: CPT 58300, J7301; ICD-10-CM Z30.430.
Case 5: Hysterosalpingogram for Infertility
- Patient is a 30-year-old female seeking evaluation for infertility due to irregular periods.
- Procedure included visualization of the cervix and injection of contrast for HSG.
- Findings showed normal uterine shape; left tube filled and spilled, while right tube filled without documented spill.
- Final codes: CPT 58340, 74740-26; ICD-10-CM N97.9.
Case 6: Amniocentesis
- Patient is a 28-year-old female at 36 weeks gestation undergoing amniocentesis due to Rh isoimmunization.
- Procedure used ultrasound guidance for needle insertion; 20 cc of amniotic fluid aspirated.
- The patient tolerated the procedure without issues; follow-up Non-Stress Test (NST) planned.
- Final codes: CPT 59000, 76946; ICD-10-CM O36.0130, Z3A.36.
Case 7: Obstetric Delivery
- Patient is a 31-year-old with a history of normal antenatal visits, admitted to labor at 39 weeks.
- Cervical exam showed 3 cm dilation; SROM occurred with light meconium.
- Delivery involved slight meconium staining; male baby born weighing 3772 grams, APGAR scores 8/9.
- Minor second-degree perineal laceration repaired post-delivery.
- Final codes: CPT 59400; ICD-10-CM O70.1, O77.0, Z37.0, Z3A.39.
Case 8: Dilation and Evacuation (D&E)
- Patient is a 29-year-old pregnant at 20 weeks with multiple fetal anomalies seeking termination.
- Procedure involved moderate sedation, cervical dilation, and removal of the fetus and placenta using ultrasound guidance.
- The cord was severed; no respiratory or cardiac effort noted on ultrasound.
- Detailed documentation of procedure steps and findings provided for clinical reference.### Case Notes Overview
Case 9
- Anesthesia utilized: General with LMA.
- Preoperative diagnosis: Patient requesting sterilization.
- Procedure performed: Tubal ligation with bilateral Falope-ring application.
- Counts for needles, sponges, and instruments were correct.
- Intraoperative medications included a local anesthetic (0.25% Marcaine with epinephrine).
- Operative findings: Mild adherence of the left ovary to the uterus; normal appearance of the right ovary and both tubes. A small subserosal fibroid (1 to 1.5-cm) identified on the left upper uterus.
- Procedure description: General anesthesia performed, dorsal lithotomy position, sterile prep, infraumbilical incision made for trocar placement, insufflation, suprapubic incision for visual confirmation.
- Ligation of the right and left tubes with Falope-ring, documentation with pictures.
- Closure of incision sites with Monocryl sutures.
- Patient emerged from anesthesia and transferred to PACU in stable condition.
- CPT® code: 58671
- ICD-10-CM code: Z30.2
Case 10
- Preoperative diagnosis: Severe cervical dysplasia.
- Procedure performed: Cold knife conization.
- Anesthesia used: General.
- No complications reported during the procedure.
- Estimated blood loss recorded at 25 cc; 500 cc crystalloid fluids administered.
- A straight catheter was placed.
- Indications: Risks, benefits, and alternatives discussed with the patient; consent obtained.
- Procedure description: General anesthesia administered, patient sterilized and positioned in dorsal lithotomy.
- Weighted speculum placed; cervical lip grasped with a single-tooth tenaculum.
- Paracervical block using Pitressin and normal saline administered.
- Cervix ligated at 3 and 9 o'clock positions using #2-0 Vicryl stitches.
- Circumferential incision made with a #11 blade, cone-shaped excision performed.
- Cervical biopsy removed and marked; cauterization of cervical bed with Bovie cautery revealed good hemostasis.
- FloSeal applied, ties on cervical stitches performed in midline.
- Post-procedure: All instruments and counts confirmed correct; patient taken to recovery room awake and stable.
- CPT® code: 57520
- ICD-10-CM code: D06.9
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Description
Test your knowledge on the correct CPT and ICD-10-CM coding for multiple case studies. This quiz covers six distinct cases, each requiring identification of the appropriate codes. Perfect for students and professionals in the medical coding field.
