Practical Applications Chapter 13 Flashcards

Case 1 Overview

• Diagnosis involves Stage III cystocele and Stage II uterine prolapse; cystocele coded under uterine prolapse.
• Procedure performed: Pessary fitting for pelvic organ prolapse treatment; patient 75, gravida 4, para 4.
• Examination revealed third-degree cystocele and uterine prolapse, with improved vaginal tissue condition.
• Multiple pessary sizes tested: #4, #5, and finally #6 ring pessary chosen for comfort and effectiveness.
• Follow-up plan includes weekly pessary removal, continued Premarin cream use, and monitoring for discharge or bleeding.
• CPT code: 57160; ICD-10-CM code: N81.3.

Case 2 Overview

• Diagnoses include complete procidentia, recurrent urinary tract infections, and postmenopausal vaginal bleeding.
• Surgical procedures: Vaginal hysterectomy, anterior and posterior colporrhaphy, cystoscopy, and vaginal vault suspension performed.
• Cervical findings included hypertrophic ulceration; biopsy negative for neoplasia.
• Procedure noted use of indigo carmine for visualization; confirmed bilateral ureteral patency.
• Comprehensive surgical procedures involved detailed dissection and suturing to ensure hemostasis and support.
• CPT codes: 57260, 58260-51, 57283-59; ICD-10-CM codes: N81.3, N95.0, N32.89.

Case 3 Overview

• Patient: 21-year-old woman, three pregnancies, one live birth, presenting for follow-up after abnormal Pap test.
• Colposcopy performed; aceto-white lesions observed, and biopsy taken via LEEP for cervical examination.
• Instructions provided for postoperative care and warning signs to monitor.
• CPT code: 57460; ICD-10-CM code: R87.619.

Case 4 Overview

• Chief complaint: Contraceptive placement of IUD; patient is a 29-year-old post-delivery female seeking Skyla IUD.
• Procedure involved positioning, cervical cleaning with Betadine, tenaculum placement, and sounding of the uterus.
• IUD properly placed and strings adjusted; patient tolerated the procedure well.
• CPT code: 58300, J7301; ICD-10-CM code: Z30.430.

Case 5 Overview

• Patient: 30-year-old female, never pregnant, with irregular periods and infertility requiring hysterosalpingogram (HSG).
• Procedure included cervical visualization, anesthetic application, and introduction of HSG catheter with contrast injection.
• Findings revealed normal uterus shape; left tube filled and spilled, right tube filled without spill observable.
• Follow-up care planned as necessary.
• CPT codes: 58340, 74740-26; ICD-10-CM code: N97.9.