Questions and Answers
What are the CPT and ICD-10-CM codes for Case 1?
What are the CPT and ICD-10-CM codes for Case 2?
What are the CPT and ICD-10-CM codes for Case 3?
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?
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Study Notes
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.
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Description
Test your knowledge on practical applications from Chapter 13 with these flashcards. This chapter covers critical diagnoses and procedures relevant to pelvic organ prolapse. Ideal for students and professionals in the medical field.