code the following three operative reports assigning the appropriate CPT and ICD-10-CM codes and modifiers.
PREOPERATIVE DIAGNOSIS: Bladder lesions with history of previous transitional cell bladder carcinoma.
POSTOPERATIVE DIAGNOSIS: Bladder lesions with
history of previous transitional cell bladder carcinoma, pathology
pending.
OPERATION PERFORMED: Cystoscopy, bladder biopsies,
and fulguration.
ANESTHESIA: General.
INDICATION FOR OPERATION: This is a 73-year-old
gentleman who was recently noted to have some erythematous,
somewhat raised bladder lesions in the bladder mucosa at
cystoscopy. He was treated for a large transitional cell carcinoma
of the bladder with TURBT in 2002 and subsequently underwent
chemotherapy because of pulmonary nodules. He has had some low
grade noninvasive small tumor recurrences on one or two occasions
over the past 18 months. Recent cystoscopy raises suspicion of
another recurrence.
OPERATIVE FINDINGS: The entire bladder was
actually somewhat erythematous with mucosa looking somewhat
hyperplastic particularly in the right dome and lateral wall of the
bladder. Scarring was noted along the base of the bladder from the
patient's previous cysto TURBT. Ureteral orifice on the right side
was not able to be identified. The left side was
unremarkable.
DESCRIPTION OF OPERATION: The patient was taken to
the operating room. He was placed on the operating table. General
anesthesia was administered after which the patient was placed in
the dorsal lithotomy position. The genitalia and lower abdomen were
prepared with Betadine and draped subsequently. The urethra and
bladder were inspected under video urology equipment (25 French
panendoscope) with the findings as noted above. Cup biopsies were
taken in two areas from the right lateral wall of the bladder, the
posterior wall of bladder, and the bladder neck area. Each of these
biopsy sites were fulgurated with Bugbee electrodes. Inspection of
the sites after completing the procedure revealed no bleeding and
bladder irrigant was clear. The patient's bladder was then emptied.
Cystoscope removed and the patient was awakened and transferred to
the postanesthetic recovery area. There were no apparent
complications, and the patient appeared to tolerate the procedure
well. Estimated blood loss was less than 15 mL.
in the question it is not shown the size of the lesio
TheCPT code for cystoscopy with biopsy/fulguration is 52354 and append with modifier 50.
code the following three operative reports assigning the appropriate CPT and ICD-10-CM codes and modifiers. PREOPERATIVE...
code the following three operative reports assigning the appropriate CPT and ICD-10-CM codes and modifiers. Assignment #1 PREOPERATIVE DIAGNOSIS: Appendicitis. POSTOPERATIVE DIAGNOSIS: Appendicitis, nonperforated. PROCEDURE PERFORMED: Appendectomy. ANESTHESIA: General endotracheal. PROCEDURE: After informed consent was obtained, the patient was brought to the operative suite and placed supine on the operating table. General endotracheal anesthesia was induced without incident. The patient was prepped and draped in the usual sterile manner. A transverse right lower quadrant incision was made directly over the...
Assign the CPT code for all 3 operative reports Assignment #1 PREOPERATIVE DIAGNOSIS: Appendicitis. POSTOPERATIVE DIAGNOSIS: Appendicitis, nonperforated. PROCEDURE PERFORMED: Appendectomy. ANESTHESIA: General endotracheal. PROCEDURE: After informed consent was obtained, the patient was brought to the operative suite and placed supine on the operating table. General endotracheal anesthesia was induced without incident. The patient was prepped and draped in the usual sterile manner. A transverse right lower quadrant incision was made directly over the point of maximal tenderness. Sharp dissection...
code the following three operative reports assigning the appropriate CPT and ICD-10-CM codes and modifiers. PREOPERATIVE DIAGNOSIS: Appendicitis. POSTOPERATIVE DIAGNOSIS: Appendicitis, nonperforated. PROCEDURE PERFORMED: Appendectomy. ANESTHESIA: General endotracheal. PROCEDURE: After informed consent was obtained, the patient was brought to the operative suite and placed supine on the operating table. General endotracheal anesthesia was induced without incident. The patient was prepped and draped in the usual sterile manner. A transverse right lower quadrant incision was made directly over the point of...
Code the following three operative reports assigning the appropriate CPT and ICD-10-CM codes and modifiers. Assignment #1 PROCEDURE PERFORMED: Cataract extraction with lens implantation, right eye. DESCRIPTION OF PROCEDURE: The patient was brought to the operating room. The patient was identified and the correct operative site was also identified. A retrobulbar block using 5 ml of 2% lidocaine without epinephrine was done after adequate anesthetic was assured, and the eye was massaged to reduce risk of bleeding. The patient was...
code the following three operative reports assigning the appropriate CPT and ICD-10-CM codes and modifiers. Assignment #1 PROCEDURE PERFORMED: Cataract extraction with lens implantation, right eye. DESCRIPTION OF PROCEDURE: The patient was brought to the operating room. The patient was identified and the correct operative site was also identified. A retrobulbar block using 5 ml of 2% lidocaine without epinephrine was done after adequate anesthetic was assured, and the eye was massaged to reduce risk of bleeding. The patient was...
code the following three operative reports assigning the appropriate CPT and ICD-10-CM codes and modifiers Description: Spontaneous controlled sterile vaginal delivery performed without episiotomy. The patient is a 29-year-old, Caucasian, para 0, 40 weeks' pregnant who presented with contractions. Prenatal care has been in my office since the first trimester. Ultrasounds have been consistent with menstrual history. Factors identified for consideration during prenatal care included maternal history of Gilbert's syndrome. The patient presented in the early morning hours of February...
Code the following three operative reports assigning the appropriate ICD-10-CM codes and modifiers. Assignment #1 PROCEDURE PERFORMED: Cataract extraction with lens implantation, right eye. DESCRIPTION OF PROCEDURE: The patient was brought to the operating room. The patient was identified and the correct operative site was also identified. A retrobulbar block using 5 ml of 2% lidocaine without epinephrine was done after adequate anesthetic was assured, and the eye was massaged to reduce risk of bleeding. The patient was prepped and...
Assign the ICD-10-CM codes to diagnoses and conditions and assign the CPT surgery code and the appropriate HCPCS level II and CPT modifiers. Do not assign ICD-10-CM external cause codes. 5. PREOPERATIVE DIAGNOSIS: Mass of lung. POSTOPERATIVE DIAGNOSIS: Carcinoma of the right lung. OPERATION PERFORMED: Bronchoscopy and right upper lobectomy. The patient was brought into the operating room; and after the administration of anesthesia, the patient was prepped and draped in the usual sterile fashion. The patient was placed in...
1. Operative Report PREOPERATIVE DIAGNOSIS: Right proximal ureteral calculi.POSTOPERATIVE DIAGNOSIS: Right proximal ureteral calculi.OPERATIONS PERFORMED:1.Cystoscopy2.Right ureteroscopy3.Laser lithotripsy of ureteral stone and basketing stone fragments 4.Placement of double-J stentANESTHESIA::General. INDICATIONS: The patient is a 59-year-old male with a history of stone disease, who has severe right flank pain and was found to have an obstructing large right proximal ureteral stone. DESCRIPTION OF OPERATION: After induction of general anesthesia, the patient was placed in the lithotomy position. Genitalia were prepped...
icd-10-pcs codes to the following operative report AUTUU w a w ure TOHOwing operative report: PREOPERATIVE DIAGNOSIS: Left ureteral calculus POSTOPERATIVE DIAGNOSIS: Same OPERATION: Cystoscopy, bilateral retrograde pyelograms, left ureteroscopy with electrohydraulic lithotripsy, and basket extraction of calculi PROCEDURE: The patient is brought to the cystoscopy suite, where general anesthesia is induced and maintained in the usual fashion without difficulty. The patient then is placed in the dorsal lithotomy position, and the external genitalia are prepped and draped in a...