Question

Q: Need help with my assignment to code diagnoses(ICD-10-CM) and CPT for the following cases with explanation.

Case-1

Patient Name:

DOB: Age: 2Y

Date of Surgery: 04/04/2014

Primary Care Physician: Cecil H Lashlee, M.D.

Referring Physician(s): John F Bealer, M.D.

PCP Operative Report

Surgeon: John F Bealer, M.D.

Assistant(s): None.

Preoperative Diagnosis: Umbilical hernia.

Postoperative Diagnosis: Umbilical hernia.

Procedure: Umbilical herniorrhaphy.

Anesthesia: General endotracheal anesthesia.

Estimated Blood Loss: Less than 5 mL.

Complications: There were no intraoperative complications.

Counts: Correct.

Specimens: No microbiologic specimens were obtained.

Blood Products: None administered.

Specimen to Pathology: None submitted.

Findings: Operative findings included an umbilical hernia.

Indications: This 2-year-old presented to the clinic with a complaint of a protuberant

umbilicus. On physical examination, the patient had an obvious and easily reducible umbilical

hernia. After discussing with the patient's family the risks and benefits of umbilical herniorrhaphy, the patient's family desired that we proceed with surgery. The risks of the procedure included, but were not limited to infection, bleeding, scar, damage to other organs, need for further surgery, and recurrence of the umbilical hernia.

Description of Procedure: With the patient placed supine upon the operating room table, general

endotracheal anesthesia was successfully induced without incident or complication. After being certain of the level of anesthesia and position of the endotracheal tube, the patient was prepped and draped in the usual fashion and perioperative antibiotics were administered as part of the preoperative prep.

An infraumbilical curvilinear incision was created, carried down through the skin and through the subcutaneous tissues until the anterior abdominal wall fascia was exposed immediately inferior to the umbilicus. The umbilical hernia sac and umbilical hernia skin complex were then circumferentially controlled and mobilized within the subcutaneous space and elevated on a hemostat clamp. The umbilical hernia skin was then sharply separated from the umbilical hernia sac. The umbilical hernia sac was then visualized and palpated before being opened between clamps and completely excised.

It should be noted that loupe magnification was worn throughout this procedure.

The resultant fascial defect was then very carefully inspected and then closed utilizing multiple interrupted 2-0 PDS sutures. Once the fascial defect was closed, it was palpated and found to be securely closed. The umbilical skin was then reapproximated to the anterior abdominal wall fascia utilizing 4-0 Monocryl. The skin was closed with 4-0 Monocryl. Prior to closure, counts were reported as being correct. There were no complications.

The patient tolerated procedure well.

I want to know if I code it right?

Diagnoses

   K42.9        Umbilical hernia without obstruction or gangrene

CPT Procedure

   49582         Repair umbilical hernia, younger than age 5 years

Am I supposed to code repair too? Please explain the CPT code for fasci closure?

Am I supposed to code Anesthesia or it is bundled with surgery? Explain please.

Case-2

Patient Name: (

Date of Surgery: 07/23/2014

Primary Care Physician: Elizabeth G Sweeney, M.D.

Referring Physician(s): John F Bealer, M.D.

PCP Operative Report

Surgeon: John F Bealer, M.D.

Assistant(s): None

Preoperative Diagnosis: Left inguinal hernia.

Postoperative Diagnosis: Left inguinal hernia.

Procedures: Left inguinal hernia repair.

Anesthesia: General endotracheal anesthesia.

Estimated Blood Loss: Less than 5 mL.

Complications: There were no intraoperative complications.

Counts: Correct.

Specimens: No microbiologic specimens were obtained

Blood Products: None administered.

Specimen to Pathology: None submitted.

Findings: Operative findings included a left inguinal hernia.

Indications: This 17-year-old presented to the clinic with the complaint of a persistent bulge

in the left groin area. On physical examination, the patient had an obvious and easily reducible left inguinal hernia. There was no hernia appreciated on the contralateral side. After discussing with the patient's family the risks and benefits of a left inguinal herniorrhaphy, the patient's family desired that we proceed with surgery. The risks of the procedure included, but were not limited to infection, bleeding, scar, damage to other organs, need for further surgery, damage to the vas deferens, cord blood vessels, testicular atrophy and/or necrosis and recurrence of the inguinal hernia.

Description of Procedure: With the patient placed supine upon the operating room table, general endotracheal anesthesia was successfully induced without incident or complication. After being certain of the level of anesthesia and the position of endotracheal tube, the patient was prepped and draped in usual fashion.

An inguinal incision was made approximately halfway between the anterior/superior iliac spine and the pubic tubercle. It was carried down through the skin and subcutaneous tissues to the anterior abdominal wall fascia of the external oblique. The external oblique was completely cleared of all of its cutaneous attachments to allow for clear visualization of the shelving edge of the inguinal ligament, as well as the external inguinal ring. The external oblique fascia was then opened parallel to its fibers to include the external inguinal ring. The cord structures were then mobilized within the inguinal canal and elevated on a hemostat clamp. Dissecting on the anteromedial aspect of the patient's spermatic cord, a hernia sac was identified and very carefully separated from the vas deferens and cord blood vessels. Great care was taken to accurately and precisely identify the vas deferens and cord blood vessels and to preserve them throughout this dissection. It should also be noted that loupe magnification was worn throughout this procedure.

Once the cord structures were completely separated from the hernia sac, the hernia sac was visualized and palpated before being opened between clamps. Opening the hernia sac confirmed 360° control of the hernia sac and ensured that there was no retained intra-abdominal viscera within the sac. The sac was then twisted and doubly suture ligated with 2-0 Vicryl suture. The redundant portion of sac was then amputated and the stump allowed to retract. Gentle traction on the left hemiscrotum confirmed the presence of a testicle within the hemiscrotum and straightened the cord structures out along the inguinal canal.

The wounds were then closed in layers and the skin approximated with Monocryl. Prior to closure, counts were reported as being correct. There were no complications, and the patient tolerated the procedure well.

Need to do ICD-10-CM and all the CPT codes with explanation

Answer 1

Case 1:
Repair Umbilical Hernia 49582
We no need to code separately for repair..we need to code Anesthesia separately..because this service performed personally by an anesthesiologist.it indicate to insurance company that the anesthesiologist provided care to the patient..
Instead of coding for fasci closure CPT code we can go with Umbilical herniorrhaphy or repair umbilical hernia. fasci closure will included in repair umbilical hernia..
Doctors used loupe magnification it should be coded separately with CPT code 69990
General endotracheal anesthesia CPT code 31500
If there is any service or special equipment used it should be coded separately for the billing purpose..
Case 2:
ICD-10-cm
Left inguinal hernia K40.90
Procedure:
Left inguinal hernia repair CPT code 49521
Loupe magnification CPT code 69990
General endotracheal anesthesia 31500