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 prepped and draped in the usual fashion.
A lid speculum was applied.
A groove incision at the 12 o'clock position was made with a 5700
blade. This was beveled anteriorly in a lamellar fashion using the
crescent knife. Then the anterior chamber was entered with a slit
knife. The chamber was deepened with Viscoat. Then a paracentesis
at the 3 o'clock position was created using a super sharp blade. A
cystitome was used to nick the anterior capsule and then the
capsulotomy was completed with capsulorrhexis forceps.
Hydrodissection was employed using BSS on a blunt 27-gauge
needle.
The phaco tip was then introduced into the eye, and the eye was
divided into 4 grooves. Then a second instrument was used, a
Sinskey hook, to crack these grooves, and the individual quadrants
were brought into the central zone and phacoemulsified. I/A
proceeded without difficulty using the irrigation/aspiration
cannula. The capsule was felt to be clear and intact. The capsular
bag was then expanded with ProVisc.
The internal corneal wound was increased using the slit knife. The
lens was inspected and found to be free of defects, folded, and
easily inserted into the capsular bag, and unfolded. A corneal
light shield was then used as the wound was sutured with a
figure-of-eight 10-0 nylon suture. Then the Viscoat was removed
using I/A, and the suture drawn up and tied.
The 0.2 ml of gentamicin was injected subconjunctivally. Maxitrol
ointment was instilled into the conjunctival sac. The eye was
covered with a double patch and shield, and the patient was
discharged.
Assignment #2
PREOPERATIVE DIAGNOSES: Bilateral chronic
otitis media
POSTOPERATIVE DIAGNOSES: Bilateral chronic otitis
media
ANESTHESIA: General mask
NAME OF OPERATION: Bilateral Myringotomy with
placement of PE tubes
PROCEDURE: The patient was taken to the operating
room and placed in the supine position. After adequate general
inhalation anesthesia was obtained, the operating microscope with
brought in for full use throughout the case. First, the left and
then the right tympanic membrane, was approached. An
anterior-inferior radial incision was made in the left tympanic
membrane. Suction revealed a substantial amount of mucopurulent
drainage. A Sheehy pressure equalization tube was placed in the
myringotomy site. Floxin drops were added. The same procedure was
repeated on the right side with similar findings noted of
mucopurulent drainage. The patient tolerated the procedure well and
returned to the recovery room awake and in stable condition.
Assignment #3
EXAM: Mammographic screening FFDM
HISTORY: 40-year-old female who is on oral
contraceptive pills. She has no present symptomatic complaints. No
prior history of breast surgery nor family history of breast
CA.
TECHNIQUE: Standard CC and MLO views of the
breasts.
COMPARISON: This is the patient's baseline
study.
FINDINGS: The breasts are composed of moderately
to significantly dense fibroglandular tissue. The overlying skin is
unremarkable.
There are a tiny cluster of calcifications in the right breast,
near the central position associated with 11:30 on a clock.
There are benign-appearing calcifications in both breasts as well
as unremarkable axillary lymph nodes.
There are no spiculated masses or architectural distortion.
IMPRESSION: Tiny cluster of calcifications at the
11:30 position of the right breast. Recommend additional views;
spot magnification in the MLO and CC views of the right
breast.
BIRADS Classification 0 - Incomplete
MAMMOGRAPHY INFORMATION:
1. A certain percentage of cancers, probably 10% to 15%, will not
be identified by mammography.
2. Lack of radiographic evidence of malignancy should not delay a
biopsy if a clinically suspicious mass is present.
3. These images were obtained with FDA-approved digital mammography
equipment, and iCAD Second Look Software Version 7.2 was
utilized.
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1.The procedure is extracapsular as the capsule has not been removed ,as it used phacoemulsification and irrigation .The CPT code will be 66984 and the modifier will be 59.
Cataract extraction,right eye ICD -10CM =Z98.41
2.Since the tympanic membrane is incised to drain the discharge and PE tubes used The CPT code will be 69436-50
Bilateral chronic otitis media,ICD10CM =H66.93
3.The CPT code for the procedure is 77067 -TC as mamography is done bilaterally.
code the following three operative reports assigning the appropriate CPT and ICD-10-CM codes and modifiers. Assignment...
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 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...
Code the following three operative reports assigning the appropriate CPT code 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 draped in...
What is the correct modifier to use for the following three operative reports 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 appropriate CPT codes and modifiers 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 draped in the usual fashion. A lid...
Code the following operative report assigning the appropriate ICD-10-CM code Assignment #3 EXAM: Mammographic screening FFDM HISTORY: 40-year-old female who is on oral contraceptive pills. She has no present symptomatic complaints. No prior history of breast surgery nor family history of breast CA. TECHNIQUE: Standard CC and MLO views of the breasts. COMPARISON: This is the patient's baseline study. FINDINGS: The breasts are composed of moderately to significantly dense fibroglandular tissue. The overlying skin is unremarkable. There are a tiny...
Assign the appropriate CPT codes and modifiers. 2. PREOPERATIVE DIAGNOSES: Bilateral chronic otitis media POSTOPERATIVE DIAGNOSES: Bilateral chronic otitis media ANESTHESIA: General mask NAME OF OPERATION: Bilateral Myringotomy with placement of PE tubes PROCEDURE: The patient was taken to the operating room and placed in the supine position. After adequate general inhalation anesthesia was obtained, the operating microscope with brought in for full use throughout the case. First, the left and then the right tympanic membrane, was approached. An anterior-inferior...
Assign appropriate CPT code and modifiers. 3. EXAM: Mammographic screening FFDM HISTORY: 40-year-old female who is on oral contraceptive pills. She has no present symptomatic complaints. No prior history of breast surgery nor family history of breast CA. TECHNIQUE: Standard CC and MLO views of the breasts. COMPARISON: This is the patient's baseline study. FINDINGS: The breasts are composed of moderately to significantly dense fibroglandular tissue. The overlying skin is unremarkable. There are a tiny cluster of calcifications in the...
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...
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...