Question

Using the techniques described in this chapter carefully read through the case study and determine the most accurate ICD-10-CM code(s) and external cause code(s) if appropriate. Remember, check the chapter specific, sub-chapter specific and category specific notations within the Tabular list.

PATIENT: Noah Logan

PREOPERATIVE DIAGNOSIS: Midface deficiency.

POSTOPERATIVE DIAGNOSIS: Cleft hard palate with cleft soft palate

OPERATIVE PROCEDURE: LeFort I osteotomy with advancement.

ANESTHESIA: General via nasal intubation.

BLOOD LOSS: 200.

FLUIDS: 600.

URINE OUTPUT: 125.

DRAINS: No drains.

COMPLICATIONS: No complications.

BRIEF HISTORY: The patient is an 8-month-old male who has been under the care of Dr. Grayson for his pre-surgical orthodontics in order to address a midface deficiency. He was also found to have a maxillary midline deficit of approximately 3 mm to his left side. It was determined that he would benefit from a maxillary advancement of approximately 6 mm with rotation in order to set the midline straight.

OPERATIVE PROCEDURE: He was seen in the preop area, brought to the operating room, placed in supine position. General anesthesia was induced. Head and neck were prepped and draped in normal fashion. Time-out was performed. An NG was placed. The external reference marks were made using the right and left medial canthal tendon areas. The nasal width was also measured.

Next, a vestibular incision was made between the right and left first molars in the maxilla. Subperiosteal dissection was performed, as well as dissection around the piriform rim into the nasal fossa. Next, using a reciprocating saw, a standard LeFort 1 osteotomy was made. The osteotomy was taken posteriorly into the pterygomaxillary junction. Next, using a series of guarded chisels, the osteotomies were completed. The nasal septum was disarticulated as were the lateral nasal walls and finally pterygomaxillary disjunction was completed with chisels. The maxilla was brought down quite easily without any bleeding. All bony interferences were removed. The maxilla was then mobilized appropriately.

Next, the maxilla was placed into intermaxillary fixation, and four 1.5 mm KLS plates were placed across the right and left piriform rims as well as the zygomaticomaxillary buttresses in order to plate the LeFort 1 osteotomy. Once this was done, the intermaxillary fixation was released and the occlusion was found to be stable and repeatable. This was approximately a 6-mm advancement move with about a 2-mm rotation to the left. At this point, a V-Y closure of the upper lip was performed. An alar cinch suture was also used to reestablish the alar width. The vestibular incision was then irrigated and closed. The throat pack was removed. NG was maintained. The patient was extubated and taken to the recovery room.

Be sure to list the codes, one code per box, in the correct order, from top to bottom. Capitalization, punctuation, and spacing can impact whether or not your answer is correct. Follow coding best practices.

What is/are the correct diagnosis code(s)?

Answer 1

CLEFT LIP (hare lip) - its resulting in the failure of the maxillary process to fuse with nasal elevation on frontal prominence. The extent of cleft lip is varying from a notch in the vermillion border to a large cleft reaching the floor of the nose. It may be unilateral or bilateral.

CLEFT PALATE- It happen due the failure of masses of lateral palantine processes to meet and fuse together . it may be unilateral, bilateral or may occur in isolation or with cleft lip.

ICDis Q37.5 because he has hard and soft palate which is failure of the fusion of the two half of the plate.pateint undergo for lefort I osteotomy with advancement in which maxillary repairing was done with v-y close and usually happen in unilteral or bilateral cleft lip as patient having alar cinch suture to prevent the lateral drift of the nasolabial muscle and decrease the risk of postoperative nasal flaire.

ICD CODE CM (Q35-37)

Q35.1		Cleft hard palate
Q35.3		Cleft soft palate
Q35.5		Cleft hard palate with cleft soft palate
Q35.7		Cleft uvula
Q35.9		Cleft palate, unspecified

Q36		Cleft lip
Q36.0		Cleft lip, bilateral
Q36.1		Cleft lip, median
Q36.9		Cleft lip, unilateral

Q37		Cleft palate with cleft lip
Q37.0		Cleft hard palate with bilateral cleft lip
Q37.1		Cleft hard palate with unilateral cleft lip
Q37.2		Cleft soft palate with bilateral cleft lip
Q37.3		Cleft soft palate with unilateral cleft lip
Q37.4		Cleft hard and soft palate with bilateral cleft lip
Q37.5		Cleft hard and soft palate with unilateral cleft lip
Q37.8		Unspecified cleft palate with bilateral cleft lip
Q37.9		Unspecified cleft palate with unilateral cleft