Question

Assign the ICD-10-CM code(s) to diagnoses and conditions and assign the CPT surgery code(s) and the appropriate HCPCS level II and CPT modifier(s). Do not assign ICD-10-CM external cause codes.

flexure status post-multiple endoscopic polypectomies

PREOPERATIVE DIAGNOSIS: Polyp of hepatic flexure, status posthurupit on

POSTOPERATIVE DIAGNOSIS: Polyp of hepatic flexure, status post-multiple endoscopic polypectomies

OPERATION PERFORMED: Right hemicolectomy.

INDICATIONS FOR PROCEDURE: The patient is a 67-year-old white female with a history of a sessile polyp in the hepatic flexure. Despite multiple prior polypectomies, the polyp could not be eradicated. Biopsies demonstrated that there was moderate to severe dysplasia within the lesion. Subsequently, the patient was taken to the operating room suite for hemicolectomy.

INTRAOPERATIVE FINDINGS: Included a 2-cm margin distal to the polyp.

Informed consent was obtained prior to surgical intervention. The patient was taken to the major operating suite and placed in the supine position, where general endotracheal anesthesia was successfully administered. The patient's abdomen was prepped and draped in a typical sterile manner. The patient's prior right paramedian incision was excised using a knife. Subcutaneous tissues were transected using a Bovie electrocautery, and the midline fascia was incised. Great care was taken upon entering the abdomen not to injure underlying bowel. A modest number of thin adhesions were then taken down sharply, using the Metzenbaum scissors. Following adequate adhesiolysis, the Bookwalter retractor was placed in position. The right colon was mobilized by incising the lateral peritoneal attachments. Following elevation of the right colon, the hepatic flexure was taken down using a combination of sharp and blunt dissection. The right branch of the middle colic artery was identified, and this was thought to be a good site for division of the transverse colon. This will allow the left branch of the middle colic to maintain flow to the distal segment of colon. The mesentery of the right colon was then sequentially clamped, divided, and ligated using 0 silk ties. Stick ties were used as larger vessels were encountered. The terminal ileum was then positioned in a side-to-side manner with the transverse colon just distal to the right branch of middle colic artery. Entrotomies were made in the transverse colon and terminal ileum, and a side-to-side anastomosis was performed using a GIA 80 stapler. The anastomosis was completed by firing a second load of the GIA stapler. The specimen was then placed on the back table and was inspected. A 2-cm margin from the polyp was identified. The polyp was marked with a stitch, and the specimen was sent to pathology for histologic evaluation. The lumen of the anastomosis was palpated and found to be widely patent. The mesenteric defect was then closed using a series of 3-0 silk simple interrupted sutures. The abdomen copiously irrigated using warm normal saline solution. Hemostasis was confirmed, and the midline fascia was reapproximated using a running #2 Prolene suture. Subcutaneous tissues were copiously irrigated, and the skin was closed with staples. Sterile dressing was applied, and the patient was awakened from general endotracheal anesthesia and escorted to the recovery room, having tolerated the procedure without apparent incident.

Answer 1

Ans) ICD-10-CM is a seven-character, alphanumeric code. Each code begins with a letter, and that letter is followed by two numbers. The first three characters of ICD-10-CM are the “category.” The category describes the general type of the injury or disease. The category is followed by a decimal point and the subcategory. This is followed by up to two subclassifications, which further explain the cause, manifestation, location, severity, and type of injury or disease. The last character is the extension.

- The extension describes the type of encounter this is. That is, if this is the first time a healthcare provider has seen the patient for this condition/injury/disease, it’s listed as the “initial encounter.” Every encounter after the first is listed as a “subsequent encounter.” Patient visits related to the effects of a previous injury or disease are listed with the term “sequela.”

To review: the first digit of an ICD-10-CM code is always an alpha, the second digit is always numeric, and digits three through seven may be alpha or numeric. Here’s a simplified look at ICD-10-CM’s format.

- Medicare uses Healthcare Common Procedure Coding System (HCPCS) codes for screening. For a patient of typical risk, the screening procedure is reported with HCPCS code G0121; for a patient at high risk, it is reported with HCPCS code G0105. Medicare has a separate modifier for situations in which polyps are found and removed during a screening colonoscopy. In these instances, the correct CPT code is used (for example, 45385), but with modifier PT. Medicare’s reimbursement policy for this type of case is the same as other payors; only the coding differs. Each endoscopist should review the policies of their insurance providers to be certain which system is used, especially for Medicare Advantage plans offered by commercial insurers.