Question

Case 1

INDICATIONS FOR

PROCEDURE: This is a 29-year-old gravida 1, para 0, who is 37 weeks' gestational age by dates and ultrasound. She has presented with elevated blood pressure of 151/103. Lab values showed platelet count of 54,000, normal liver function test, a hematocrit of 35.0, and normal PT and PTT. It was felt that the patient was suffering from preeclampsia when examination revealed intrauterine growth retardation and hematemesis. Contractions were occurring but not regularly. Patient was dilated 3 cm, but due to the problems presented, we felt delivery could not wait. Patient was advised that an emergency cesarean was needed, and she agreed. PROCEDURE: This 29-year-old female was brought to the OR, after which epidural anesthesia was administered. Once patient showed no response to sensitivity, we proceeded. Patient was supine and right hip was slightly elevated to keep pressure off the vena cava. A low transverse incision with a #10 blade was carried to the level of the fascia. Mayo scissors were used to open the incision laterally. The posterior fascia was dissected bluntly from the rectus abdominus muscle. The aponeurosis was cut superiorly near the umbilicus and inferiorly to the symphysis pubis. Clamps were placed, and Metzenbaum scissors were then used to make a longitudinal peritoneal incision and extend the fascial opening. At this point, we were able to palpate the uterus, and fetal position was good. The bladder was freed from the uterus and retracted, a small transverse incision was made in the lower uterine segment, and the amniotic sac was exposed and incised. I then manipulated the fetus from the uterus. The infant female was drawn out, and the mouth and nose were immediately suctioned. The umbilical cord was clamped and cut, and cord samples were sent for pathology. The placenta was then recovered, and then a laparotomy sponge was used to clean the interior before a layered closure was performed: 2-0 absorbable sutures were used when closing the uterus. 3-0 Vicryl was used to close the bladder. The skin was closed with staples. Patient tolerated procedure well; mother and baby were fine.

ICD-10-PCS Code Assignment:________________

Case 2

INDICATIONS FOR SURGERY: A 34-year-old female presents with severe abdominal pain. After examination was completed and ultrasound results were reviewed, it was determined that patient had an ectopic pregnancy and surgical intervention was needed. PROCEDURE: Patient was taken to the operating room, and after general anesthesia was induced, she was prepped and draped in the usual sterile fashion. Examination was performed after anesthesia, which showed a normal-sized, nontender uterus, a left adnexal mass, and a fullness in the vagina, all consistent with hyperperitoneum. A 10-mm trocar was inserted directly into the abdomen through a small incision in the umbilicus. Using 3.5 liters of carbon dioxide, a pneumoperitoneum was created. The hemoperitoneum was noticed, and another 10-mm trocar was placed in a small suprapubic incision. Two 5-mm ports were also placed under direct visualization in both the right and left lower quadrants. With an irrigator and aspirator, the hemoperitoneum was reduced. The left fallopian tube was noted to be almost to the point of rupture due to a mass in the tube. The fallopian tube was distended beyond repair; so this needed to be removed. The tube was tied off and removed with its contents through an Endo Catch bag through the 10-mm port. Inspection of the abdomen noted no other problems; adequate hemostasis was noted, and ports were removed. Defects were closed with 0 Vicryl, and the skin was closed with 4-0 Dexon. She was sent to the recovery room in stable condition.

ICD-10-PCS Code Assignment:  ___________ and ____________

Case 3

DIAGNOSIS: False labor without delivery, antepartum complication

This patient is a 20-year-old female who presents today dilated 7 cm with contractions occurring every 3-4 minutes lasting 30-40 seconds. This mother is also an admitted cocaine addict who is worriedabout how her baby will be when born. At this time we are going to try to obtain a blood sample of the fetus to determine whether we need to have any special services on standby in the NICU.

The fetal monitor is showing a stable heart rate at this time. The amniotic sac is broken, and the amnioscope is inserted through the vagina. A 0.05-mm incision is made in the scalp, and a blood sample is aspirated into a tube for a STAT to the lab. Contractions stopped, and the baby was not delivered at this time.

Procedure completed was an endoscopic drainage via the vagina for fetal blood sample.

ICD-10-PCS Code Assignment:___________

Answer 1

Case 1 ICD-10-PCS Code Assignment

036.5931 - Maternal care for other known or suspected poor fetal growth, third trimester.