Question

The following documentation is from the health record of a 42-year-old male patient.

Physician Office Record Entries

Hospital Copy: History and Physical

Admitting Diagnosis: Herniation of intervertebral disc, L5–S1 right side

Present Medical History: Patient is a 42-year-old Native American male who initially developed problems with his back in July of this year. He was treated with anti-inflammatory agents and started on an exercise program; his condition improved enough to return to work. About one month ago, he had recurrence of pain, which has become steadily worse in the past week. He noticed some numbness of his right foot, primarily the toes and right heel. The patient was initially evaluated by his family physician and is now admitted to the orthopedic service for microdiskectomy after MRI revealed herniation and protrusion of the disc encroaching on the nerve root.

Past Medical History: Patient denied any known allergies or drug sensitivities. He has been taking Advil on a p.r.n. basis. Also takes Lotensin 10 mg daily for hypertension and has a history of incomplete bundle branch block, hyperlipidemia (no meds), hiatus hernia with gastroesophageal reflux.

Previous Surgeries: Tonsillectomy as a child and also tendon repair to the right hand in 1989. Does state that he injured his kidney in a motorcycle accident at age 21 years and was hospitalized with viral pneumonia in 1983.

Family History: Father is 62 years with heart disease and hypertension problems. Mother is 64 years and in good health, without significant illness. Three siblings, all in good health.

Social History: Patient is employed full-time at the Harley-Davidson dealership. At the present time, he is divorced and has one child who lives with her mother. He does not smoke, is sexually active, and admits to sporadic alcohol use.

Review of Systems

HEENT: Patient denies any unusual problems with headaches and dizziness, or visual or hearing difficulty. Cardiorespiratory: Denies chest pain; does have occasional asthma symptoms with some wheezing but does not use medications. Hypertension for 2 years, well controlled on medication. Gastrointestinal: Denies distention, diarrhea, and constipation. Genitourinary: Negative. Musculoskeletal: See present complaint.

Physical Examination: Reveals a well-developed, well-nourished male in no acute distress. Does have a hard time sitting due to pain on the right side. Height 6910, weight 210 lb, blood pressure 122/90, pulse 72, respiration 20. Skin is clear, normal temperature and texture. HEENT: Head normal cephalic. Pupils are round, equal, and reactive to light accommodation. Canals are clear. Tympanic membranes, nose, and throat are clear of infection. Neck: Supple, thyroid negative. No adenopathy,331no distomegaly or carotid bruits. Chest: Symmetrical, lungs clear to P & A. Heart: Normal sinus rhythm, no thrills or murmurs. Abdomen: Soft, no tenderness or masses. No organomegaly. Normal male genitalia. Extremities: Normal development. Patient does have tenderness in the area of the right sciatic knot and in the lower lumbar area on the right side. Has positive leg raising and some decrease in the deep tendon reflexes on the side.

Impression: Herniation of intervertebral disc at L5–S1 right side

Plan: Microdiskectomy tomorrow morning

Operative Report

Preoperative Diagnosis: Herniated nucleus pulposus, right

Postoperative Diagnosis: Same

Operation: Right L5–S1 diskectomy with minifacetectomy foraminotomy

Complications: None

Indications: The patient is an otherwise healthy 42-year-old Native American male who has had six months of disabling right leg pain. He has tried extensive physical therapy, nonsteroidal anti-inflammatory drugs, and an epidural injection, without relief. He has a positive straight leg-raising test on the right side and an absent ankle jerk. MRI scan confirms the disk herniation at L5–S1 on the right side.

Description of Procedure:

The patient was brought to the operating room, and general anesthesia was administered in the usual fashion. He was positioned in the prone position onto a well-padded Andrews frame. All pressure points were well padded. The back was prepped and draped in a sterile fashion. He received 1 g of Ancef prior to the beginning of the case, along with 30 mg of IV Toradol.

Initially, an x-ray was checked that showed we were at the L4–5 interspace, so we went down one level. A 3/4 skin incision was made in the midline of the lumbar sacral spine, and this was carried down to the subcutaneous tissue. The fascia over the L5–S1 lamina was then dissected away. The paraspinal muscles were then elevated above the lamina, and a laminotomy was performed in between L5 and S1. The superior facet of S1 was undercut using a Kerrison rongeur. The S1 nerve root was well visualized and this area was protected throughout the procedure. Following this, a foraminotomy was performed over the top of the S1 nerve root. The S1 nerve root was then gently retracted medially, and a very large extrusive disk fragment was pulled out from underneath the S1 nerve root. The annulotomy that had been made from the disc herniation was then explored, and no further fragments could be found. The wound was thoroughly irrigated with a bacitracin solution. Gelfoam and thrombin were placed over the top of the dura, and the deep fascia was closed with interrupted 0 VICRYL sutures. The subcutaneous tissue was closed with 2-0 VICRYL suture, and the skin was closed with 4-0 VICRYL suture. Benzoin and Steri-Strips were applied to the wound. The patient was returned to recovery in stable condition. EBL 10 cc.

Pathologic Diagnosis: Intervertebral disc L5–S1 resection, herniated nucleus pulposus

Which of the following is the correct ICD-10-CM and CPT code assignment for physician service? Code for surgical services only.

1. M51.37, I10, 63047
2. M51.06, I10, 63030
3. M51.27, 63047
4. M51.27, I10, 63030

Answer 1

Answer: (C) M51. 27, 63047

( The ICD 10 CM code for the Herniated nucleus pulposus, right is M51. 27, which can be used for the reimbursement purpose)