Question

Assign the ICD-10-CM code(s) to diagnoses and conditions and assign the CPT surgery code(s) and the appropriate HCPCS level 11 and CPT modifier(s). Do not assign ICD-10-CM external cause codes.

With the patient under general anesthesia, a vertical midline scrotal incision was made, carried down through the skin and subcutaneous tissues. With use of the cautery, the hemiscrotum was entered. The left testicle was delivered into the wound. There was no active bleeding, and the testicle was sent for analysis. The operative wounds were closed into multiple layers. Blood loss was minimal. The pathology report was positive for testicular cancer, left testicle. Thus, patient also underwent placement of needles into pelvic organs for subsequent interstitial radioelement application.

Answer 1

Diagnosis - Testicular cancer (left)

ICD -10-CM code - C62.92

Procedure - Scrotal incision under general anaesthesia

CPT code - 54700

Modifier - 51

Procedure - Radioelement application

CPT code - 76965

Answer 2

Patient's neck was palpated, and a thyroid cyst was indentified on the right.  Local anesthesia was administered; the cyst was confirmed.  A needle was inserted through the skin into the cyst.  The needle was withdrawn with the sample of tissue and sent for analysis