Question

EOPERATIVE DIAGNOSIS: Deltoid muscle pain and swelling.

POSTOPERATIVE DIAGNOSIS: Same.

PRELIMINARY NOTE: This patient was brought down to the operating room on the ventilator, and we used the operating room because of this.

OPERATIVE NOTE: With the patient in the supine position we prepped and draped the left deltoid region. After infiltration with 0.5% Marcaine with epinephrine, a vertical incision was made over the palpated muscular belly. Sharp dissection was carried down to the muscle belly and then we freed up a segment of muscle. We did infiltrate the ends of the muscle away from where we were taking our biopsy with the Marcaine. A segment of muscle was then isolated between clamps and then we excised the segment of muscle and submitted it immediately to the histology department for proper processing. The ends of the muscle were ligated using 2-0 chromic and then the muscular fascia was brought together using 2-0 chromic. Subcutaneous tissue was closed using 2-0 chromic and then the skin was closed using 4-0 nylon in running mattress fashion. A sterile dressing was applied. The patient tolerated the procedure well and was discharged from the operating room in stable condition. At the end of the procedure all sponges and instruments were accounted for.

PATHOLOGY REPORT LATER INDICATED: See Report 59.

Using the CPT and ICD-10-CM manuals, indicate the modifer that would be reported.

Answer 1

Answer :

Deltoid muscles pain and swelling :

ICD 10 CM code is S46.812 A .

CPT coding for muscle biopsy is 20200 vs 27324.

According to this the modifier is 59 is aloted for the procedural services.