27 Oct A 39-year-old male with a past medical history of diabetes mellitus type 2

 A 39-year-old male with a past medical history of diabetes mellitus type 2, hypercholesterolemia, hypertriglyceridemia, obesity, and chronic systolic heart failure has been treated for symptomatic cholelithiasis and acute cholecystitis without improvement. A patient comes to outpatient surgery for laparoscopic cholecystectomy. Due to previous abdominal surgery, adhesions were encountered. During the course of the laparoscopic cholecystectomy procedure, the adhesions were lysed, but this did not prolong the procedure. The patient is homeless and obese with a BMI of 42. What codes are assigned? 

ICD-10-CM and CPT codes

5.15.  This 77-year-old patient admitted to the special procedures room has an endoscopic-directed percutaneous endoscopic gastrostomy tube placed because of moderate malnutrition. The patient has had a stroke, with residual right dominant-sided hemiparesis. Assign the codes that the hospital would use to bill this service.

 

ICD-10-CM and CPT  codes

 

 

 

5.16.  This 59-year-old female patient with a past medical history of chronic diastolic heart failure. Obstructive Sleep Apnea(OSA). Major Depressive Disorder(MDD), and anxiety came into the emergency department because of passing melanotic stools. The ED physician initially saw her. The gastroenterologist was called into consultation. Because of the massive amounts of bleeding, it was decided to proceed with endoscopy. The endoscope was passed into the esophagus, stomach, and duodenum. Blood and clots were noted. This patient could possibly have a duodenal ulcer, but because of the amount of blood, it was difficult to delineate an ulcer crater. Diagnosis: Melanotic stools, and possibly a duodenal ulcer. The patient.s BMI is 19.2 and the patient has been diagnosed with severe protein-calorie malnutrition. What codes are assigned in this case?

 

ICD-10-CM Reason for Visit code:

 

ICD-10-CM  and CPT codes:

 

 

 

5.17. Preoperative Diagnosis: Rectal mass

 

Postoperative Diagnosis: Rectal prolapse

 

                                           Colonic polyps, Biopsies x 2

 

                                            Significant sigmoid diverticulosis with nonspecific colitis

 

Procedure: Colonoscopy performed to the level of the cecum, 110cm

 

Procedure: The 62-year-old male patient was prepped in the usual fashion, followed by placement in the left lateral decubitus position. I administered 3mg of Versed. Monitoring of sedation was assisted by a trained registered nurse. Next, the Pentax Video Endoscope was passed through the rectal verge after a negative digital examination and advanced to the level of the cecum. The scope was then slowly retracted with a circular tip motion. There was mild nonspecific colitis noted. He did have significant sigmoid diverticulosis and several small polyps just inside the rectum, as well as a large prolapsing mass of mucosa approximately 5cm inside the rectum. This appears to have prolapsed previously. Two of the small polyps were biopsied using the cold biopsy forceps and sent to pathology for examination. The remainder of the examination was unremarkable. The patient tolerated the procedure well. 

 

Pathology Report 

 

Clinical Information: Change in bowel habits, Colonoscopy performed.

 

Gross Examination: The specimen is labeled polyps 2 at 3 cm. Submitted are 2 fragments of tan tissue measuring up to 0.3cm in greatest dimension.

 

Diagnosis: Rectum biopsies at 3cm: rectal polyps

 

What codes are assigned in this case?

 

ICD-10-CM  and CPT  codes:

 

 

 

5.21. Preoperative Diagnosis: Aspiration pneumonitis

 

         Postoperative Diagnosis: Aspiration pneumonitis

 

         Operative Procedure: NJ Tube Placement

 

 Description of Procedure: The identity of the patient was confirmed. The planned procedure was confirmed with the staff. Consent was verified. The patient was prepared with IV sedation. An 8 Fr CorPak tube was lubricated and inserted into the stomach. Fluoroscopic guidance was provided by radiology. This allowed passage of the tube through the pylorus, through the duodenum, and into the jejunum. The position of the tube was confirmed by contrast instillation. Water flushed well through the tube. The tube was taped securely to the face. The patient was sent to the recovery room in good condition.

 

Impression: Successful NJ tube placement

 

ICD-10-CM and CPT codes:

 

 

 

5.24. Preoperative Diagnosis: Ventral hernia

 

          Postoperative Diagnosis: Ventral hernia

 

          Operation Performed: Ventral hernia repair via laparoscopy

 

Description of Procedure: The patient was prepped and draped in the usual fashion after being placed in a supine position. A 1-cm incision was made, and a Veress needle was introduced into the abdominal cavity. A 10mm trocar was inserted, and the laparoscope was introduced. Additional trocars were inserted. Direct observation of the abdomen revealed a 2-to 3-cm hernia defect just below the umbilicus. Following plication of the rectus abdominal muscle, mesh Martex was fashioned to an appropriate size, applied around the area, and sutured using a 2.0 Prolene suture. Two Jackson-Pratt drains were placed in the subcutaneous area and attached using a 2-0 thread. The scope and trocars were removed, and incisions were sutured. The patient tolerated the procedure well and left the OR in good condition. 

 

What codes are assigned in this case?

 

ICD-10-CM and CPT codes: