Cumulative Coding Challenge 13
Using the knowledge you have gained so far and your coding resources, code the following report as accurately and completely as possible.
Code this operative report as if you work in a physician office.
Coding Hint: Look for the main diagnosis. Two diagnosis codes are associated with this report. There are two CPT® procedure codes. One CPT code has two modifiers appended.
1. Fill In The Blank.
Enter the proper code(s) in the blank(s) provided. If a specific category of code is not applicable please leave the box blank. When entering multiple codes in the same box separate them with a comma and a space (i.e. E11.9, I10).
Operative Report
PREOPERATIVE DIAGNOSIS:
1. Recurrent acute otitis media.
2. Adenoidal hypertrophy.
POSTOPERATIVE DIAGNOSIS: Same. OPERATION PERFORMED:
3. Bilateral myringotomy with insertion of tympanostomy tubes.
4. Adenoidectomy.
INDICATIONS:
The patient is a 10-year-old white male with a history of recurrent acute otitis media in both ears, refractory to antibiotics. He is also noted to snore loudly and on exam has markedly enlarged adenoidal tissue.
DESCRIPTION OF PROCEDURE:
Patient taken to operating room and placed in supine position. General endotracheal anesthesia was induced without difficulty. The operating microscope was placed over the right ear.
A speculum was introduced and cerumen removed with a curet. A small incision was made in the anterior inferior quadrant of the tympanic membrane, and a tympanostomy tube was inserted without difficulty.
Cortisporin eardrops and a cotton ball were then placed in the external auditory canal. The operating microscope was then placed over the opposite ear, and a tympanostomy tube was inserted in an identical fashion.
The operating table was rotated 90 degrees, and the patient was draped in the usual sterile fashion. Mouth gag retractor was placed with care to avoid trauma.
Exam failed to reveal a submucous cleft or pulsatile adenoidal tissue. The adenoidal pad was removed with multiple swipes of the adenoid curet. Hemostasis was obtained using the electrocautery unit. The nose and mouth were irrigated with saline and suctioned. The mouth gag retractor was let down for a period of 1 minute.
Reinspection revealed adequate hemostasis. The case was terminated. The patient was allowed to awaken from anesthesia. He was extubated in the operating room. He was transferred to the post anesthesia recovery room in stable condition. EBL: 20 ml. Fluids: 200 ml crystalloid. Complications: None.
5. Primary ICD-10-CM Code:
6. Secondary ICD-10-CM Code(s):
7. Z Code(s):
8. External Cause of Morbidity Code(s):
9. Primary CPT Code:
10. Secondary CPT Code(s):
11. HCPCS Code(s):