What CPT and ICD-10-CM codes are reported?

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1 A patient is seen in the hospital s outpatient surgical area with a diagnosis of a displaced comminuted fracture of the lateral condyle, right elbow. An ORIF (open reduction) procedure was performed and included the following techniques: An incision was made in the area of the lateral epicondyle. This was carried through subcutaneous tissue, and the fracture site was easily exposed. Inspection revealed was the fragment to be rotated in two places about 90 degrees. It was possible to manually reduce this quite easily, and the manipulation resulted in an almost anatomic reduction. This was fixed with two pins driven across the humorous. The pins were cut off below skin level. The wound was closed with plain catgut subcutaneously and 5-0 nylon for the skin. Dressings and a long arm cast were applied. What CPT and ICD-10-CM codes are reported?

2 Procedure: Colectomy with a take-down of splenic flexure The patient was taken to the operating room and placed in the dorsal lithotomy position, prepped and draped in the usual sterile fashion. A vertical paramedian incision was made along the left side of the umbilicus from the symphysis and taken up to above the umbilicus. This incision was carried down to the rectus muscles, which were separated in the midline. The peritoneal cavity was entered with findings as described. The ascetic fluid was removed and hand-held retractors were used to assist in surgical exposure. The malignant intra-abdominal tumor was resected from the hepatic flexure into the mid transverse colon. The resection was extended into the left upper quadrant and the attachments were also clamped, cut and suture ligated with 2-0 silk sutures in a stepwise fashion until mobilization of the tumor mass could be brought medial and hemostasis was obtained. Attempts to find a dissection plane between the malignant tumor mass and the transverse colon were unsuccessful as it appeared that the tumor mass was invading into the wall of the bowel with extrinsic compression and distortion of the bowel lumen. Given the mass could not be resected without removal of bowel; attention was directed to mobilization of splenic flexure.

3 Retroperitoneal dissection was started in the pelvis and continued along the left paracolic gutter. The ligamentous and peritoneal attachments were taken down with Bovie cautery in a stepwise fashion around the splenic flexure of the colon until the entire left colon was mobilized medially. Similar steps were then carried on the right side as the right colon and hepatic flexure were mobilized. The peritoneal and ligamentous attachments were taken down with Bovie cautery. Vascular attachments were clamped, cut, and suture ligated with 2-0 silk until the right colon was mobilized satisfactorily. The GIA stapler was introduced and fired at both ends to dissect the tumorous bowel free. The bowel was delivered off the operative field. Attention was then directed towards re-anastomosis of the colon. Linen-shod clamps were used to gently clamp the proximal and distal segments of the large bowel. The staple line was removed with Metzenbaum scissors, and the colon lumen was irrigated. The silk sutures were used to divide the circumference of the bowel into equal thirds, and the proximal and distal edges of the bowel were reapproximated with silk sutures. The posterior segment of the bowel was then retracted and secured with a TA stapler, ensuring a full thickness bowel wall insertion into the staple line. The additional two thirds were also isolated and, with the TA stapler, clamped, ensuring that all layers of the bowel wall were

4 incorporated into the anastomosis. A third staple line was fired and the integrity of the anastomosis was checked. First complete hemostasis was noted. There was well beyond a finger width lumen within the large bowel. The linen-shod clamps were released and gas and bowel fluid were moved through the anastomosis aggressively with intact staple line, no leakage of gas or fluid. The abdomen was then irrigated and water was left over the anastomosis. The anastomosis was manipulated with no extravasation of air. The abdomen and pelvis were then irrigated aggressively. The Mesenteric trap was then re-approximated with interrupted 3-0 silk suture ligatures. All sites were inspected and noted to be hemostatic. Attention was directed towards closing. Pathology report showed intra-abdominal cancer. Also showed transverse colon and hepatic flexure cancer; did not indicate the origin of the cancer of the specimen given. What is the correct CPT and ICD-10-CM coding for this report?

5 Procedure: Mid Urethral Sling with cystoscopy Postoperative Diagnosis Code: Stress Urinary Incontinence The patient was taken to the operating room where general anesthesia was given by the anesthesiologist. Patient was then sterilely prepped and draped in dorsolithotomy position with her legs in Allen stirrups. Time-out was done. Nature of the procedure and identity of the patient was confirmed with the whole OR team. A Lone Star retractor was placed to help with vaginal retraction, a Foley catheter was placed using all sterile precautions. The mid urethral region was identified using the Foley bulb as guide at the bladder neck. This area was held with 2 Allis clamps. We made a mixture by mixing 20 ml of 1% lidocaine and 100 ml of injectable normal saline. This solution was infiltrated in the suburethral region and bilaterally in the sulcus region to aid with hydrodissection. A full-thickness vaginal epithelial incision was then made with a scalpel, followed by sharp dissection with Metz in the suburethral region, then in the sulcus bilaterally until the inferior pubic ramus was reached. Once the dissection was completed, the mini sling was loaded onto the introducer, and was first started on the right side. The introducer was passed through the vaginal incision through the sulcus behind the inferior pubic ramus and was advanced further till 2 pops were felt. Once the midline was reached, the anchor was deployed. Same procedure was repeated on the patient's left side. I did not

6 deploy the anchor. I did a cystoscopy at this time. No holes, no mesh material was seen inside the bladder or the urethra. The bladder was filled retrograde with 200 ml of normal saline at this time. Suprapubic pressure was applied to help with the final adjustment of the sling. Once the final adjustment was done, the anchor was deployed. The introducer was removed. The vaginal incision was closed with a running 2-0 Vicryl stitch. At this time, the procedure was completed. The patient was awakened and was taken from operating room to recovery room in stable condition. What CPT and ICD-10-CM codes are reported?

7 PROCEDURE PERFORMED 1. Ureteroscopy. 2. Laser lithotripsy of upper pole stone. 3. Basket stone extraction. 4. Irrigation of fragments. 5. Placement of 2 double-j ureteral stents. 6. Fluoroscopic interpretation. DRAINS 4.8-French 26-cm double-j ureteral stents PROCEDURE Patient was met and greeted in the preop holding area. Informed consent was verified. Risks, benefits, and alternatives of procedure were explained to the patient. He agreed to proceed. He was brought into the operating room, placed on table in supine position. Anesthesia was induced. Preoperative antibiotics were administered. Patient was repositioned in dorsal lithotomy position, appropriately padded and secured. He was then prepped and draped in standard sterile fashion. Time-out was announced. A 22-French rigid cystoscope was introduced into patient's urethra. Next to the emanated stent from the left ureteral orifice a Sensor wire was placed which appears

8 to advance into the lower pole of the kidney. At this point, the stents were removed. A second Sensor wire was placed at the time of direct ureteroscope which was advanced into the upper renal moiety, after that the ureteroscope was replaced and a second Sensor wire was placed in the same location entering the upper moiety of the left kidney. At this point, the ureteroscope was removed completely and 11/13 navigated HD access sheath was advanced into the upper moiety collecting system. Through this access sheath, disposable litho view scope was introduced, several stone fragments were seen within the upper ureter which were irrigated out subsequently. Pyeloscopy was performed and multiple stone fragments were seen. These were extracted with a basket. There were several other stones that were too big to be extracted and these were broken down with a 200 micron fiber in the lower posterior portion of the collecting system there were a lot of mucoid debris, as well as stone fragments. I was able to irrigate through the debris and localize some of the bigger stones which were once again broken down with the laser. These were all broken down into small fragments. Overall the staged procedure was successful and at this point, the ureteroscope was removed with direct visualization of the ureter. No trauma to the ureter was seen. Over the safety wires 4.8, 26-cm double-j ureteral stents were introduced into the upper and lower collecting system. Good coiling of the stents was seen in both. At this point the patient's bladder was emptied. He

9 was awakened from anesthesia and transferred to PACU in stable condition. Stones were submitted for analysis. ASSESSMENT AND PLAN Patient will present in 1 week for cystoscopy double-j ureteral stent removal. What CPT and ICD-10-CM codes are reported?

10 Postoperative Diagnosis Code: Congenital left breast deformity Procedure Performed: Placement of left breast implant using mentor catalog #, lot #, serial #, and 425 cc smooth round moderate profile implant filled with 475 cc of normal saline for breast reconstruction. Indications for Surgery: The patient is a 34 year old females who approximately 15 to 16 years ago had a left breast implant placed for breast reconstruction for her congenital deformity of the left breast. This implant ruptured and in late September, I performed a capsulectomy and exchanged her ruptured implant for a new implant. About a week after surgery, the patient developed an infection, due to the infection; her implant had to be removed. The patient s infection has completely resolved and she is now ready to have her implant replaced. In the preoperative holding area, I marked her for the ideal position of this implant and performed a breast exam not showing a mass in either breast and no mass in axillae and we proceeded. We did discuss with the patient, even though her original implant was placed in subglandular position today and the patient agreed and we proceeded.

11 Description of Procedure: The patient was given 1 g of IV Vancomycin. The patient was taken to the operating room; general anesthesia was induced and bilateral pneumatic compression stockings were worn throughout the procedure. A lower body Bair Hugger was placed. Both arms were secured to padded arm boards using Kerlix rolls. The neck, chest, axillae, and upper abdomen were prepped and draped in sterile fashion. I began by incising the central portion of her previous scar. I dissected down to the pectoralis major muscle. A submuscular plane was developed through a lateral approach and the inferior and medial origin of the muscle was partially divided using the Bovie cautery. Meticulous hemostasis was achieved using Bovie cautery. There were no signs of infection nor were there any pockets of seroma fluid or hematoma. The wound was carefully inspected. Meticulous hemostasis was achieved. Gloves were changed. The implant was opened and air was evacuated. It was placed in the submuscular pocket and the wound was temporarily closed using a skin stapler. The implant was filled to its maximum volume of 475 cc of normal saline. The patient was sat up. I adjusted the volume and ultimately felt she needed a 475 cc implant for breast symmetry with her contralateral breast. Once I was satisfied with the position of the implant, the patient

12 was placed supine. Gloves were changed again. The fill tube was removed and I then secured the filled valves digitally and the deepest layer of breast tissue was closed using 3-0 Vicryl in running suture and the skin was closed in three layers using 4-0 Monocryl, 5-0 Monocryl, and 5-0 Prolene. The wound was dressed with Xeroform and gauze. The patient tolerated the procedure well. She was taken to recovery in good condition. What CPT and ICD-10-CM codes are reported?