A 36-year-old female patient presents to the ED with a severe headache, listlessness, light sensitivity, nausea, and vomiting.
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Get it written →A 36-year-old female patient presents to the ED with a severe headache, listlessness, light sensitivity, nausea, and vomiting. The headache has been growing in intensity over the past three days. The patient does not have a fever. The patient has a programmable cerebrospinal fluid shunt in place, and after an MRI of both the head and the abdomen, it is determined that there is fluid accumulation in the intracranial portion of the shunt, indicating a malfunction. The neurosurgeon takes the patient to the outpatient surgical suite and performs a magnetic adjustment of the valve pressure. The diagnoses are documented as headache, and idiopathic normal pressure hydrocephalus blocked ventricular shunt. Excluding the E/M code and the MRI codes assigned by the chargemaster, what codes would be assigned for the facility in this case?
ICD-10-CM and CPT codes:
5.79) Preoperative Diagnosis: Endophthalmitis left eye
Postoperative Diagnosis: Endophthalmitis left eye
A standard 20-gauge pars plana vitrectomy was carried out with the pars placed 3mm posterior to the limbus. A full vitrectomy was performed. A posterior vitreous detachment was induced, and then further vitrectomy was carried out. The sclerotomy was closed with 7-0 Vicryl, as was the conjunctiva. Then 0.1mL of vancomycin(1mg), 0.1mL of ceftazidime(2mg), and 0.1mL of triamcinolone(4mg) were injected into the vitreous cavity at the end of the case.
The patient was patched after atropine and Maxitrol were applied to the eye. The patient will follow up tomorrow at 8 a.m.
No qualified resident was available for the case.
What are the correct ICD-10-CM and CPT codes for this ambulatory surgery?
a. H44.002, 67036-LT, 66030-59-LT
b. H44.19, 67036-LT, 66030-59-LT
c. H44.002, 67036-RT
d. T81.43XA, H44.002, 67036-LT, 66030-LT
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