Intravenous sedation
Preoperative Diagnosis: A 5-mm stone in the right lower pole
Postoperative Diagnosis: A 5-mm stone in the right lower pole
Operation Performed: Right extracorporeal shockwave lithotripsy
Anesthesia: Intravenous sedation
Indications for Procedure: This is a 32-year-old male who recently presented with right renal colic. An x-ray showed a stone in the proximal ureter. On June 1, 20XX, he underwent cystourethroscopy, the stone was successfully flushed into the kidney, and a double-J stent was placed in the ureter. Today, he presents for ESWL. An x-ray confirmed the location of the stone in the right lower pole.
Description of Procedure: The patient was placed on the treatment table and sedated. He was positioned over the shockwave electrode. Biaxial Fluoroscopy was utilized to position the stone at the focal point of the shockwave generator. The stone was treated with a total OF 3,000 shocks. At the conclusion of the procedure, the stone appeared to have fragmented nicely, and the patient was discharged to the PACU. Which of the following ICD-10-CM and CPT codes are reported for this service?
a. N21.1, 52332, 50590
b. N20.0, 50590
c. N20.0, 52353
d. N20.1, 50590, 52353
5.39) Indications: The patient is a 50-year-old male with four children. He desires a permanent form of birth control via vasectomy.
Preoperative Diagnosis: Elective vasectomy
Postoperative Diagnosis: Elective vasectomy
Procedure: Bilateral trans-scrotal segmental vasectomy
Anesthesia: Local with 1 percent Xylocaine infiltration
Description of Procedure: The patient was taken to the procedure room where, in the supine position., he was prepped and draped in a routine fashion. The left vas deferens were identified and isolated. Local anesthesia was obtained using infiltration of 1 percent Xylocaine without epinephrine. An incision was made overlying the vas deferens. The vas deferens were identified and delivered to the operative field. A 2.5-cm segment of vas deferens was then excised between hemostats. The ends of the vasa were then cauterized with electrocautery. The distal end was sutured and folded back upon itself with 3-0 chromic. The proximal end was sutured and folded back upon itself. Hemostasis was obtained. Next, attention was directed to the right side where the procedure was performed in a mirror-image fashion. After confirming adequate hemostasis, the vasa were returned to the normal location within the scrotum. The skin was closed using interrupted sutures of 3-0 chromic. The patient was returned to the recovery room in good condition. What codes are assigned for this encounter?
ICD-10-CM and CPT codes:
5.40) Discharge Diagnosis: Torsion, right appendix testis
Operation: Right scrotal exploration, excision appendix testis
Summary: HPI patient is a 4-year-old white male patient who has a moderate intellectual disability as well as obesity; otherwise he gets along reasonably well. However, the patient presented to his pediatrician this morning with a 1-hour history of sudden onset of testicular pain. Physical exam at that time was suggestive of testicular torsion, and he was admitted for surgical repair. A physical exam showed an obese white male who was crying. Lungs clear, Heart regular, without murmur or gallop. Abdomen obese, no masses appreciated; bowel sounds normal and active. The genital exam showed a small penis that was engulfed in the suprapubic fat; testes down bilaterally; the right side was exquisitely tender.
Pathology Report
Gross Description: The specimen consists of a dark reddish-brown polyp-like tissue fragment, 8x4x4mm. The entire specimen is submitted.
Microscopic Description: The specimen consists of histologic sections of a papillomatous tissue fragment lined by what appears to be mesothelium. The core of the specimen is composed of extremely loose connective tissue showing vascular
congestion and hemorrhage.
Diagnosis: Appendix—testis; Edema and hemorrhage
What codes are assigned to this case?
ICD-10-CM and CPT codes:
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