PRE- AND POSTOPERATIVE DIAGNOSIS: Abscess, left leg PROCEDURE: Incision and drainage of leg abscess DETAILS: The patient was brought to the operating room where the leg was prepp

Please answer the questions for Each Scenario

Scenario #1

PRE- AND POSTOPERATIVE DIAGNOSIS: Abscess, left leg

PROCEDURE: Incision and drainage of leg abscess

DETAILS: The patient was brought to the operating room where the leg was prepped and draped in the usual sterile fashion. An incision was made over the abscess and carried down to the abscess cavity where the hematoma and purulent fluid were encountered, evacuated, and sent for analysis. The wound was irrigated and packed with saline gauze in wet-to-dry fashion. The patient tolerated the procedure well and was taken to PACU
in stable condition.

Questions:

Question #1: Can you assign a more specific body system than Anatomical Regions, Lower Extremities for this procedure?

Question #2: When the documentation states “Incision and Drainage,” which approach is identified? Can this be supported in the procedure details?

Question #3: What ICD-10-PCS code(s) would be assigned?

Scenario #2

DIAGNOSIS: PROCEDURE:

Left acoustic Schwannoma

INDICATION: Microsurgical resection of left cerebellar pontine angle acoustic Schwannoma with Stealth stereotactic guidance, complex patch duraplasty

The patient presented to us with a hearing dysfunction and was found to have a 2 cm vestibulocochlear nerve mass on MRI.

PROCEDURE: The patient was taken to the MRI scanner for normal Stealth MRI registration prep. Afterward, the patient was taken to the OR and general anesthesia was administered. The head was registered against the Stealth computer. An incision was fashioned and the flap was elevated and held in retraction. We turned a stan- dard craniotomy and opened the dura. We then opened the cerebellar pontine angle cistern and identified the tumor. We did central debulking and were able to mobilize the edge of the tumor to identify cranial nerve VIII as arose from the brainstem. We continued to debulk until we had removed tumor to the extent possible. The wound was carefully irrigated with antibiotic saline multiple times. The dura was closed via patch duraplasty with Durepair dural patch and a running 4-0 nylon suture and glue. The bone flap was replaced with multiple micro plates and screws. Soft tissue closure was carried out in standard fashion.

Questions:

Question #1A . Knowing the type of tumor will help you determine the body part value. What is a schwannoma?

Question #1B. The tumor is found in which body part?

Question #1C. Would you assign a code for the duraplasty with Durepair? If so, what is the root operation?

Question #1D. Research Durepair to determine the type of device value to assign. What is the appropriate choice and why?

Question #1E. In addition to 8E09XBH for the Stealth Stereotaxis (computer-assisted navigation), what code(s) would be assigned?

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