What ICD-10-PCS codes would be reported
What ICD-10-PCS codes would be reported?
Patient Record:
Date of Visit: 07/22/YYYY
Patient Name: Georgia Gilmore
Date of Birth: 12/29/1950
Gender: F
Patient Type: Inpatient
Reason for Visit: Botox
Notes/Comments: Unit 4 Case Study 2
PREOPERATIVE DIAGNOSIS: Achalasia
POSTOPERATIVE DIAGNOSIS: Achalasia
PROCEDURE: Endoscopy with Botox injection
The patient is a 68-year-old with achalasia. She received Botox six months ago that has been
very successful and effective until recently. She presents today for the Botox injection to be repeated.
PROCEDURE: She is brought to the OR suite, prepped, draped and the Olympus video upper endoscope was
passed through the upper esophagus and advanced into the esophagus. The distal esophagus showed the
lower esophageal sphincter in spasm. The stomach and duodenum did not show any abnormalities. Botox
injections were performed with 1 mL in 4 quadrants of the esophagus. She tolerated the procedure without
complications and was taken to recovery.
IMPRESSION: Achalasia status post Botox injections
What ICD-10-PCS codes would be reported?
Q2) What ICD-10-PCS codes would be reported?
Patient Record :
Date of Visit: 06/19/YYYY
Patient Name: Myla Milestone
Date of Birth: 10/14/1998
Gender: F
Patient Type: Inpatient
Reason for Visit: Delivery
Notes/Comments: Unit 4 Case Study 1
PREOPERATIVE DIAGNOSIS: Term intrauterine pregnancy at 39 weeks
POSTOPERATIVE DIAGNOSIS: 1. Term intrauterine pregnancy at 39weeks
PROCEDURE: Vaginal delivery
INDICATIONS: This is a 20-year old gravida 1 para 1 who presented at 39 weeks in active labor. She is taken
to the labor and delivery suite.
PROCEDURE DESCRIPTION: The patient is taken to the labor and delivery suite in active labor dilated to a 6.
Her labor progressed rapidly and she was placed in the McRoberts position, the patient pushed, but without
delivery of the head. The nurse then applied Suprapubic pressure and gentle traction on the baby’s head
during the next major push and the baby was then delivered. The baby was bulb suctioned. The cord was then
clamped, cut, and the baby was given to the awaiting pediatric staff. She delivered a viable male infant with
Apgars of 8 and 9. weighing 7 pounds, 2 ounces over an intact perineum. The placenta was delivered intact
with three-vessel cord. Cervix was intact. Mom and baby were taken to postpartum recovery in stable
condition.
What ICD-10-PCS codes would be reported
Q3 ) What ICD-10-PCS codes would be reported?
Patient Record
Date of Visit: 02/22/YYYY
Patient Name: Sarah Smith
Gender: F
Patient Type: Inpatient
Reason for Visit: Botox
Notes/Comments: Unit 4 Case Study 3
PREOPERATIVE & POST
DIAGNOSIS Fetal hydrocephaly, 12 weeks
PROCEDURE: Elective abortion with vacuum aspiration
INDICATIONS: Sara Smith is a 32-year old female at 12 weeks gestation. The fetus has hydrocephaly upon
ultrasound and is determined to be non-viable. After a series of discussions between the patient and her
husband the decision was made to have an elective abortion.
PROCEDURE: She is brought to the OR suite, prepped, draped where a vacuum aspiration curettage was
completed to remove the non-viable fetus. Mom is recovering well and social services is counseling the
patient.
What ICD-10-PCS codes would be reported?
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