Using the coding techniques you have learned, carefully read...

Using the coding techniques you have learned, carefully read through the case study and determine the most accurate procedure code(s) and modifier(s), if appropriate.

 

Be sure to list the codes, one code per box, in the correct sequence, from top to bottom, and in the proper row. Capitalization, punctuation, and spacing can impact whether or not your answer is correct. Follow coding best practices. Please list modifiers with the code they relate to as necessary. Include a hyphen in between the code and the modifier. Example Procedure: 43846-74 or for Anesthesia: 00797-P2.

 

WESTON HOSPITAL

629 Healthcare Way • SOMEWHERE, FL 32811 • 407-555-6541

 

PATIENT: WHEATON, MARLA

ACCOUNT/EHR #: WHEAMA001

Admission Date: 09/18/18

Discharge Date: 09/18/18

DATE: 09/18/18

Preoperative DX: High-grade squamous intraepithelial lesion of the cervix

Postoperative DX: Same

Operation: Loop electrosurgical excision procedure (LEEP) and ECC (endocervical curettage)

Surgeon: Ralph L. Goff, MD

Assistant: None

Anesthesia: General by LMA

Findings: Large ectropion, large nonstaining active cervix essentially encompassing the entire active cervix

Specimens: To pathology

Disposition: Stable to recovery room

 

PROCEDURE: The patient was taken to the OR, where she was placed in the supine position and administered general anesthesia. She was then placed in candy cane stirrups and prepped and draped in the usual fashion. Her vaginal vault was not prepped. The coated speculum was then placed and the cervix exposed. It was then painted with Lugol and the entire active cervix was nonstaining with the clearly defined margins where the stain began to be picked up. The cervix was injected with approximately 7 cc of lidocaine with 1% epinephrine. Using a large loop, the anterior cervix was excised, and then the posterior loop was excised in separate specimens. Because of the size of the lesion, one piece in total was not accomplished. Prior to the excision, the endocervical curettage was performed, and specimens were collected. All specimens were sent to pathology. The remaining cervical bed was cauterized and then painted with Monsel for hemostasis. The case was concluded with this. Instruments were removed. The patient was taken down from candy cane stirrups, awakened from the anesthesia, and taken to the recovery room in stable condition.

 

RLG/mgr D: 09/23/18 12:33:08 PM T: 09/25/18 3:22:54 PM

 

 

NOTE: The CPT Changes: An Insider's View; CPT Assistant and Clinical Examples are not considered symbols or notations for this exercise.

 

Determine the accurate surgery CPT code(s) and modifier(s), if appropriate.

 

You may not need all of the spaces provided.

CPT code(s) and any applicable modifier(s) | Anesthesia code(s) and any applicable modifier(s) | HCPCS Level II code(s) and any modifier(s)

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