MCCG146 - Week 6 Coding Scenarios (1)

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Bryant & Stratton College *

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MCCG146012

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Biology

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Apr 3, 2024

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MCCG146 – CPT and HCPCS Level II Coding Week 6 Coding Scenarios This Assessment is part of the Coding Scenarios category, which is worth 15% of your grade. Deadline Due by the end of Week 6 at 11:59 pm, ET. Completing this Assessment will help you to meet the following: Course Outcome  Utilize CPT guidelines, including abbreviations, punctuation, and symbols, to assign codes and achieve standards. Directions For this Assessment, you will be presented with two more scenarios. Read each scenario below and then assign the appropriate codes in the boxes provided. Scenario 1 Title of Procedure: Upper Intestinal Endoscopy with Biopsy Diagnosis Eosinophilic esophagitis Description of Procedure: The risks and benefits of the procedure were reviewed with mother and father and informed consent was obtained. A time-out was completed verifying correct patient, procedure, site, positioning, and special equipment if applicable. underwent satisfactory anesthesia as described above. The Olympus GIF Q180 endoscope was introduced under direct visualization and advanced into the esophagus. The esophageal mucosa was remarkable for mild furrowing, slightly irregular surface pattern more prominent in distal esophagus, and overall esophagus seemed less pliable. The lower esophageal sphincter was located 30 cm from the mouth. The stomach appeared normal. Retroflexion appeared normal. The duodenum was intubated, was remarkable for small patch of erythema in duodenal bulb but was otherwise normal appearing. Biopsies were taken from the duodenum, antrum, body, distal esophagus and proximal esophagus for histology. Urease testing was not performed. No additional diagnostic maneuvers were performed. The endoscope was readvanced to the stomach, which was suctioned of all contents, and then withdrawn.

MCCG146 – Coding Scenarios 2 Now that you have read Scenario 1, complete the following: Provide the ICD-10-CM Diagnosis Code K20.0 Provide CPT code with modifier if applicable: 43239 Modifier 59 Scenario 2 Postoperative Diagnosis: Left inguinal hernia. Operative Procedure: Repair of left inguinal hernia of 25-year-old. A standard left groin incision was accomplished, carried down through subcutaneous tissue. The external oblique was divided in line with its fibers, the cord structures were carefully freed up and protected with a Penrose drain. The cremasteric muscle was incised and a large sac identified. This was very thin walled and had the appearance of being extremely acute. The sac was carefully freed up from the surrounding tissues, twisted and high ligation accomplished with an 0 silk followed by a 2-0 silk suture ligature. The sac was excised. The wound was then again irrigated with antibiotics after which the dermis was approximated with continuous 3-0 Vicryl and the epidermis with Steri-Strips. Now that you have read Scenario 2, provide the following: Provide the ICD-10-CM Diagnosis Code K40.90 Provide CPT code with modifier if applicable: 49525 Scenario 3 Procedure : Steroid injection. Indications : Right shoulder bursitis, rotator cuff syndrome.

MCCG146 – Coding Scenarios 3 Procedure : This procedure was done in our surgical suite. After obtaining consent, area of the right shoulder was prepped in the usual fashion with Betadine. 6 cc of 1% lidocaine with 1 cc of Kenalog was injected in the right subacromial bursa without difficulty. The patient tolerated the procedure well without immediate complications. There was moderate relief of pain afterward. The patient was advised to call me if he gets any signs of infection, such as fever, chills, erythema, or swelling. He will call me in 2 days and tell me how he is doing. Scheduled for follow-up in 10 days. Now that you have read Scenario 3, provide the following: Provide ICD-10-CM Diagnosis Code Z92.241 Provide CPT code with modifier if applicable: 64400 Modifier 59

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