Procedure Performed: Hysteroscopy, dilation, and curettage
Important Elements:
Pre-op and post-op diagnosis for correct ICD-10-CM primary call assignment
Procedure name for understanding treatment
Narrative description to validate and support procedure codes
Pathological findings for crucial information on diagnosis and procedure co-assignment
Coding Details
ICD-10-CM Codes: (Looked up in index and double-checked in tabular list)
Post-coital bleeding: N93.0
Thickening of endometrium: R93.89
CPT Code: Hysteroscopy, surgical with biopsy: 58558
Key Takeaway: Only one CPT code (58558) for hysteroscopy with D&C, biopsy, or polypectomy
Operative Report #7
Pre-op and Post-op Details
Pre-op Diagnosis: Small lung incision area, history of cholecystectomy
Procedure to be performed: Robotic incisional hernia repair with mesh
Key elements: Whether hernia is initial or recurrent, reducible or incarcerated/strangulated, and defect size (cm)
Coding Changes 2023
Hernia Repair Codes: Codes streamlined to include all approaches (open, laparoscopic, robotic)
Key Factors:
Initial vs. Recurrent
Reducible vs. Incarcerated/Strangulated
Defect size: <3 cm, 3-10 cm, >10 cm
Deleted CPT Code: CPT 49568 for implantation of mesh
Report Analysis
Details: (Key elements obtained from body of the report)
Procedure: Robotic, via small incisions
Diagnosis: Initial incisional hernia, incarcerated, 3 cm defect
ICD-10-CM: K43.0 for incarcerated hernia without gangrene
CPT Code: 49593 for robotic incisional hernia repair with mesh
Key Takeaway
CBD Code Changes 2023: Focus on type (initial/recurrent), condition (reducible/strangulated), and size of hernia defect. No need to differentiate between approach or mesh usage.
New Homework Assignments
Operative Report #8
Pre-op Diagnosis: Benign prostatic hyperplasia with urinary obstruction, bladder calculi
Post-op Diagnosis: Benign prostatic hyperplasia with urinary obstruction, bladder calculi