Icd 10 code lumbar facet arthropathy

M132 Module 04 Coding Assignment Answers

1. Case Study #1

PREOPERATIVE DIAGNOSIS: Sensorineural hearing loss.

POSTOPERATIVE DIAGNOSIS: Sensorineural hearing loss.

OPERATION: Right cochlear implant, Nucleus Contour Advance multi-channel device, right facial nerve monitor.

ANESTHESIA: General endotracheal.

FINDINGS: Complete insertion, normal anatomy, Nucleus Contour Advance placed.

SURGICAL PROCEDURE: The patient was brought to the operating room and placed in the supine position. A general endotracheal anesthetic was administered. The right ear was examined and there was no evidence of ear infection. The area of the anticipated incision was shaved and infiltrated with lidocaine 1% with epinephrine

1 :100,000. The right ear and face were prepped and draped in the standard sterile fashion. Bipolar pin electrodes were placed in the orbicularis oris and oculis with ground electrodes in the left shoulder.

An extended postauricular incision was created and brought down to the subgaleal level. Flaps were elevated and periosteal incisions were designed. The mastoid was widely exposed. A recess was created to accommodate the receiver/stimulator case. Mastoidotomy was then performed. The area of the aditus was identified and the short process of the incus exposed. The facial recess was opened. The promontory was identified. The stapes and area of the oval window was exposed as was the round window niche. A cochleostomy was performed. Holes were created at the lateral aspect of the receiver/stimulator recess and the mastoidotomy. The wound was irrigated copiously with sterile saline and hemostasis was achieved with suction cautery.

The device was then introduced into the field and secured in the recess. 3-0 Nurolons were used to secure the device. The ground electrode was placed deep to the temporalis fascia. The electrode array was inserted and a complete insertion was obtained with an advance off stylet technique. The cochleostomy was packed with soft tissue from the lateral incision. The stylet was removed.

The wound was then closed in 3 layers using 3-0 chromic to approximate the periosteal layer, 4-0 chromic to approximate the galea layer, and 5-0 Monocryl in a running subcuticular fashion.

ICD-10-PCS Code: Click here to enter text.

2. Case Study #2

DIAGNOSIS: Low back pain, lumbar facet arthropathy, lumbar radiculopathy, failure of conservative management.

PROCEDURE: Neural modulation with a spinal cord stimulator implant under fluoroscopic guidance.

INTERIM HISTORY: Patient is well known to me. She has had conservative management with injections and medication from other pain physicians. At this time, the patient is unable to return to work because of the persistent pain, and she had a spinal cord stimulator trial which gave her significant relief so we are going ahead with the spinal cord stimulator implant. The patient understands the risks and benefits of this. Patient understands if she has any side effects, she has to reach me or reach the emergency room.

DESCRIPTION OF PROCEDURE: After taking informed consent, with the patient in prone position the back was prepped aseptically and draped aseptically. The patient was then spontaneously breathing and communicating throughout the procedure. Under AP view of fluoroscopy, L1 interspinous process was identified. Local was infiltrated using 3 mL of 1% lidocaine and 4 mL of 1% preservative-free Marcaine using a 2S-gauge needle. Number 14-gauge epidural needle was then advanced under continuous AP and then under continuous lateral fluoroscopy to reach the epidural space by loss-of-resistance technique. Once reaching the epidural space, on aspiration no CSF or heme, no paresthesia at any point. An 8-contact Bionics lead was then advanced with the help of the navigation. I was able to place the needle right in the middle of the spine and the posterior epidural space. There was no CSF or heme at any point, no paresthesia at any point. This was confirmed both with the lateral and AP view. The needle was then advanced to T8-T9 level. At this level, the patient had good paresthesia and there was good coverage of all her painful parts. Continuous fluoroscopic pictures were taken during this procedure with the help of the Bionics rep, The stimulator was analyzed, had good coverage and normal impedance. Once the patient appreciated good paresthesia and good coverage of all her painful spots, the lead was anchored by extending the incision at the paraspinal area around Ll-2, and the lead was anchored in the spinal canal with 2-0 silk. At this time, the procedure was taken over by Dr. X who did the pocket for the generator. The patient was discharged uneventfully.

(Code only the Spinal Cord Stimulator Implant for this case)

ICD-10-PCS Code: Click here to enter text.

3. Case Study #3:

PREOPERATIVE DIAGNOSIS:

1. Left chest wall mass.

2. Ovarian cancer.

POSTOPERATIVE DIAGNOSIS:

1. Left chest wall mass.

2. Ovarian cancer.

PROCEDURE PERFORMED:

1. Bronchoscopy with evaluation of bronchial tree tube.

2. Left video-assisted thoracoscopy.

3. Resection of anterior chest wall mass with resection of pleura.

PROCEDURE: After proper consent was obtained the patient taken to and placed on

operating room table in supine position. General sedation was administered by oral endotracheal tube. The bronchoscope was inserted. Right upper lobe, middle lobe and lower lobe were normal. No endobronchial lesions seen. Scope was inserted in left upper lingula lobe segments were normal. The patient was placed in a right lateral decubitus position. Left chest prepped and draped in normal sterile fashion. Incision made and the thoracoscope inserted. Under direct vision additional lateral port placed. Dissection was then carried down. The mass identified within chest wall. It was confined to the pleura. This appeared to be a large plaque, approximately 10 x 4 cm. Separate satellite mass was present. Using the Bovie electrocautery, the pleura was then dissected from the chest wall. The entire chest wall mass was resected including the pleural lesion. It was then placed in EndoCatch, removed and sent to Pathology. No other areas were seen on the pleura. Meticulous hemostasis obtained. Chest tube placed to the apex and anchored with heavy silk. Lung re-expanded no significant air leak. Wound then closed in layers with absorbable suture. Chest tube anch