Using your ICD-10-CM and CPT code books
Using your ICD-10-CM and CPT code books to, identify which diagnoses, and procedure services, including modifier(s), are to be coded for each case. All codes and answer will be added to the Coding Surgery Scenarios Answer Key for Candidates. Outpatient Surgery Patient Case Number: OPSX29-Grady, Kent Patient Name: Kent Grady DOB: 07-13-70 Sex: M Date of Service: 01-22-XX Surgeon: Mary Hollister, MD Pre-Operative Diagnosis Acute Pancreatitis Post-Operative Diagnosis Esophageal Varices Procedure Performed: EGD & Endoscopic ultrasound Anesthesia: Conscious sedation Complications: None PROCEDURES: 1. EGD 2. Endoscopic ultrasound. INDICATIONS: 1. Acute pancreatitis. 2. Abnormal CT scan, rule out pancreas head mass. PROCEDURE #1 EGD: The Olympus GIF-190 forward-viewing video-endoscope was lubricated and advanced into the hypopharynx. The scope passed into the esophagus. Examination of the stomach was performed in straight and retroflexion views. The scope was passed into the second portion of the duodenum. FINDINGS: 1. Grade 1 esophageal varices x1. 2. Food debris in the proximal stomach, otherwise, normal stomach. 3. Normal duodenum. 4. Acute and chronic pancreatitis PROCEDURE #2 ENDOSCOPIC ULTRASOUND: The Olympus linear echoendoscope was lubricated and advanced into the hypopharynx. The scope passed through the esophagus, stomach, pylorus second portion duodenum. With the water-filling technique of the balloon and lumen, endoscopic ultrasound examination performed. The pancreas parenchyma appeared with diffuse inhomogeneity, hypoechoic foci, lobulation, and a few calcifications in the head of the pancreas. The main pancreatic duct was not dilated, and it had thickened borders. Folds features are suggestive of chronic pancreatitis. The common bile duct was dilated measuring 9 mm. There was free fluid around the pancreas body and tail. The splenic vein was distended, consistent with portal hypertension.
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