Reference no: EM134003492

Question 

Case 1

Preoperative diagnosis: Chronic tonsillitis and enlarged adenoids

Postoperative diagnosis: Chronic tonsillitis and enlarged adenoids

Procedure: Tonsillectomy with adenoidectomy

The patient, a 6-year old male, was placed under general anesthesia for bilateral removal of tonsils with adenoids. The tonsils were grasped with an Allis forceps, and the incision made around the anterior tonsillar pillar. The tonsillar capsule was identified, and the tonsils bluntly dissected free. Next we turned our attention to the nasopharynx, which was viewed indirectly. There was a considerably amount of hypertrophic adenoids present; they were removed by curette, and al nubbins of adenoid tissue were removed. All bleeding was controlled with pressure sponges, and several small bleeding areas were touched with electrocoagulation. At the close of both procedures, there was no bleeding present. Blood loss was minimal, and the postoperative condition of the patient was good.

Process 1: CPT

1. What is the procedure?

2. Locate the main term in the index.

3. What additional questions or set of questions can be determined?

4. Upon review of all the code choices identified in the index, what additional questions can be determined?

5. Based on the documentation, what is the correct code for this case?

a. 42830

b. 42831

c. 42820

d. 42825

Process 2: ICD-10-CM

1. Based on the operative report header, what is the preoperative diagnosis?

2. Is the postoperative diagnosis the same as or different from the preoperative diagnosis?

3. Is the postoperative diagnosis supported?

4. What is the main term for this condition?

5. Based on the subterm choices, what question(s) can be developed for this condition?

6. Based on the information in the Tabular List, is additional information needed to determine the appropriate diagnosis code?

7. Is there any sign, symptom, or additional condition documented?

8. Is the additional condition, sign, or symptom an integral part of the primary (or other) condition coded?

9. Does the additional condition require or affect patient care, treatment, or management?

10. Based on the documentation, what is (are) the correct ICD-10-CM code(s) for this case?

a. J35.01, J35.2

b. J35.01, J35.02

c. J35.2

d. J35.3

Process 3: Modifiers

1. Was the procedure performed different from that described by the nonmenclature of the code?

2. Was the procedure performed at an anatomical site that has laterality?

3. Was the procedure performed in the global period of another procedure?

4. Were additional procedures performed during the operative session, and does the documentation support them?

5. Did the surgeon have help from another surgeon or another appropriate person?

6. Did a physician different from the surgeon provide the preoperative or postoperative portion of the procedure?

7. What modifier should be appended to the CPT code for this case?

a. 50

b. 58

c. 51

d. None