AAPC - Chapter 13 Practical Applications (CASES 1-10) Answered 100% Correctly
CASE 1
DIAGNOSES: Stage III cystocele, stage II uterine prolapse. (Do not
... [Show More] code the
cystocele separately as it is included in the diagnosis code for the uterine prolapse.)
PROCEDURE: Pessary fitting.
INDICATIONS: A 75 year-old, gravida 4, para 4,(This information indicates that
the patient has had four pregnancies with four term births and the last two babies
were quite large.) female with pelvic organ prolapse. She had atrophic vaginitis so
we had her use Premarin vaginal cream twice a week for six weeks. She is back for
a pessary fitting today.
FINDINGS: She has a third-degree cystocele, and after examination we've
determined she actually has a third-degree uterine prolapse.(The diagnosis is
cystocele with uterine prolapse. Stage III uterine prolapse is considered a complete
prolapsed.) Her vaginal tissues are improved, although still atrophic, but much less
thin than prior appointment.
DESCRIPTION OF PROCEDURE: After her exam, I started with a #4 ring
pessary with support. This was clearly not large enough and the cystocele was
coming around it. I then went to a #5 ring pessary with support with the same
problem. I went to the #6 ring pessary with support.(The provider indicates the size
of the pessary that he is fitting.) It did not lodge behind her pubic bone very well,
but it definitely reduced all of her prolapse. She mentioned earlier in the
appointment that she could not void when she came in today. She has not tried
reducing it. I am hopeful that the pessary may help with that. The #6 was
comfortable for her. I stood her up and put her through some maneuvers and it
stayed nicely in place. Then she went walking with the pessary in place for 10 or
15 minutes and went up and down the stairs. She definitely was able to void more
easily with it in. It was comfortable and she did not really notice it was in.
On recheck it still seemed like she had a little more room in the pelvis. I removed
the #6 and went up to a #7 size. This seemed to reduce the prolapse a bit better, but
was a little uncomfortable for her. We went back to the #6 ring pessary with
support. She was able to remove it and place it with instruction in our clinic today.
DISPOSITION: We have ordered the #6 ring pessary (If the provider supplied the
pessary, a HCPCS Level II code would be reported.) with support and it will be
sent to her. After she gets the pessary, she will remove it once a week and leave it
out overnight. She will continue to use the Premarin vaginal cream twice a week.
She will return to clinic after she has used the pessary for 2 or 3 weeks, so we can
check her tissues. She is to report if she has vaginal discharge or bleeding, as she is
at risk for getting ulceration from the pessary.
I answered all of her questions about her condition of pelvic organ prolapse and
treatment with estrogen and pessary. She will call if she has any bleeding.
What are the CPT® and ICD-10-CM codes reported?
57160
N81.3
CASE 2
DIAGNOSES:
1. Complete procidentia (The stated diagnosis is Complete Procidentia, and this is
well supported in the body of the operative note. A review of several medical
dictionaries shows the definition of Procidentia, prolapse of an organ or part.) [Show Less]