CPC 5 series (Urinary & Reproductive System)

  1. 1 : Pre-Operative diagnosis: Urinary tract infection. Post-Operative diagnosis: Urinary tract infection. Procedure performed: Cystometrogram. Description: The physician inserts a transurethral catheter to fill the bladder with water. As the bladder is being filled, intravesical pressure is measured by a micro tip transducer. The patient is instructed to attempt to void upon the feeling of bladder fullness, and recordings are taken of bladder sensation and volume at specific times. How would you report this procedure?

  1. 2 : A new born baby is planned for circumcision surgery. Physician uses a clamp device to perform circumcision. How would you report this procedure?

  1. 3 : Pre-Op diagnosis: Spontaneous Abortion. Post-Op diagnosis: Spontaneous Abortion. Patient was admitted, physically and Dr. X performed a detailed examination and comprehensive history and moderate complexity MDM was managed. Procedure description: A tenaculum is used to grasp the cervix, pull it down, and exert traction. A dilator is inserted into the endocervix and through the cervical canal to enlarge the opening. The physician places a cannula in the endocervical canal and passes it into the uterus. No contents present in uterus hence no curettage performed. Code the scenario.

  1. 4 : Pre-Operative Diagnosis: Dysuria. Post-Operative Diagnosis: Dysuria. Procedure Performed: Cystoscopy with catheterization and possible brush biopsy. Description: The physician passes the cystourethroscope through the urethra into the bladder. After insertion of a catheter into the ureter, the physician flushes saline solution to better view structures, and introduced contrast medium for retrograde pyelogram. A tumor like growth found in ureter which appears to be low grade, hence brush biopsy was obtained from renal pelvis. The physician removes the cystourethroscope.

  1. 5 : Pre-Op Diagnosis: Right Ureteral calculus. Post-Op Diagnosis: Right Ureteral calculus. Indications: Vinoth has ureteral calculus which is found to be on his lower one third of ureter during an ultrasound some days back. Today he presents for calculus removal. Procedure Performed: Cystoscopy with lithotripsy and stent insertion. Description: Patient was taken to Endoscopic suite where the patient was prepped and draped using sterile technique. Anesthesia was then induced and once the patient sedated physician passes the cystourethroscope through the urethra into the bladder and inserts an instrument through the cystourethroscope and ultrasonic waves were passed to crush the calculus in the right ureter. Once the stone was crushed it was taken out and physician placed a double J stent inside the right ureter. Cystoscope was the taken out. How would you report this procedure?

  1. 6 : Pre-Op Diagnosis: Cervix mass. Post-Op Diagnosis: Cervix mass. Procedure Performed: Colposcopy with biopsy and ECC. Description: The provider places the patient in the dorsal lithotomy position. The provider then inserts a speculum and cleans the cervix of mucous with saline. He then inspects the entire length of the cervical canal which includes the endocervix, or the transformation zone, and exocervix, for visible abnormalities using a bright light. The provider then applies a 3 to 5 percent solution of acetic acid to the cervix and upper vagina to highlight lesions. Physician inserts colposcope and inspects the entire cervical canal where the mass is present has been biopsied and Curettage has been perfomed. He also examines the upper, adjacent area of the vagina where no other abnormalities found, he withdraws the scope and the speculum. How would you report this procedure?

  1. 7 : Pre-Op Diagnosis: Lesion on vulva and perineum. Post-Op Diagnosis: Lesion on vulva and perineum. Procedure Performed: Biopsy of lesions. Description: Patient was taken to OR and placed in Lithotomy position and After injecting a local anesthetic around the lesion, the physician obtains a sample using a sharp scalpel from both vulva and perineal lesion. Once done a clip is used to control bleeding. What CPT codes should be coded?

  1. 8 : Rama a 33-year-old king had hydrocele over testis. Ravana a surgeon excised the hydrocele over Rama’s right testicle. How would you report this procedure?

  1. 9 : Meera gets admitted for vaginal delivery in a hospital. She was taking prepartum care in some other hospital. This is her second delivery where the first baby was delivered under c-section. Patient was taken to OR and after 3 hours of attempt baby comes out. Patient was then transferred to PACU and she is planned for postpartum care in the same hospital.

  1. 10 : Pre-Operative diagnosis: Uterine cancer. Post-Operative diagnosis: Uterine cancer. Procedure performed: TAH with lymph node biopsy. Description: The patient was taken to the operating room and placed in supine position, at which time general form of anesthesia was administered by the anesthesia department. The patient was then prepped and draped in the usual fashion for a low transverse incision. This was extended down to the level of the fascia. The fascia was nicked in the center and extended in a transverse fashion. The edges of the fascia were grasped with Kocher. Both blunt and sharp dissection both caudally and cephalic was then completed consistent with Pfannenstiel technique. The abdominal rectus muscle was divided in the midline and extended in a vertical fashion. Perineum was entered at the high point and extended in a vertical fashion as well. Uterus was grasped with a double-tooth tenaculum and removed, vagina was removed partially along with fallopian tubes and ovaries the excised contents were taken out through the abdominal incision. Biopsy was taken from surrounding para-aortic and pelvic lymph nodes. Samples sent to pathology for evaluation. The incisions were closed with continuous locking stitch of 0 Vicryl which was used to re-approximate the edges. What CPT codes you would report for this procedure?

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