A 28-year-old female patient has been bothered with excessive tearing and was found to have an obstruction in the right lacrimal duct. Today at the ambulatory surgery center she was given general anesthesia and the physician performed an endoscopic dacryocystorhinostomy. Postoperative diagnosis is granuloma of the lacrimal passage. (Hint: You are coding for the physician who performed the endoscopic dacroyocystorhinostomy. One CPT® code with modifier.)
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PATIENT: Margaret Hill
ATTENDING PHYSICIAN: Ronald Green, MD
SURGEON: Gary Sanchez, MD
PREOPERATIVE DIAGNOSIS: Chronic cholecystitis and cholelithiasis
POSTOPERATIVE DIAGNOSIS: Chronic cholecystitis and cholelithiasis
PROCEDURE PERFORMED: Laparoscopic cholecystectomy
INDICATION: Mrs. Hill has been having RUQ pain with nausea and vomiting and diarrhea. The patient was found to have chronic cholecystitis with cholelithiasis and she was taken to the operating room.
PROCEDURE: The patient received Ancef 1 gram intravenously preoperatively. She was prepped and draped in the usual manner. An infra umbilical incision was made; the abdomen was entered under direct vision. Two stay sutures of 0 Vicryl were placed on either side of the incision. The Hasson sheath was then inserted. The abdomen was then inflated with CO2 gas. Three additional ports were then placed. The hilum of the gallbladder was then dissected free. The cystic duct and cystic arteries were identified. The cystic duct was clipped with three white clips and divided. The cystic arteries were clipped with three white clips and divided. There was another small branch of the artery encountered up on the gallbladder bed. This was also clipped with three white clips and divided. The gallbladder was then dissected free from the gallbladder bed using hook cautery. The specimen was placed in a bag and brought out through a lateral port. The
lateral port fascia was approximated with 0 Vicryl sutures. The operative area was thoroughly irrigated and the incisions were then closed with 3-0 Vicryl sutures for the subcutaneous tissues and a 4-0 Vicryl subcuticular stitch for the skin. Steri-Strips were
applied. Incisions were then injected with 0.5% Marcaine with Epinephrine. The patient tolerated the operation and returned to Recovery in stable condition.
Identify the correct diagnosis (ICD-9-CM) code(s) for the inpatient hospital visit for patient Margaret Hill
68720
To code for the physician who performed the endoscopic dacryocystorhinostomy for the 28-year-old female patient with a postoperative diagnosis of granuloma of the lacrimal passage, you will need to use the appropriate CPT® code with a modifier.
First, you need to identify the correct CPT® code for the procedure being performed. A dacryocystorhinostomy is a surgical procedure used to treat an obstruction in the lacrimal duct. In this case, an endoscopic approach was utilized.
The CPT® code for endoscopic dacryocystorhinostomy is 31299. This code encompasses the endoscopic approach for the dacryocystorhinostomy procedure. However, this code does not specifically indicate the presence of a granuloma.
To accurately represent the presence of a granuloma, you will need to append a modifier to the CPT® code. The most appropriate modifier to use in this case would be the -22 modifier for "increased procedural services," as this indicates that the procedure required additional work due to the presence of a granuloma.
So, the complete CPT® code with modifier for the physician who performed the endoscopic dacryocystorhinostomy for the patient with a postoperative diagnosis of granuloma of the lacrimal passage would be 31299-22.