A 75-year-old male presented to the ambulatory surgical unit for a cystoscopy. The patient's complaint was hematuria. A transurethral diagnostic cystoscopy was performed. No acute or abnormal findings were determined to be the cause of his hematuria. The patient was sent to the recovery room in good condition and was discharged home later that same day.
a. Assign the ICD-9-CM codes to the first-listed diagnosis code and the additional diagnoses code(s), if applicable. Assign the CPT code(s) to the procedure(s).
First listed Diagnosis Code: ____________
Additional Diagnosis Code: _____________
Additional Diagnosis Code: _____________
ICD-9-CM Procedure Code: ______________
Procedure Code: ______________
First listed Diagnosis Code: 599.70 - Hematuria, unspecified
Additional Diagnosis Code: None
ICD-9-CM Procedure Code: 57.91 - Cystoscopy
Procedure Code: 52000 - Cystoscopy, diagnostic
To assign the ICD-9-CM codes and CPT code to this case, we first need to understand the terms and information given in the scenario:
1. Cystoscopy: This is a procedure in which a healthcare professional examines the inside of the bladder using a thin, lighted instrument called a cystoscope.
2. Hematuria: This term refers to the presence of blood in the urine.
3. Transurethral: This describes a procedure that is performed by inserting an instrument through the urethra and into the bladder.
Based on the information provided, we can assign the following codes:
First Listed Diagnosis Code: 599.70 - Hematuria, unspecified
Additional Diagnosis Codes: None provided.
ICD-9-CM Procedure Code: 57.91 - Diagnostic cystoscopy
Procedure Code: 52000 - Diagnostic cystoscopy (transurethral)
Note: The CPT code 52000 represents a diagnostic cystoscopy, and this code is used for both the first-listed diagnosis and the procedure code.
It is important to note that these codes may vary depending on the specific coding guidelines and conventions in use. It is always recommended to consult the most recent coding manuals and any specific guidelines or instructions for accurate coding.