How to Answer Code This Study Questions (Complete Guide)
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Key Explanation
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Original Question
How to code this study case? PREOPERATIVE DIAGNOSIS: Breast cancer with known BRCA2 mutation carrier, requesting prophylactic bilateral salpingo-oophorectomy. POSTOPERATIVE DIAGNOSIS: Breast cancer with known BRCA2 mutation carrier, requesting prophylactic bilateral salpingo-oophorectomy. OPERATION PERFORMED: Laparoscopic bilateral salpingo-oophorectomy. ANESTHESIA: General endotracheal anesthesia. SPECIMEN: Pelvic washing and bilateral fallopian tubes and ovaries. OPERATIVE FINDINGS: 1. Normal ovaries and fallopian tubes bilaterally. 2. Mildly enlarged uterus. COMPLICATIONS: None. DESCRIPTION OF OPERATION: The patient was taken to the operating room where general endotracheal anesthesia was induced. The patient was prepped and draped in the normal sterile fashion. The patient was placed in the lithotomy position in Allen Stirrups. Foley catheter was placed. The cervix was grasped with a single-toothed tenaculum. A HUMI uterine manipulator was inserted through the cervix for uterine manipulation. Subsequently, attention was turned to the laparoscopic part of the procedure. A 1.5 cm incision was made below the umbilicus. The incision was taken down to the fascia, which was incised sharply. The two sides of the fascia were tied with 0 Vicryl sutures. Subsequently, the peritoneal cavity was then entered sharply. At this point, the Hasson trocar was placed. The abdomen was insufflated with carbon dioxide, and the laparoscope was used to inspect the abdomen. Intra-abdominal anatomy was normal. The uterus was mildly enlarged. At this point, two other 5 mm trocars were placed in the right lower quadrant and left lower quadrant under direct visualization. Subsequently, the ureter was traced on both sides prior to the start of the procedure. Subsequently, with the help of the 5 mm LigaSure, the fallopian tube and ovaries on the patient’s left side was removed. Prior to the start of the procedure, the pelvic washing were taken and sent to pathology. Subsequently, the left fallopian tube and ovaries were excised. The specimen was left in the anterior cul-de-sac. Subsequently, the same procedure was repeated on the left side. At this point, the Endocatch was inserted to collect the specimens in the bag, which was subsequently removed and sent to pathology. All pedicles were then inspected for hemostasis, which was noted. Then, the 5 mm ports were removed under direct visualization. Subsequently, the Hasson trocar sleeve was removed. The fascia was closed with 0 Vicryl suture, and the skin was approximated with 4-0 Monocryl suture. The patient tolerated the procedure well. What are the appropriate ICD-10-CM diagnosis codes and CPT procedure codes for this case?
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