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A 57-year-old male with low rectal cancer presents for abdominoperineal resection (APR) of the rectum with reconstruction to follow. A cylindrical APR was performed, along with excision of the sigm...
Yes, the res...
This same patient underwent reconstruction of the perineum immediately following the APR. The resection resulted in a 6x10 centimeter defect, and was repaired using a right fascial sparing two-vess...
Because the ...
The above patient also had colostomy creation at the same time that the lower anterior resection of the rectum was performed. Should the colostomy be coded?
...Yes, creatio...
When a right colectomy is performed with side-to-side functional end-to-end anastomosis, is it appropriate to report an additional code for the side-to-side anastomosis?
...Do not assig...
A patient diagnosed with blighted ovum underwent vacuum D&C. During the surgery, a curette was placed into the uterine cavity and suction was applied to remove the tissue/products of conception...
For the extr...
By definition, a second degree perineal laceration involves rupture or tearing of the perineal muscle(s). Would physician documentation stating, “Second degree perineal laceration repair” be su...
A second deg...
A patient underwent a repeat low transverse cesarean section. During the cesarean delivery, vacuum extraction was used to assist with the delivery of the infant. What is the correct ICD-10-PCS qual...
Vacuum assis...
The patient was taken to the operating room post vaginal delivery for control of bleeding using a Bakri balloon. We are unsure if the Bakri balloon is coded to the Obstetrics section or the Medical...
The root ope...
How is an open posterior colporrhaphy/rectocele repair coded in PCS? Should one or two codes be assigned for this procedure?
...In the conte...
What is the appropriate ICD-10-PCS code, when a combination of drugs is administered during a single injection (e.g., corticosteroid and local anesthetic)?
...If two subst...