The patient is a 29-year-old woman who discovered several large ...

[WhattoUnderstand]

The patient is a 29-year-old woman who discovered several large lumps in both breasts when she was doing her monthly self-examination. Based on the physical exam, the physician ordered ultrasound and MRI exams of both breasts. The results were showed her bilateral breast implants were leaking.
 
  Dx: Leaking breast implants
 
   Procedures: Bilateral breast Ultrasound and bilateral breasts  MRI  with and without contrast
 
   Principal/first-listed Dx: ________
   Procedures: ________
  What will be an ideal response?

Question 2

Patient is 34-year-old female who has four children and she and her husband have decided they are through with childbearing. She has for permanent sterilization and will be having a tubal ligation on an outpatient basis. She has normal menstrual periods and no preexisting medical conditions. The risks and benefits of the procedure were discussed with the patient, including the fact that once the procedure is done, she will no longer be able to conceive children. Sterilization is a permanent procedure. Stating she fully understands the consequences and reiterating that she is refusing other forms of birth control, plans were made for the procedure.
 
  Dx. Permanent sterilization
 
   Procedure: Percutaneous endoscopic tubal ligation
 
   First-listed/principal Dx: ________
   Procedure: ________
 
  What will be an ideal response?

[swimkari]

Answer to Question 1

Principal/first-listed Dx: ________
Answer: Leaking breast implants  T85.43XA

Procedures: ________
Answer: Either exam can be sequenced first  bilateral breast US  BH42ZZZ; bilateral MRI of breasts, with and without contrast  BH32Y0Z

Answer to Question 2

First-listed/principal Dx: ________
Answer: Encounter for sterilization  Z30.2

Procedure: ________
Answer: Bilateral tubal ligation  0UL78ZZ

[WhattoUnderstand]

Thanks for the timely response, appreciate it

[raili21]

Gracias!