Code the following cases for outpatient facility purposes using ICD-9-CM, ICD-10-CM, and CPT codes. Sequence codes in the correct order.
Calculate the APC.
Assign modifiers when appropriate.
Use external cause codes when appropriate.
Do NOT code procedures that are captured by the facility chargemaster.
SAME DAY SURGERY
PATIENT: TERRY OFFICE
RECORD NUMBER: 12-68-23
DATE OF SERVICE: 04-10-XX
PHYSICIAN: DR. KIM. M. D.
SUBJECTIVE: This 72-year-old established patient presents today with complaints of a lump on the left side of his neck.The patient had been previously advised it would be best to excise the lump and send to pathology for definitive diagnosis.
OBJECTIVE: Examination today reveals the patient has an area of induration, which is approximately 1.5 cm in diameter below his left jaw line.The procedure, risks, complications, and alternatives were discussed with the patient.The patient agreed to proceed with a resection of the lump today.
ASSESSMENT: Lump left neck, which appears to be dermatofibroma.
PROCEUDRE: The left jaw line was injected with local anesthetic.The 1.5 cm lump was excised with a wide excision.After resection, the lump appeared to be a dermatofibroma.Specimen was sent to pathology.Closure was performed with interrupted 4–0 Vicryl and Dermabond to seal the skin edges.Routine wound care was given.The patient is to follow up on a prn basis. We will call with pathology report results.
PATHOLOGY: 1.5 cm Dermatofibroma left neck.
ICD-9-CM diagnosis code(s): _____________________
ICD-10-CM diagnosis code(s): _____________________
CPT code(s) with modifier, if applicable: _____________________
APC: _____________________
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