AAPC - Chapter 13 Practical Applications (CASES 1-10) Answered 100% Correctly

AAPC - Chapter 13 Practical Applications (CASES 1-10) Answered 100% Correctly CASE 1 DIAGNOSES: Stage III cystocele, stage II uterine prolapse. (Do not code the cystocele separately as it is included in the diagnosis code for the uterine prolapse.) PROCEDURE: Pessary fitting. INDICATIONS: A 75 year-old, gravida 4, para 4,(This information indicates that the patient has had four pregnancies with four term births and the last two babies were quite large.) female with pelvic organ prolapse. She had atrophic vaginitis so we had her use Premarin vaginal cream twice a week for six weeks. She is back for a pessary fitting today. FINDINGS: She has a third-degree cystocele, and after examination we've determined she actually has a third-degree uterine prolapse.(The diagnosis is cystocele with uterine prolapse. Stage III uterine prolapse is considered a complete prolapsed.) Her vaginal tissues are improved, although still atrophic, but much less thin than prior appointment. DESCRIPTION OF PROCEDURE: After her exam, I started with a #4 ring pessary with support. This was clearly not large enough and the cystocele was coming around it. I then went to a #5 ring pessary with support with the same problem. I went to the #6 ring pessary with support.(The provider indicates the size of the pessary that he is fitting.) It did not lodge behind her pubic bone very well, but it definitely reduced all of her prolapse. She mentioned earlier in the appointment that she could not void when she came in today. She has not tried reducing it. I am hopeful that the pessary may help with that. The #6 was comfortable for her. I stood her up and put her through some maneuvers and it stayed nicely in place. Then she went walking with the pessary in place for 10 or 15 minutes and went up and down the stairs. She definitely was able to void more easily with it in. It was comfortable and she did not really notice it was in. On recheck it still seemed like she had a little more room in the pelvis. I removed the #6 and went up to a #7 size. This seemed to reduce the prolapse a bit better, but was a little uncomfortable for her. We went back to the #6 ring pessary with support. She was able to remove it and place it with instruction in our clinic today. DISPOSITION: We have ordered the #6 ring pessary (If the provider supplied the pessary, a HCPCS Level II code would be reported.) with support and it will be sent to her. After she gets the pessary, she will remove it once a week and leave it out overnight. She will continue to use the Premarin vaginal cream twice a week. She will return to clinic after she has used the pessary for 2 or 3 weeks, so we can check her tissues. She is to report if she has vaginal discharge or bleeding, as she is at risk for getting ulceration from the pessary. I answered all of her questions about her condition of pelvic organ prolapse and treatment with estrogen and pessary. She will call if she has any bleeding. What are the CPT® and ICD-10-CM codes reported? 57160 N81.3 CASE 2 DIAGNOSES: 1. Complete procidentia (The stated diagnosis is Complete Procidentia, and this is well supported in the body of the operative note. A review of several medical dictionaries shows the definition of Procidentia, prolapse of an organ or part.)