Practicum Module 9: Digestive System Coding: 40000 Series
Study online at https://quizlet.com/_7gqi4b
1. Repair of umbilical hernia for a 62-year-old male. Inci- 49585
sion was carried through subcutaneous tissue to the
fascia level. The hernia sac was opened and excised
along the umbilicus, and the incision was closed.
49653
49587
49585
49652
2. 5Planned colonoscopy with biopsy is not completed 45380-52
to reach the cecum due to tortuous colon.
45380-52
45380-53
45378-52
45378
3. The practice performs both laparoscopic and open Supraumbilical incision, tro-
cholecystectomies. An internal review of these proce- car(s), pneumoperitoneum,
dures coded/billed by the practice indicated some of Endobag
the codes were assigned as open procedures not la-
paroscopic as performed. In an effort to train staff on
the specifics of a laparoscopic cholecystectomy, the
practice management team decided to provide ad-
ditional training. The following documentation was
provided: Procedure: Cholecystectomy. A supraum-
bilical incision was made, a trocar was placed, and
a pneumoperitoneum was insufflated. Ports were
placed, and the gallbladder was identified and dis-
sected free from the attachments with cautery. The
gallbladder was brought out through the Endobag.
What words or phrases in this example are most ben-
eficial for training staff to recognize a laparoscopic
, Practicum Module 9: Digestive System Coding: 40000 Series
Study online at https://quizlet.com/_7gqi4b
cholecystectomy?
Supraumbilical incision, trocar(s), pneumoperi-
toneum, Endobag
gallbladder was dissected free from liver attach-
ments.
Procedure: Cholescystectomy
adhesions were taken down.
4. Dilation of stricture of GE junction through guidewire 43245, 43239-59
and EGD were completed to the second portion of the
duodenum. Several ulcerations around the pylorus
were biopsied.
43248
43245, 43239-59
43249, 43239-51
43249, 43239-59
5. Procedure: Esophagogastroduodenoscopy with 43239, 45378
biopsy, colonoscopy. Scope was introduced into the
oropharynx and then into the entire esophagus, Both an EGD (esophagogas-
stomach, and duodenum without difficulty. Severe troduodenoscopy) and up-
erosive gastritis was noted with long rows of stri- per GI are performed
ation. Biopsies were taken to rule out H. pylori. with biopsy as well as
A recital exam revealed mild hemorrhoids. Normal a colonoscopy with biopsy.
prostate. The scope was transversed through entire Codes 45378 and 43239 are
colon to the ileocecal valve. An excellent prep was both assigned in this in-
noted. There was no evidence of pathology whatso- stance.
ever.
43239, 45378-52
43235, 45378
45378, 43239
43239, 45378
, Practicum Module 9: Digestive System Coding: 40000 Series
Study online at https://quizlet.com/_7gqi4b
6. Patient seen for follow-up anoscopy who previously 46615, 46612-51
had bleeding rectal polyps. The scope was inserted,
and a single polyp was removed by hot biopsy tech-
nique that required cauterization at the base, and an
additional flat polyp was ablated as it was not able to
be removed by forceps.
46615, 46611-51, 46610-51, 46606-51
46615, 46612-51, 46606-51
46615, 46612-51, 46614-51
46615, 46612-51
7. Colonoscopy with polypectomy X 4 by snare 45385
45385 x4
45385
45384
45380
8. Incidental appendectomy during an intra-abdominal Never appropriate if inciden-
surgery does not usually warrant a separate identifi- tal
cation. If it is necessary to report a separate identifi-
cation, how should the service be reported?
Never appropriate if incidental
59
57
51
9. Upper endoscopy is performed. Following direct visu- 43246
alization of the esophagus, stomach, and duodenum,
a small cut is made to enter the stomach percuta-
neously. Guidewire was inserted, and a #20 PEG tube
was placed over the top of the guidewire and pulled
into position.
Study online at https://quizlet.com/_7gqi4b
1. Repair of umbilical hernia for a 62-year-old male. Inci- 49585
sion was carried through subcutaneous tissue to the
fascia level. The hernia sac was opened and excised
along the umbilicus, and the incision was closed.
49653
49587
49585
49652
2. 5Planned colonoscopy with biopsy is not completed 45380-52
to reach the cecum due to tortuous colon.
45380-52
45380-53
45378-52
45378
3. The practice performs both laparoscopic and open Supraumbilical incision, tro-
cholecystectomies. An internal review of these proce- car(s), pneumoperitoneum,
dures coded/billed by the practice indicated some of Endobag
the codes were assigned as open procedures not la-
paroscopic as performed. In an effort to train staff on
the specifics of a laparoscopic cholecystectomy, the
practice management team decided to provide ad-
ditional training. The following documentation was
provided: Procedure: Cholecystectomy. A supraum-
bilical incision was made, a trocar was placed, and
a pneumoperitoneum was insufflated. Ports were
placed, and the gallbladder was identified and dis-
sected free from the attachments with cautery. The
gallbladder was brought out through the Endobag.
What words or phrases in this example are most ben-
eficial for training staff to recognize a laparoscopic
, Practicum Module 9: Digestive System Coding: 40000 Series
Study online at https://quizlet.com/_7gqi4b
cholecystectomy?
Supraumbilical incision, trocar(s), pneumoperi-
toneum, Endobag
gallbladder was dissected free from liver attach-
ments.
Procedure: Cholescystectomy
adhesions were taken down.
4. Dilation of stricture of GE junction through guidewire 43245, 43239-59
and EGD were completed to the second portion of the
duodenum. Several ulcerations around the pylorus
were biopsied.
43248
43245, 43239-59
43249, 43239-51
43249, 43239-59
5. Procedure: Esophagogastroduodenoscopy with 43239, 45378
biopsy, colonoscopy. Scope was introduced into the
oropharynx and then into the entire esophagus, Both an EGD (esophagogas-
stomach, and duodenum without difficulty. Severe troduodenoscopy) and up-
erosive gastritis was noted with long rows of stri- per GI are performed
ation. Biopsies were taken to rule out H. pylori. with biopsy as well as
A recital exam revealed mild hemorrhoids. Normal a colonoscopy with biopsy.
prostate. The scope was transversed through entire Codes 45378 and 43239 are
colon to the ileocecal valve. An excellent prep was both assigned in this in-
noted. There was no evidence of pathology whatso- stance.
ever.
43239, 45378-52
43235, 45378
45378, 43239
43239, 45378
, Practicum Module 9: Digestive System Coding: 40000 Series
Study online at https://quizlet.com/_7gqi4b
6. Patient seen for follow-up anoscopy who previously 46615, 46612-51
had bleeding rectal polyps. The scope was inserted,
and a single polyp was removed by hot biopsy tech-
nique that required cauterization at the base, and an
additional flat polyp was ablated as it was not able to
be removed by forceps.
46615, 46611-51, 46610-51, 46606-51
46615, 46612-51, 46606-51
46615, 46612-51, 46614-51
46615, 46612-51
7. Colonoscopy with polypectomy X 4 by snare 45385
45385 x4
45385
45384
45380
8. Incidental appendectomy during an intra-abdominal Never appropriate if inciden-
surgery does not usually warrant a separate identifi- tal
cation. If it is necessary to report a separate identifi-
cation, how should the service be reported?
Never appropriate if incidental
59
57
51
9. Upper endoscopy is performed. Following direct visu- 43246
alization of the esophagus, stomach, and duodenum,
a small cut is made to enter the stomach percuta-
neously. Guidewire was inserted, and a #20 PEG tube
was placed over the top of the guidewire and pulled
into position.
