Chapter 6 Case Studies

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Chapter 6. Case Studies from Physician-Based Health Records Unless otherwise stated, code set answers given in Chapter 6 are ICD-9-CM and/or CPT. Anesthesia Services 6.1. a. 00404 Incorrect answer. Code 00402 specifies reconstructive procedures on the breast. b. 00406 Incorrect answer. Code 00402 specifies reconstructive procedures on the breast. c. 00402 Correct answer. d. 00400 Incorrect answer. Code 00402 specifies reconstructive procedures on the breast. 6.2. a. 660.11, 653.41, 64493 Incorrect answer. Code 64493 is for injection of the facet joint or facet nerve. The correct answer is 01967 and 01968. b. 660.11, 653.01, 01961 Incorrect answer. This is for a C-section delivery that does not involve an epidural (that is, general anesthesia). The correct answer is 01967 and 01968. The disproportion was specified as cephalopelvic; thus, the correct ICD-9-CM code is 653.41. c. 660.11, 653.41, 01967, 01968 Correct answer. d. 660.11, 653.91, 01996 Incorrect answer. The code 01996 should be used only for each subsequent day if a long-term epidural is used for pain control. The correct answer is 01967 and 01968. The disproportion was specified as cephalopelvic; thus, the correct ICD-9-CM code is 653.41. ICD-10-CM Code(s): O65.4 ICD-10-CM Rationale: The Alphabetic Index main term is Delivery with subterms complicated by, obstruction, due to, fetopelvic disproportion. 6.3. a. 521.00, 00170-AA-23 Correct answer. b. 521.00, 00170-AA Incorrect answer. Modifier -23 should be added to identify the instance of unusual

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