Coding Recommendations - Feature Article 06/15/98
   

Procedure Practice
    

Using ICD-9-CM and CPT-4, assign codes for the procedure(s) described in this "real-life" operative report.

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Indications for Procedure: The patient is a 56-year-old female on estrogen replacement therapy. For the past several months she has experienced mild weight loss, intermittent RUQ pain, and bouts of nausea and vomiting. Physical examination reveals an enlarged tender liver with questionable mass laterally. LFTs have been elevated. She is seen here today in the Radiology Department to undergo liver biopsy. Procedure: The patient was sterilely prepped and draped in the usual manner. Anesthesia was achieved with 2% Lidocaine and supplemented with intravenous Versed throughout the examination. The mass in the lower portion of the right lobe of the liver was localized using CT guidance. Four passes of an 18 gauge Temno needle biopsy system were made into the mass without apparent complication. The cytotechnologist reviewed the specimens and found them to be adequate for histologic diagnosis. Follow-up CT scan showed no discrete hemorrhage around the mass. The patient tolerated the procedure well and left the Radiology Department in a satisfactory, sedated condition. She will go home when she is fully recovered from anesthesia later this morning. Cytology report returned showing presence of a hepatocellular adenoma.

Using the above samples, do your own coding and then compare it with our recommendations.

Notice: This part of our web site was prepared to assist in understanding and maintaining good coding skills. For proper use of this feature, reference must be made to official coding guidelines when necessary. The information here presented is only to be used as a supplement to those guidelines. Laguna Medical Systems, Inc., makes no representations or guarantees as to amounts that will be paid by Medicare or other third party payers.