Case #10 Winner, Answer Key, & Rationale

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Julie S. is the winner of case #10. See below for the answer key and rationale.

CPT: 43239
CPT Modifiers: none
ICD-9: 530.11, 530.20, 535.40, 535.60

The provider performs an esophagogastroduodenoscopy including biopsies. There were multiple findings. Although the indication for the procedure was GI bleeding, all findings are described as non-bleeding. The findings support the service therefore GI bleeding is not reported.

CPT: 43239

Steps to look up: Esophagogastroduodenoscopy/Transoral/Biopsy

ICD-9-CM: 530.11, 530.20, 535.40, 535.60

Steps to look up: Esophagitis/reflux; Ulcer/esophagus; Gastritis/erosive/without mention of hemorrhage (fifth digit); Duodenitis
Case # 10 clinical added for Answer key & Rationale

Case # 10 clinical added for Answer key & Rationale
Since the clinical info wasn't included in posting of answer & rationale; and the link to case clinical info given now is not accessible (error page shows up) .... I thought it wise to include the missing clinical info.

Hint: This next case involves coding for an esophagogastroduodenoscopy (EGD) on an elderly patient. Your index will be most helpful along with your ICD-10 knowledge!

Case # 10

PROCEDURE TYPE: Esophagogastroduodenoscopy (EGD)

Preoperative History: Patient is an 87-year-old Caucasian female.

Allergies: None.

Consent: The indications, alternatives and potential complications of endoscopy were discussed with the patient and/or representative(s). Potential complications of bleeding, perforation, infection and complications of sedation were discussed. The need for surgery, blood transfusion, hospital admission if a complication occurs was explained to the patient. Informed consent was obtained from the patient after providing the opportunity for questions.

Indications: Recent acute GI bleed.

Esophagogastroduodenoscopy performed with Regular gastroscope to second part of duodenum (depth of insertion 100 cm). Diet: NPO >6 hours. Prep: None. Patient was in the left lateral position.

1.Grade III (Savary Miller) esophagitis non-bleeding esophagitis of lower third of esophagus
2.Two (2) (10-15 mm) ulcers of lower third of esophagus. Biopsy obtained using regular forceps; sent for histologic examination.
3.Two (2) diffuse non-bleeding erosions of stomach antrum. Biopsy obtained using regular forceps; sent for histologic examination.
4.Focal erythematous mucosa of duodenal bulb.

The remainder of the examination to second part of duodenum was normal.

Therapeutic Outcomes & Specimens: No therapies performed. Specimen retrieved for examination, findings #2, #3.

Endoscope cleaned with Metrozyme mechanical wash and Cidex disinfectant soak.

Procedure Medications: 50 mg Meperidine administered by IV; 2 mg Midazolam administered by IV.

Complications: Heart rate, blood pressure and O2 saturation monitored and stable. No immediate complications.

Disposition & Recommendations: Returned patient to hospital room. Recommendations: Will need long term PPI. No NSAIDS. Repeat EGD in 3 months to eval for Barretts.

1.Non-bleeding, erosive reflux esophagitis of lower third of esophagus
2.Non-bleeding ulcers of lower third of esophagus
3.Non-bleeding erosive gastritis of stomach antrum
4.Non-erosive duodenitis of duodenal bulb