Case # 15 clinical added to Answer key & Rationale
Case # 15 clinical added to 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.
See below for the answer key and rationale for Case# 15.
ANSWER KEY
CPT: 59514
CPT Modifiers: none
ICD-9: 661.91, 645.11, 659.51, V27.0 or 652.51, 645.11, 659.51, V27.0
RATIONALE
This is an induction for a vaginal delivery that was converted to a cesarean delivery. There is no indication the provider who performed the delivery performed antepartum or postpartum care which results in coding the delivery only.
CPT: 59514
Steps to look up: Cesarean Delivery/Delivery Only.
The provider documented failure to descent but the patient reaches full dilation and pushes for three hours so it can not be reported with 661.01 or 661.11. The baby's head did not move down into the birth canal which lead to the Cesarean being performed. The reason is not stated. We accepted 661.91 Unspecified abnormality of labor with delivery or 652.51 High head at term delivered.
ICD-9-CM: 661.91, 645.11, 659.51, V27.0 or 652.51, 645.11, 659.51, V27.0
Steps to look up: Delivery/Cesarean/; Postmaturity, postmature/affecting management of pregnancy/post-term pregnancy; Pregnancy/management affected by/elderly primigravida; Outcome of delivery/single/liveborn.
HINT#15
Hint: This scenario involves a C-section resulting in a healthy baby boy! CCI Edits and lay terms can really help with this one!
Case #15
PREOPERATIVE DIAGNOSES:
1. Intrauterine pregnancy at 41 plus 0 weeks estimated gestational age.
2. Induction of labor for postdates.
3. Failure to descend.
POSTOPERATIVE DIAGNOSES:
1. Intrauterine pregnancy at 41 plus 0 weeks estimated gestational age.
2. Induction of labor for postdates.
3. Failure to descend.
PROCEDURE: Primary lower transverse cesarean section via skin incision.
ANESTHESIA: Epidural.
INDICATIONS: The patient is a 40-year-oid gravida 1 with an intrauterine pregnancy at 41 plus 0 weeks who presented on 08/14/20XX for induction of labor for postdates. The cervix upon presentation was closed, thick and high. Cytotec was initially given to the patient for cervical ripening followed by Pitocin. The patient later received an epidural. She progressed over the course of the next day to complete dilation at the +1 station, however, after 3 hours of pushing there was no further descent of the fetal head, It was recommended to proceed with delivery by cesarean section at this time and the patient was amenable to this.
FINDINGS: Vigorous male infant delivered in direct OP position with Apgars of 9 and 9 at 1 and 5 minutes respectively. Weight 8 pounds 1 ounce, Uterus, fallopian tubes and ovaries normal bilaterally
DESCRIPTION OF PROCEDURE: After informed consent was obtained, the patient was brought to the operating room, where epidural anesthesia was found to be adequate, She was placed in the dorsal supine position with a leftward lateral tilt and prepped and draped in the normal sterile fashion. A Pfannenstiel skin incision was made with the scalpel and carried down to the underlying layer of fascia with the scalpel. Fascial incision was then extended bilaterally with the Mayo scissors and dissected off the underlying rectus muscles bluntly and with the use of the Mayo scissors the rectus muscles were separated at the midline. The peritoneum was identified and incised and entered sharply. Peritoneal incision was then manually stretched bilaterally. The bladder blade was inserted. The vesicoutcrine peritoneum was identified and incised and a bladder flap was created digitally. The bladder blade was then reinserted. A lower transverse uterine incision was made with a scalpel and finger fraction caudad and cephalad. Clear fluid was noted at delivery all instruments were removed.. Mouth and nose were suctioned with bulb suction. The cord was clamped and cut and infant handed off to waiting nursing staff. The placenta was spontaneously extracted and noted to be intact with a three-vessel cord. The uterus was then exteriorized and cleared of any clots and debris. The bladder blade inserted reinserted and the hysterectomy incision was repaired in a double layer closure using 0 Vicryl for the first layer and 0
Monocryl for the imbricating layer, There was good hemostasis noted. The uterus, lubes and ovaries were visualized and were normal in appearance. The posterior cul-de-sac was then irrigated. The uterus was returned to the abdominal cavity and the periodic gutters were irrigated bilaterally. The bladder flap was inspected and made hemostatic with a small amount of electrocautery. All remaining surgical sites were inspected and noted to be hemostatic. Fascial layer was reapproximated using 0 Vicryl in a running fashion. The subcutaneous tissue was irrigated and electrocautery was used to obtain hemostasis. The subcutaneous tissue was reapproximated with 3 simple interrupted sutures using 3-0 Vicryl. The skin was closed with subcuticular stitch of 4-0 Vicryl for the closure of the subcutaneous tissue and then the skin was closed with subcuticular stitch of 4-0 Vicryl. The patient tolerated the procedure well and was brought to recovery in stable condition, All counts were correct x2, Dr._ was present and scrubbed for the entire procedure.
https://www.aapc.com/code/aapc-coding-challenge/cases.aspx