Question

Code CPT and ICD-10-CM code

LOCATION: Inpatient, Hospital

PATIENT: Sally Jacobson

ATTENDING PHYSICIAN: Leslie Alanda, MD

PREOPERATIVE DIAGNOSIS: Acute appendicitis

POSTOPERATIVE DIAGNOSIS: Acute appendicitis

ANESTHESIA: General anesthesia

INDICATION: The patient is a 17-year-old female with insulin- dependent diabetes mellitus who presents with crampy, colicky right lower quadrant abdominal pain and an ultrasound showing a question of appendicitis. Her white count is within normal limits. She continues to have pain in the right lower quadrant. She presents today for elective open appendectomy. We discussed the risks of bleeding, infection, and possible abscess formation with the patient’s mother, and they wish to proceed.

PROCEDURE: The patient was brought to the operating room and prepped and draped sterilely. A right lower quadrant skin incision was made with a no. 10 blade and carried down through subcutaneous tissues using electrocautery. The anterior sheath of the rectus was scored. The rectus retracted medially, and the posterior sheath and peritoneum were grasped with curved clamps and sharply incised, thus allowing entry into the peritoneal cavity. Some serous fluid was found in the right lower quadrant, and this was aspirated. The cecum was grasped, and the appendix was delivered up and into the wound. The mesoappendix was taken down between the right-angle clamps. The base of the appendix was transected sharply and sent to pathology for examination. The tip was cauterized and inverted into the cecum with a 3-0 silk pursestring suture. Two to three feet of the terminal ileum were explored, with no evidence of Meckel’s diverticula. The remainder of the abdominal cavity was within normal limits. The abdomen was irrigated with saline solution, and then the posterior sheath and peritoneum were closed with running 3-0 Vicryl. The anterior sheath was closed with interrupted 3-0 Vicryl. The skin was closed with subcuticular 4-0 undyed Vicryl. Steri-Strips and sterile bandage were applied.

SPONGE AND NEEDLE COUNT: All sponge and needle counts were correct. The patient tolerated the procedure well and was taken to recovery in stable condition.

Answer 1

Condition ICD Code for the case will be K35.2 OR K35.3.

ICD-10-CM (PR) Operative codes for above procedure can be referred as follows

- 0DQJ (repair, appendix)

- 0DQJ0ZZ (repair appendix, open approach)
- 0DQJ3ZZ (repair appendix, percutaneous approach)
- 0DQJ4ZZ (repair appendix, percutaneous endoscopic approach)
- 0DQJ7ZZ (repair appendix, via natural or artificial opening)
- 0DQJ8ZZ (repair appendix, via natural or artificial opening endoscopic)

Whereas CPT codes for above case study can be assigned as

44960 (appendectomy for ruptured appendix, with abscess or generalized peritonitis).