INDICATIONS FOR SURGERY: A 34-year-old female presents with severe abdominal pain. After examination was completed and ultrasound results were reviewed, it was determined that patient had an ectopic pregnancy and surgical intervention was needed. PROCEDURE: Patient was taken to the operating room, and after general anesthesia was induced, she was prepped and draped in the usual sterile fashion. Examination was performed after anesthesia, which showed a normal-sized, nontender uterus, a left adnexal mass, and a fullness in the vagina, all consistent with hyperperitoneum. A 10-mm trocar was inserted directly into the abdomen through a small incision in the umbilicus. Using 3.5 liters of carbon dioxide, a pneumoperitoneum was created. The hemoperitoneum was noticed, and another 10-mm trocar was placed in a small suprapubic incision. Two 5-mm ports were also placed under direct visualization in both the right and left lower quadrants. With an irrigator and aspirator, the hemoperitoneum was reduced. The left fallopian tube was noted to be almost to the point of rupture due to a mass in the tube. The fallopian tube was distended beyond repair; so this needed to be removed. The tube was tied off and removed with its contents through an Endo Catch bag through the 10-mm port. Inspection of the abdomen noted no other problems; adequate hemostasis was noted, and ports were removed. Defects were closed with 0 Vicryl, and the skin was closed with 4-0 Dexon. She was sent to the recovery room in stable condition.
ICD-10-PCS Code Assignment: ___________ and ____________
DIAGNOSIS: False labor without delivery, antepartum complication
This patient is a 20-year-old female who presents today dilated 7 cm with contractions occurring every 3-4 minutes lasting 30-40 seconds. This mother is also an admitted cocaine addict who is worriedabout how her baby will be when born. At this time we are going to try to obtain a blood sample of the fetus to determine whether we need to have any special services on standby in the NICU.
The fetal monitor is showing a stable heart rate at this time. The amniotic sac is broken, and the amnioscope is inserted through the vagina. A 0.05-mm incision is made in the scalp, and a blood sample is aspirated into a tube for a STAT to the lab. Contractions stopped, and the baby was not delivered at this time.
Procedure completed was an endoscopic drainage via the vagina for fetal blood sample.
ICD-10-PCS Code Assignment:___________
Case 2 :
ICD-10-PCS Assignment: 000.9 and 10P73ZZ
Character 1 - Section - 1. Obstetrics.
Character 2 - Body system - 0 Pregnancy
Character 3 - Root operation - P. Removal
Character 4 - Body part - 7. Skin, Abdomen.
Character - 5 Approach- 3. Percutaneous.
Character - 6 - Device Z. No device.
Character - 7 -Qualifier- Z No qualifier.
ICD-10-PCS Code Assignment: 10908Z9
Character 1- section -1.
Character 2 - Body system- 0
Character 3 - Root operation- 9 indicates drainage.
Character 4 - Body part - 0 . In the obstetric section, the body system is 0 for pregnancy. And also the incision is made on the scalp of the fetus.
Character 5- Approach - 8. via natural or artificial opening endoscopic.
Character 6- Z. No device.
Character 7- Qualifier - 9. Fetal blood.
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